Download Segmental Osteotomy Technique Can Realign Malposed Implants

Segmental Osteotomy Technique Can Realign Malposed Implants
Repositioning Malposed Implants: Report of Two Cases.
Rosen D:
Implant Dent 2010; 19 (June): 184-188
The segmental osteotomy technique may be used to reposition malposed implants in order to achieve a
restorative result with improved esthetics and function.
Background: Malposed implants may result from bone-driven positioning of the fixture, surgical template
inaccuracies, operator inexperience and error, or growth-related factors. Unfavorable positions of implants, as
well as vertical bone deficiency, present functional and esthetic challenges. Edentulous areas being restored
often have undergone significant alveolar bone loss, especially if the area has been edentulous for a long time.
Objective: To present 2 case reports of malaligned implants that were realigned using a segmental osteotomy,
which can be completed in a single visit, and the final prosthesis can be constructed after only a few weeks.
Case 1: A 56-year-old woman complained of "long, horse-like" teeth. Implants had been placed where there
was a vertical bone deficiency in the left premaxillary area. An autogenous bone graft had been performed,
which later failed. The operative procedure involved fracturing the bone with osteotomes and repositioning it to
an inferior location. Stabilization of the free segment with a titanium plate was followed by grafting BioOss into
the gap. In this case, a greater amount of denture base material had been used to allow placement of teeth at
the proper occlusal level to avoid creating "long teeth." Custom abutments are considered if implants are only
slightly malposed. Removal of the implant, while possibly indicated in some cases, does result in bone loss
and usually precludes immediate implant placement. Case 2: A 60-year-old woman had a malpositioned
implant in the area of tooth #7. The alveolar bone surrounding the implant was exposed, and a bony segment
was mobilized. A prefabricated temporary bridge was used as a guide, and the segment was repositioned to a
more optimal position.
Results: Both cases were restored with a final prosthesis after a 6-week healing period. This amount of time
was sufficient to allow for clot stabilization, callus formation, and osseous repair. The healing time is relatively
short since the bone segmentalization is a vascularized graft, and the segment is not totally detached from its
blood supply.
Conclusions: The author believes the segmental osteotomy technique is the best alternative in these cases.
Malpositioned implants were relocated, and patients were not subject to risks and extended treatment time that
would have resulted if implants had been removed and replaced. This surgery is not always possible, as in
situations where adjacent structures such as teeth or nerves are too close.
Reviewer's Comments: The author presents a good summary of an alternative technique, segmental
osteotomy, as an approach to managing areas with malpositioned implants. Preoperative treatment planning
and discussion between the surgeon and restorative dentist is very important when considering this technique.
(Reviewer-Edward N. Friedman, DDS).
© 2010, Oakstone Medical Publishing
Keywords: Dental Implants, Segmental Osteotomy, Implant Realignment
Print Tag: Refer to original journal article
Desensitizing Efficacy Depends on Choice of Adhesive, Desensitizer
Comparative In Vivo Study on the Desensitizing Efficacy of Dentin Desensitizers and One-Bottle Self-Etching Adhesives.
Yu X, Liang B, et al:
Oper Dent 2010; 35 (May-June): 279-286
Dentin hypersensitivity may be relieved through use of dentin desensitizers and self-etching adhesives.
Background: As much as 74% of the population may experience dentin hypersensitivity due to stimuli that are
thermal, evaporative, tactile, osmotic, or chemical. The most widely accepted etiology of tooth sensitivity
proposes a hydrodynamic theory, which states that when open dentinal tubules are exposed to dentinal tubular
fluid, this will activate the intradental nerves and cause pain. In this study, dentinal tubules are more open and
wider in hypersensitive teeth than in control teeth. The effect of applying dentin desensitizers and adhesives to
these exposed dentin surfaces to depolarize intradental nerves or occlude these open tubules was evaluated.
Objective: To evaluate the clinical effectiveness of 2 dentin desensitizers, two 1-bottle self-etching adhesives,
and a placebo (warm water) for treating dentin hypersensitivity, and to observe the micromorphology of this
dentin after it was treated with these liquids.
Design/Participants: Randomized placebo-controlled study of 31 volunteers.
Methods: Measurement of mechanical and thermal sensitivity of hypersensitive dentin was recorded at
baseline, immediately after application, and 1 month later. To eliminate other extraneous factors, strict
exclusion criteria were used for volunteers. No teeth were included if there was sensitivity from defective
restorations, caries, tooth fracture, or pulpitis. No use of desensitizing toothpaste by subjects for the past 6
weeks or use of some medications such as analgesics or anti-inflammatory agents were permitted.
Results: All dental materials used in this study significantly reduced dentin hypersensitivity. Desensitizers help
occlude open tubules, and thereby achieve their effects by precipitation of dentinal fluid proteins. This reduces
intratubular fluid flow in the exposed dentin. Comparatively, dentin adhesives of the 1-bottle, all-in-1 type also
reduced dentin permeability. As opposed to dentin desensitizers, self-etching adhesives adhere to the dentin
surface, producing an acid-resistant hybrid layer. This may provide more long-lasting clinical effectiveness than
would be seen with desensitizers, which do not adhere to the dentin surface. The placebo (warm water) was
reported by subjects to have a short-term palliative effect to thermal stimuli.
Conclusions: Short- and long-term reduction in the levels of dentin hypersensitivity may be achieved through
use of 1-bottle self-etching adhesives or dentin desensitizers. The effectiveness is related to which dentin
desensitizers or adhesives are used. One of the materials tested, a fluoride-containing varnish, reduced dentin
thermal and mechanical sensitivity immediately, but did not relieve the latter over the long term.
Reviewer's Comments: This excellent study addresses the problem of dentin hypersensitivity. The authors
compare the efficacy of different types of products within each category. Eliminating extraneous causes of
sensitivity provides results specific to each material tested, and gives a means of comparison of their clinical
effectiveness. (Reviewer-Edward N. Friedman, DDS).
© 2010, Oakstone Medical Publishing
Keywords: Dentin Desensitizers. One-Bottle Self-Etching Adhesives, In Vivo Study
Print Tag: Refer to original journal article
Papillary Enhancement Techniques Can Improve Esthetics Around Implants
Factors and Techniques Influencing Peri-Implant Papillae.
Chow YC, Wang H-L:
Implant Dent 2010; 19 (June): 208-219
Interproximal papillae formation may be enhanced through use of materials and techniques that serve to
preserve or regenerate the soft tissue in this area postoperatively.
Background: No matter how successful our shade matching and tooth anatomy are, the loss of interproximal
papilla becomes a major esthetic concern to our patients, especially around implants restored anteriorly. By
definition, the papilla in the natural dentition is the gingival tissue that occupies the embrasure space beneath
the contact area of adjacent teeth. The peri-implant papilla is the soft tissue underneath the contact area
between a natural tooth and an implant or 2 adjacent implants. Since implants are usually positioned below the
interproximal crest, loss of interproximal bone makes it challenging to preserve the papilla at an optimal height.
Differences in soft tissue histology, vascularity, lack of cementum, and biologic width all affect vertical height.
In addition, esthetic and phonetic problems and food impaction will result with loss or shrinkage of papillae.
Objective: To discuss relevant clinical factors involved with managing the soft tissue in the interproximal
space. The authors discuss surgical and nonsurgical techniques available in the field of papillary enhancement
to achieve an esthetic result. Discussion: Due to the unpredictability of reconstructing the peri-implant papilla
space, a sequenced treatment plan is recommended. Crestal bone height is a major determinant of papilla
location and is especially a challenge between 2 implants as the horizontal distance between them increases.
Tooth position, morphology, and gingival thickness also will affect the appearance of the inter-implant papilla.
Methods: Surgical and nonsurgical approaches were discussed. The surgical technique involved different flap
designs and grafting, with the goal of minimizing crestal bone loss. A less traumatic extraction procedure,
immediate implant placement, and flapless implant surgery all help to achieve better esthetics. Nonsurgical
options are also used to enhance esthetics. Moving the contact of the crowns more apically will reduce the size
of the open embrasure space. Gingival response can be modified by temporaries, as well as by orthodontic
movement.
Conclusions: Crestal bone level and interproximal distance are the 2 main determinants of esthetics of periimplant papillae.
Reviewer's Comments: This study examines factors that may affect esthetics of peri-implant papillae.
Although it does not provide statistics on the relative success of those techniques, it does present a thorough
review of treatment options to improve esthetics. Recognition of the potential esthetic dilemma preoperatively
should guide the restorative dentist, and this article comprehensively provides facts and techniques needed to
do that. (Reviewer-Edward N. Friedman, DDS).
© 2010, Oakstone Medical Publishing
Keywords: Papillae, Esthetics, Interproximal Soft Tissue
Print Tag: Refer to original journal article
All-Ceramic Restorative System Is Viable Option When Used Appropriately
Clinical Evaluation of an All-Ceramic Restorative System: A 36-Month Clinical Evaluation.
Barnes D, Gingell JC, et al:
Am J Dent 2010; 23 (April): 87-92
When used appropriately, low-fusing, low-leucite, all-ceramic restorations provide a similar clinical
performance to other all-ceramic restorative systems.
Background: Conventional leucite glass ceramics over an existing metal substructure (ie, porcelain-fused-tometal [PFM] restorations) have been used to restore teeth for >40 years. However, glass ceramics with high
levels of leucite have been associated with wear of the opposing dentition. Finesse, a low-fusing, low-leucite
veneering porcelain, was developed in the mid 1990s to restore teeth, with similar strength and esthetics as
conventional PFM restorations, but it produces less opposing dentition wear.
Objective: To evaluate the 36-month effectiveness of (1) Finesse in conjunction with an all-ceramic core
material and (2) the full contour all-ceramic crowns, inlays/onlays, and veneers used with a surface shading
material.
Materials/Methods: 40 single all-ceramic crowns, 20 inlays/onlays, and 26 veneers were placed in 43
patients. Crowns and inlays/onlays were placed in maxillary and mandibular anterior and posterior premolar
teeth; veneers were limited to maxillary anterior teeth from cuspid to cuspid. Three calibrated operators placed
all restorations according to recommended procedures of Latta and Barnes. Direct clinical evaluation was
performed by 2 calibrated investigators at baseline and at 6, 12, 24, and 36 months. Criteria included (1) color
match to the Vita Lumin shade guide tab on the laboratory model, prior to and after cementation, and at recall;
(2) marginal adaption on their respective dies at 25x magnification, intraorally, and radiographically, according
to the Modified Ryge/USPHS Criteria; (3) staining and pitting (via the Modified Ryge criteria); (4) postoperative
sensitivity; (5) transillumination for possible fracture lines in the porcelain; (6) clinical photographs at
cementation and at 6 and 12 months post-cementation; (7) gingival response via gingival and plaque indices;
and (8) postoperative sensitivity via air blast or cold stimulation.
Results: A bulk fracture in an all-ceramic onlay occurred at 24 months, resulting in 1 clinical failure.
Additionally, 1 crowned tooth had to be extracted due to a vertical root fracture. No failures were reported with
any restoration type at 36 months. Of all crowns, 97% rated alfa for shade match to the Vita Lumin shade
guide at 36 months, while no restorations exhibited marginal discoloration or secondary caries at 36 months.
Of full-coverage all-ceramic restorations, 78% demonstrated a gingival index score of 0 or 1, while 86%
demonstrated a plaque index score of 0 or 1. All restorations demonstrated a postoperative sensitivity score of
0 at 36 months.
Conclusions: Clinical performance of Finesse, a low-fusing, pressable, all-ceramic system was acceptable at
the 3-year recall and demonstrated a clinical performance consistent with other available all-ceramic systems.
Reviewer's Comments: The authors quoted multiple studies demonstrating failures with use of low-fusing,
low-leucite, all-ceramic restorations in posterior molar teeth, but they emphasized these restorations as viable
options, based on esthetics, marginal, and functional integrity when used appropriately. (Reviewer-Kelly A.
Halligan, DDS).
© 2010, Oakstone Medical Publishing
Keywords: Crowns, All-Ceramic, Inlays, Onlays, Veneers
Print Tag: Refer to original journal article
Repair of RMGICs With Resin Is Possible, Sometimes Advisable
The Repair Potential of Resin-Modified Glass-Ionomer Cements.
Maneenut C, Sakoolnamarka R, Tyas MJ:
Dent Mater 2010; 26 (July): 659-665
Repair of resin-modified glass-ionomer cements (RMGICs) using resin composites is not only possible
but, in some situations, is also advisable compared to using additional RMGICs.
Background: Resin-modified glass-ionomer cements (RMGICs) have an established and important place in
restorative dentistry, both as final restorative materials and as luting and lining cements. They are particularly
useful where adhesion is required. Additionally, RMGICs have shown evidence of reducing secondary decay
and remineralization of inner carious dentin. Unfortunately, like other water-based cements, brittleness
prevents their use in areas of stress and wear.
Objective: To assess repair potential of 2 RMGICs using similar RMGICs or a resin composite.
Design: Benchtop study testing shear bond strength.
Methods: 2 RMGIC blocks were constructed (Ketac N100 and Fuji II LC) and placed in water for 4 days.
Samples were then finished using 600-grit silicon carbide paper. The surface was then treated with phosphoric
acid (etch) or polyacrylic acid (conditioner). Fresh RMGIC (same brand as block) or composite (Single
Bond/Filtek) resin was then bonded to simulate a clinical repair. Specimens were stored in water for 24 hours.
Shear bond strength was tested, and the interface surface was examined for mode of failure.
Results: Ketac N100 had very poor results in the order of 1.7 MPa, many times even failing before testing
could be accomplished. Fuji II LC did better, in the order of 10 MPa, irrespective of surface treatment (etch or
conditioner). Resin composite did the best on both RMGICs. Bond strengths ranged between 9 and 16 MPa.
Scanning electron microscopy surface examination of RMGICs showed no substantial difference between
polyacrylic acid- and phosphoric acid-treated groups.
Conclusions: (1) It is not advisable to repair Ketac N100 with Ketac N100. (2) Fuji II LC could be repaired with
Fuji II LC or resin. (3) Use of resin appears to be the best option in all cases tested.
Reviewer's Comments: The philosophy of minimal invasive dentistry has been widely accepted. This article’s
findings should help the clinician decide whether to repair or replace a defective RMGIC restoration. The
success of resin supports the idea that it is a chemical bond (resin-resin) that provides improved bond strength.
The limitation of this study, also recognized by the authors, was that researchers tested only 4-day-old
RMGICs. Other researchers have found that repair strength may depend on the age of repaired material. Thus,
a repair of older RMGICs might have different results. It is my opinion that bond strengths would only reduce
over time, but resin repairs should remain more constant. When clinically possible, I repair most RMGICs with
resin composite, or I replace the restoration when resin composite is not clinically indicated. (Reviewer-Timothy
J. Halligan, DMD).
© 2010, Oakstone Medical Publishing
Keywords: Repair, Glass-Ionomer, Resin-Modified, Resin Composite, Adhesion
Print Tag: Refer to original journal article
Crown-Lengthening Procedures Are Not Dead Yet
Contemporary Crown-Lengthening Therapy: A Review.
Hempton TJ, Dominici JT:
J Am Dent Assoc 2010; 141 (June): 647-655
Many patients will accept great risks to keep their own teeth and will prefer crown lengthening to implant
placement if there is a reasonable prognosis.
Background: Both esthetic enhancement and restoration of severely broken teeth often require use of crownlengthening procedures.
Design: Literature review and case presentation.
Methods: A literature search, using PubMed and Google Scholar, was performed to evaluate clinical and
radiographic studies, surgical exposure of the natural dentition to allow restorative therapy, and address
esthetic needs. A final case presentation was also included.
Results: Gargiulo et al (1961) initially reported an average length of the dentogingival junction to be 2.04 mm.
Vacek and others (1994) not only reported mean values of 1.91 mm for the attachment apparatus, but also
reported a wide range of variation. Additionally, Ingber and colleagues (1977) suggested that the attachment
junction approximated 2 mm, but they suggested an additional 1 mm be added coronal to this as the optimum
distance between the bony crest and restorative margin. These articles established the average 3-mm biologic
width that is generally considered a safe separation for the margin of the restoration to the osseous crest.
Many teeth present broken down or fractured to a level requiring some type of internal post-and-core buildup
type of support. These often present with very little tooth structure between the surface of the buildup and the
osseous crest. The authors quoted studies suggesting a 1.5- to 2.0-mm ferrule be placed circumferentially in
the preparation, allowing occlusal forces to be expressed at the periodontal ligament rather than at the crown
or buildup interface itself. Many times, this impinges on the biologic width, and some sort of crown-lengthening
surgery becomes necessary. While some sources of literature state that a ferrule is unnecessary, these appear
to be the minority. This can be addressed by crown lengthening or forced orthodontic eruption. Treatment of
delayed, passive eruption is addressed in this manner. A case report was presented in which a 58-year-old
female had a foundation restoration, or buildup, nearly to the osseous crest, subsequent to endodontic therapy
and placement of a post. The root length was adequate for osseous resective surgery, and an apical
repositional flap was done after osseous resection, establishing a 4.5-mm superosseous tooth structure on the
buccal and palatal aspects. After healing, there was adequate tooth structure left for a preparation having a
1.5-mm ferrule.
Conclusions: Good planning and adequate diagnosis should precede any crown-lengthening surgery, and a
crown-lengthening surgery can be an appropriate option to allow restorative therapy or improve esthetic
appearance.
Reviewer's Comments: Crown lengthening can allow patients to maintain teeth that would otherwise be lost,
and it is still a very valid treatment modality. Proper preoperative treatment planning using established
periodontal and restorative principles is required to obtain predictable results. (Reviewer-Charles R.
Hoopingarner, DDS).
© 2010, Oakstone Medical Publishing
Keywords: Crown Lengthening, Ferrule, Post-and-Core Buildup
Print Tag: Refer to original journal article
Patients Don't Always Remember Accurately
Accuracy of Patients’ Recall of Temporomandibular Joint Pain and Dysfunction After Experiencing Whiplash Trauma: A
Prospective Study.
Salé H, Hedman L, Isberg A:
J Am Dent Assoc 2010; 141 (July): 879-886
Patients have been shown to display reduced accuracy of symptom reports over time.
Background: Most past studies have been based on the assumption that patients are giving an accurate
history when interviewed at a date distant from the injury itself. Many research studies are based on this
premise.
Objective: To determine if patient historical reporting of events associated with whiplash-type injuries is
accurate if taken at a time distant to the event.
Design: Prospective study to determine the ability of a patient to accurately recall timing of symptoms as they
occurred.
Participants: 60 patients seen consecutively over an 18-month period in the emergency department of a
Swedish hospital.
Methods: Patients were involved in rear-end car collisions but had no direct trauma to the head or neck. A
self-administered questionnaire in conjunction with MRI was obtained. They were asked if they had a
perception of daily living as being stressful at the time of the evaluation. The physician examiner met with the
patient for a 20- to 30-minute interview immediately after completion of their questionnaire to validate the
patient's understanding and accurate completion of the instrument. Follow-up examination was done 1 year
after initial intake evaluation. This consisted of a self-administered questionnaire and telephone interview
similar to the first, except a different examiner who was blinded to the first evaluation was used. Reports were
analyzed for addition of symptoms, omission of symptoms, backward telescoping, and forward telescoping.
One mis-recollection constituted an inaccurate history.
Results: With a 95% confidence interval, 40% of patients had inaccurate recall of pain and dysfunction. There
was no variation based on sex, age, previous presence of temporomandibular joint (TMJ) dysfunction, or pain
in the TMJ. There was a higher inaccurate recall among patients who described activities of living as stressful
at the inception interview. The most common error was incorrect referral of onset of TMJ pain and dysfunction
to the date of the whiplash trauma.
Conclusions: First, we should be cautious when interpreting results of previous studies that were based on
retrospective recollection of symptoms. Second, researchers who use patient history should design studies to
take into consideration that temporal inaccuracies are evident.
Reviewer's Comments: It was stated that, even though recall was inaccurate, participants were probably
accurate in relating the TMJ pain to the whiplash trauma as it has been shown that during the 1 year posttrauma timeframe, the instance of delayed TMJ pain was 5 times that of a matched control group. Even though
secondary gain looms as an issue, in this study, all treatment was covered by the Swedish health system, and
there is seldom a remunerative award at stake. (Reviewer-Charles R. Hoopingarner, DDS).
© 2010, Oakstone Medical Publishing
Keywords: Temporomandibular Joint Pain, Dysfunction, Whiplash, Trauma, Historical Accuracy
Print Tag: Refer to original journal article
Most Patients Want to Be Informed of Complications
Informed Consent: What Do Patients Really Want to Know?
Degerliyurt K, Gunsolley JC, Laskin DM:
J Oral Maxillofac Surg 2010; 68 (August): 1849-1852
In spite of patient ambivalence about informed consent, be sure to include a list of specific complications
to address the patient's "need to know."
Background: While informed consent is a necessary prerequisite to any surgical procedure, little is known
about the extent to which patients wish to be informed regarding risks of the procedure.
Objective: To determine the amount of information regarding potential risks of an oral surgical procedure that
patients wish to know.
Design: Anonymous questionnaire.
Participants: Male and female adult patients who were consenting for oral surgery.
Methods: A 12-question questionnaire was administered to 225 patients who were classified by age and sex
and who were to undergo dentoalveolar surgery for toothache or infection. The questionnaire asked about
what information patients would like to know, including all complications, none, or only the most common, and
if the complication occurs 1 in 1000 times, 1 in 100 times, or 1 in 10 times. Questions were also based on type
of complication patients would want to know about (failure of the procedure to improve symptoms, technical
complications requiring additional procedures, potential nerve damage, postoperative infection, postoperative
bleeding, pain), and patients were asked whether they wanted written information about complications and
when they would like the information presented.
Results: 212 questionnaires were completed by 85 patients (51 women, 34 men) aged 18 to 30 years, 93 (51
women, 42 men) aged 30 to 49 years, and 34 (17 women, 17 men) aged ≥50 years. Of respondents, 57%
wanted to know about all complications, 33% wanted to know about the most common complications, and 10%
did not want to know anything about possible complications. However, the desire for information increased
directly with the increased frequency of the complication. Most (75% to 89%) patients wanted to know about
complications that were specifically named (eg, nerve damage, bleeding, pain, etc). There was no relationship
between responses and patient age.
Conclusions: A thorough informed consent process generally provides patients with more information. These
findings should not preclude obtaining a detailed informed consent, which should be provided in advance of the
scheduled procedure and again just before it is performed.
Reviewer's Comments: The findings of this study likely confirm what many health care professionals know
about patient attitudes toward informed consent. However, the discussion of specific types of complications
should be used to prompt patients to consider the importance of the process. (Reviewer-Arthur H. Jeske, DMD,
PhD).
© 2010, Oakstone Medical Publishing
Keywords: Informed Consent, Oral Surgery, Complications
Print Tag: Refer to original journal article
Function, Not Appearance, Motivates Patients for Orthognathic Surgery
Motivating Factors for Patients Undergoing Orthognathic Surgery Evaluation.
Proothi M, Drew SJ, Sachs SA:
J Oral Maxillofac Surg 2010; 68 (July): 1555-1559
Analysis of occlusal and other orofacial functions should be carefully considered when referring patients
for orthognathic surgery, not just appearance.
Background: While smaller-scale studies have supported the common belief that patients with facial
abnormalities seek orthognathic surgery to address esthetic concerns, this association has not been confirmed
in a single study with a large patient sample.
Objective: To evaluate primary motivations for orthognathic surgery and characteristic symptoms associated
with dentofacial abnormalities in a large sample size.
Design: Retrospective, random evaluation of orthognathic surgery patients in a large oral and maxillofacial
surgical treatment center.
Participants: Male and female surgical patients of various age groups without skeletal syndromes.
Methods: 637 patient records were randomly selected from a surgical center's database for patients who had
orthognathic surgery during the period 1990 to 2006. Records were assessed for patient age, sex,
appearance, oropharyngeal function, patient's primary motivation for orthognathic surgery, and ability of the
patient to identify his/her correct dentofacial profile from 6 sample profiles.
Results: The majority (57%) of patients reviewed were female, and 76% believed that their dentofacial
abnormality affected their appearance. Of patients, 33% indicated speech problems associated with their
condition, and only 15% indicated difficulty with swallowing. With regard to the primary factor that motivated
patients to have orthognathic surgery, 37.0% indicated bite, 14.0% appearance, and only 5.0%, 4.5%, and
3.0% indicated pain, smile, and speech, respectively. Interestingly, 39% of patients could not appropriately
answer the question; 61% did not correctly identify their own dentofacial abnormality from 6 sample drawings
of deformed facial profiles.
Conclusions: Patients with dentofacial abnormalities should be considered as having a functional problem
and not just an esthetic concern, making quality-of-life issues very important in this patient group. The lack of
some patients to appropriately identify their motivation for orthognathic surgery may be related to their
concerns over insurance reimbursement for the cost of care and the tailoring of their responses accordingly.
Reviewer's Comments: This study should change our approach to referrals of patients with dentofacial
abnormalities, in that function is probably of equal or greater importance than esthetics in many patients.
(Reviewer-Arthur H. Jeske, DMD, PhD).
© 2010, Oakstone Medical Publishing
Keywords: Orthognathic Surgery, Facial Profile, Dentofacial Deformity
Print Tag: Refer to original journal article
Steps for Best Front-Line Strategies in Caries Management
Strategies for Noninvasive Demineralized Tissue Repair.
Peters MC:
Dent Clin N Am 2010; 54 (June): 507-525
Frequent fluoride applications, as varnishes, gels, or in toothpastes, combined with sealants are the best
front-line caries management strategies.
Background: Noninvasive management of early carious lesions is based on caries as being a multifactorial
disease involving acidic demineralization of enamel and dentin, and it can be effective both in repairing existing
damage and preventing further tooth destruction.
Objective: To provide a literature-based review of current evidence for noninvasive management of carious
lesions.
Design: Expert literature review by a single author.
Methods: The author performed a critical summary of scientific publications, citations from 1977 through the
present, with an emphasis on reports from randomized controlled trials (RCTs), systematic reviews, and metaanalyses, based on quality and quantity of scientific evidence for and against various noninvasive caries
management techniques.
Results: 70 peer-reviewed articles were reviewed, covering mechanisms of tooth demineralization and lesion
arrest and repair with plaque reduction/removal, fluoride toothpastes, modification of plaque organisms and
oral fluids, topical home fluorides, professionally applied fluorides, management of root caries, and calciumbased products.
Conclusions: Arrest of carious lesions is possible, even when dentin is involved. Effective delivery of fluorides
plays a key role and requires use of fluoridated over-the-counter toothpastes 3 times daily with minimal rinsing
afterward and the addition of fluoride mouthrinses. Fluoride gels and varnishes work similarly for adults as well
as children and adolescents (varnishes should be applied twice annually), and in-office products (gels, foams)
should be applied for 4 minutes. Evidence for the effectiveness of sealants in both non-cavitated and cavitated
lesions is overwhelming, with caries reductions of about 71% for 5 years, and concerns about sealing
undetected dentin caries are unfounded. Sealant protection is particularly indicated for children aged 5 to 6
years and 10 to 12 years, as well as for older, high-risk patients and those with orthodontic and restorative
appliances (eg, over brackets and around removable partial denture clasps). There is insufficient evidence to
recommend use of lasers as stand-alone therapy for carious lesions, and amorphous calcium phosphates may
enhance remineralization when saliva flow is reduced.
Reviewer's Comments: Excellent information on the state-of-the-art in caries management, which will
hopefully cause dentists to re-evaluate how they are using in-office fluoride applications and how they are
recommending use of toothpastes to their patients at risk of caries. (Reviewer-Arthur H. Jeske, DMD, PhD).
© 2010, Oakstone Medical Publishing
Keywords: Tissue Repair, Remineralization, Fluoride, Sealants, Infiltration, Lasers
Print Tag: Refer to original journal article
Deep Caries Requires Stepwise Excavation, Time
Treatment of Deep Caries Lesions in Adults: Randomized Clinical Trials Comparing Stepwise vs. Direct Complete
Excavation, and Direct Pulp Capping vs. Partial Pulpotomy.
Bjørndal L, Reit C, et al:
Eur J Oral Sci 2010; 118 (June): 290-297
A stepwise versus a direct complete excavation approach to deep caries removal in adults is desired, as
it causes less damage to the pulp and increases the pulp survival rate.
Background: A stepwise approach to caries excavation, as opposed to a direct complete excavation, may
decrease the number of pulp exposures, potentially allowing the pulp to heal.
Objective: To test the effect of: (1) stepwise excavation versus direct complete excavation of deep caries
lesions in adults, and (2) direct capping versus partial pulpotomy of pulps exposed as a result of caries.
Design/Methods: The excavation trials were conducted at a centrally randomized, patient-blinded multicenter
trial with 2 parallel groups. In stepwise versus complete excavation, the procedure is as follows: all superficial
necrotic and peripheral demineralized dentin was removed. A calcium hydroxide base material was applied
over the remaining carious dentin close to the pulp, and a temporary restoration placed. After 8 to 12 weeks,
the temporary and base materials were removed, a calcium hydroxide base reapplied, and the tooth was
restored with a composite restoration. For complete excavation, all caries was removed and a base material
and temporary restoration placed. At 8 to 12 weeks, the temporary restoration was removed, and the tooth was
restored with a permanent restoration. If excavation led to pulp exposure, the patient was assessed for the
pulp capping trial. For this procedure, complete caries excavation was performed, a rubber dam placed, and
the tooth cleaned with an alcohol/chlorhexidine rinse. The exposed pulp was irrigated with sterile saline, a
calcium hydroxide cement placed over the exposure, and a temporary restoration placed. After 1 month, a final
restoration was placed, leaving a thin layer of the existing temporary restoration over the pulp capping area.
For the partial pulpotomy, 1.0 to 1.5 mm of the pulp was removed, and the same protocol for the pulp capping
procedure followed.
Results: All treatment results were assessed after 1 year. The stepwise excavation group had a significantly
higher proportion of success (74.1%) at follow-up compared with the direct complete excavation group
(62.4%), with pulpal exposures of 17.5% and 28.9%, respectively. Overall, 89.8% of teeth retained pulpal
vitality after stepwise excavation; 87.7% after direct complete excavation. Patients with pretreatment pain were
significantly less likely to show a successful treatment result at follow-up compared to those without pain.
Treatment of patients aged <50 years was more likely to result in a sustained pulp vitality versus treatment of
older patients. The total proportion of teeth retaining pulp vitality without apical radiolucency at 1-year follow-up
did not differ significantly between the direct pulp capping group and the partial pulpotomy group.
Conclusions: The stepwise excavation group had a significantly higher proportion of unexposed pulps with
sustained vitality without periapical radiolucency compared with direct complete excavation of deep caries
lesions in adult teeth.
Reviewer's Comments: This study was well controlled with an appropriate time frame. It clearly proved that a
stepwise versus complete caries excavation approach leads to long-term pulpal vitality. (Reviewer-Kelly A.
Halligan, DDS).
© 2010, Oakstone Medical Publishing
Keywords: Caries Removal, Pulp Exposure, Stepwise Excavation
Print Tag: Refer to original journal article
Meds Taken for Chronic Diseases Linked to Complaint of Xerostomia
Medications in Elderly People: Its Influence on Salivary Pattern, Signs and Symptoms of Dry Mouth.
Leal SC, Bittar J, et al:
Gerodontology 2010; 27 (June): 129-133
Medication increases the chance that an elderly patient will present with signs and symptoms of
xerostomia. Not only can you measure a reduction in non-stimulated saliva, but the residual saliva has
reduced buffering capability.
Background: Qualitative reduction in saliva is defined as hyposalivation; the complaint of dry mouth is defined
as xerostomia. It was once believed that salivary reduction was associated only with old age. Recent literature
now proves that many medications (diuretics, anticholinergics, antipsychotics, antihypertensives,
bronchodilators, anti-inflammatory medications, and antidepressants) significantly reduce salivary production.
Objective: To compare stimulated and non-stimulated salivary flow, pH, buffering capacity, and presence of
signs/symptoms of hyposalivation in elderly patients.
Participants/Methods: 40 patients (mean age, 68.5 years) were stratified into 2 groups according to the use
and non-use of medications. Patients in the medication use category were also concurrently diagnosed with
mild dementia. Clinical exam identified signs associated with hyposalivation and xerostomia. Stimulated and
non-stimulated saliva flow, pH, and buffering capacity were also evaluated.
Results: Stimulated saliva of both groups was below normal. Patients taking more drugs that are known to
produce xerostomia had increased dry and cracked lips. It was also noted that the medication group had
decreased salivary buffering ability and flow (statistically significant for non-stimulated saliva).
Conclusions: Use of medication increases the chances that elderly patients will have signs related to
xerostomia (dry/cracked lips, fissured tongue). There is also a reduction of non-stimulated saliva and reduced
buffering capacity.
Reviewer's Comments: The weakness of this study, as admitted by the author, was a lack of a power
calculation to determine the number of patients required to study. Therefore, these findings need to be taken
with caution. I believe the literature is very conclusive that many medications cause significant hyposalivation
and xerostomia. For this reason, dental care providers must be aware of this possible complication and look for
its signs and symptoms. Being a critical member of the patient’s health care team, our findings should be
relayed to the patient’s physician who may not be aware of this complaint and possible dental sequelae. With
this information, the physician can then weigh risks versus benefits of the medication used and consider other
treatment options. (Reviewer-Timothy J. Halligan, DMD).
© 2010, Oakstone Medical Publishing
Keywords: Xerostomia, Hyposalivation, Saliva, Medication
Print Tag: Refer to original journal article
Microscopy for Endodontic Procedures Is Validated
Magnification's Effect on Endodontic Fine Motor Skills.
Bowers DJ, Glickman GN, et al:
J Endod 2010; 36 (July): 1135-1138
If you are doing endodontic procedures, consider the advantages of a microscope in yielding greater
procedural accuracy of instrument placement.
Background: Intuitively, magnification should facilitate and improve endodontic procedures, and while it has
been shown to assist with diagnostic steps, its ability to enhance fine motor skills required by endodontic
operators has not been well studied.
Objective: To objectively evaluate whether the use of magnifying loupes and an operating microscope can
enhance the fine skills required in root canal treatment.
Design: Randomized comparison of 2 groups of operators using 2 types of magnification to perform a
standardized series of psychomotor tests.
Methods: 20 general dentists without experience in using an operating microscope and 20 endodontists
experienced with it performed 3 precision manual-dexterity tests using normal (unaided) vision, 2.5x loupes,
and an 8x operating microscope, under standard fluorescent lighting. The test involved repeated, timed
placement of the tip of a #10 endodontic file into computer-generated paper targets of 0.35-mm diameter.
Accuracy of placement was assessed by scoring the placements as completely within the target, >50% within,
>50% outside, and completely outside the target.
Results: Use of the operating microscope nearly doubled the average time required to complete the test, but
this effect was most pronounced for those operators without microscope experience. With regard to accuracy,
however, when compared to unaided vision, loupes increased accuracy 17.5%, while the microscope
increased it statistically significantly by nearly 58.0%. Interestingly, subjects aged >35 years did not
demonstrate a significant improvement with loupes when compared with unaided vision.
Conclusions: Magnification with an operating microscope significantly enhances endodontic motor skills.
Reviewer's Comments: There are probably few dentists who would be surprised at these outcomes, which
greatly support the use of operating microscopes in endodontics. However, it appears that 2.5x loupes may not
be quite as helpful as some may have assumed. (Reviewer-Arthur H. Jeske, DMD, PhD).
© 2010, Oakstone Medical Publishing
Keywords: Endodontics, Loupes, Magnification, Manual Dexterity, Operating Microscope
Print Tag: Refer to original journal article
All Apex Locators Are Not Created Equal
Investigation of Apex Locators and Related Morphological Factors.
Ding J, Gutmann JL, et al.:
J Endod 2010; 36 (August): 1399-1403
Under certain test conditions, some apex locators perform differently than others, and these outcomes
should be considered when using this technology.
Background: Electronic apex locators (EALs) have become an important adjunct in endodontic treatment, but
their precise localization of the foramen of the root canal at the apex may vary from instrument to instrument,
and if this determination is imprecise, excessive instrumentation length can result.
Objective: To investigate the accuracy of 3 EALs in detection of the minor foramen of root apices and to
characterize the morphologic factors that contribute to precise working length determination.
Design: In vitro laboratory testing using standardized testing equipment and stereomicroscopic
characterization of tooth root anatomy.
Methods: The 3 EALs evaluated were the Root ZX, Raypex 5, and the Elements Apex Locator. In total, 356
single-rooted, extracted human teeth were prepared by removal of crowns and flaring of the coronal two thirds
of their root canals, after which they were mounted in a micrometer device and bathed in isotonic saline. The
detection electrode of the EAL was connected to a #10 K-file, which was then attached to the micrometer and
advanced through the root canal system until the EAL registered detection of the minor foramen. These values
were then compared to stereomicroscopic evaluation of the same length (visualization of the tip of the file at
the most coronal border of the major foramen).
Results: The average difference between electronic lengths and visually detected lengths was 0.261 mm for
the Root ZX, 0.376 mm for the Raypex 5, and 0.383 mm for the Elements device. For the Root ZX, tips were
located <0.5 mm from the major foramen in 83% of tests, 68% for the Raypex 5, and 64% for the Elements
device. Localization of the minor foramen was significantly correlated with foramen morphology, as file tips
were found to be much closer to the major foramen in teeth with a lateral major foramen when the EALs had
indicated detection of the minor foramen.
Conclusions: EALs vary significantly in their ability to detect the minor foramen of a single root canal, with the
Root ZX giving readings of a minor foramen when it was actually closer to the major foramen.
Reviewer's Comments: EALs will continue to be an important tool to supplement radiographic and tactile
determinations of working lengths when performing root canal therapy. However, we should note the variations
in readings that can occur and the quantitative and qualitative factors that play into these variations when using
this technology. (Reviewer-Arthur H. Jeske, DMD, PhD).
© 2010, Oakstone Medical Publishing
Keywords: Electronic Apex Locator, Root ZX, Raypex 5, Morphological Factor
Print Tag: Refer to original journal article
GERD -- A Somewhat Likely Accompaniment to TMD, Vice Versa
Prevalence of Temporomandibular Disorders in Patients With Gastroesophageal Reflux Disease: A Case-Controlled
Study.
Gharaibeh TM, Jadallah K, Jadayel FA:
J Oral Maxillofac Surg 2010; 68 (July): 1560-1564
When managing patients with temporomandibular disorders, give careful consideration to the possible
presence of gastroesophageal reflux disease.
Background: While no cause-and-effect relationship has been proven, a significant number of patients with
temporomandibular disorders (TMDs) also have gastroesophageal reflux disease (GERD), so physicians and
dentists should be aware of this comorbidity.
Objective: To investigate the association between TMD and GERD by assessing the prevalence of TMD in a
series of patients with and without GERD.
Design: Case-controlled human subjects study.
Participants: Adult patients from a large teaching university hospital.
Methods: 60 gender- and age-matched, consecutive patients previously diagnosed with GERD and 60 GERDfree patients from an internal medicine clinic were evaluated for the presence of TMD by trained oral and
maxillofacial surgeons using the Research Diagnostic Criteria for TMDs. Patients were further subclassified
according to presence of myofascial pain, disc displacement, other joint inflammatory conditions, as well as
presence of depression and nonspecific pain symptoms.
Results: The average age of male subjects was 39 years and females 43 years. All subjects diagnosed with
TMDs had myofascial pain without limitation of opening, but none were diagnosed with group III problems
(inflammatory/degenerative conditions such as osteoarthritis). For overall prevalence of TMDs, 32% of patients
with GERD were diagnosed with TMD (32% of whom had group I myofascial pain), while the control group
(without GERD) had an overall 18% prevalence -- the difference being statistically significant.
Conclusions: Patients with GERD have an increased prevalence of TMD, and dentists and physicians should
be aware of this association and treat the patient accordingly. The authors suggest that the use of drugs that
irritate the gastrointestinal tract (eg, NSAIDs) should be prescribed with caution in patients with GERD and
TMD, and other precautions are important, including endoscopic techniques that reduce dental and
temporomandibular joint trauma during gastroenterology care.
Reviewer's Comments: The outcomes of this study are somewhat intuitive, in that the endoscopic procedures
frequently employed in the diagnosis of GERD likely put great stresses on the tissues of the
temporomandibular joint. We should be alert to the increased likelihood of TMDs in patients with GERD and
avoid certain classes of analgesic drugs that can aggravate gastrointestinal conditions. (Reviewer-Arthur H.
Jeske, DMD, PhD).
© 2010, Oakstone Medical Publishing
Keywords: Temporomandibular Disorders, Gastroesophageal Disorders
Print Tag: Refer to original journal article
Evidence Does Not Support Amoxicillin Role in Hypomineralization
No Evidence to Support the Claim That Amoxicillin Causes Molar-Incisor Hypomineralization.
Phipps KR:
J Evid Based Dent Pract 2010; 10 (June): 112-114
When prescribing antibiotics in children aged 8 to 12 years, amoxicillin is not contraindicated based solely
on a risk of hypomineralization of developing teeth.
Background: Antibiotics, particularly tetracyclines, are known to cause discoloration and/or demineralization
of developing teeth in humans, but the problem is difficult to assess scientifically because of ethical
considerations.
Objective: To evaluate the scientific validity of a previous study of grade school-aged children that concluded
that the administration of amoxicillin to children may cause hypomineralization of permanent molar teeth.
Participants: 217 children ranging in age and attending the second through fifth year of school in a nonfluoridated community in Finland were included in the original study.
Methods: In the original study, the children were examined for hypomineralization of the permanent first molar
tooth and evaluated for a history of taking penicillin, amoxicillin, erythromycin, sulfonamide and/or trimethoprim
during the first year of life. The same investigators then combined these outcomes with outcomes from a study
of exposure of mouse embryos to various, high concentrations of amoxicillin.
Results: 85% of children evaluated had been given at least 1 course of antibiotic. In total, 35% had received
penicillin or amoxicillin, and 5% had received erythromycin. Of subjects, 16% exhibited at least 1 first molar
with hypomineralization, and of these, half had been exposed to an antibiotic by age 1 year, while 34% of
those not exposed to antibiotics had a hypomineralized first molar. Based on the original statistical analysis
that pooled the human data with the mouse embryo data, the original investigators determined that amoxicillin
is a cause of first-molar hypomineralization.
Conclusions: The present author noted several flaws in the design of the original study, including the
unquantifiable contribution of environmental factors to hypomineralization (eg, poor nutrition, illnesses), and the
combination of data from both control (no amoxicillin) and low-dose amoxicillin exposure in mouse embryos,
which would suggest that there were no differences in these 2 animal groups and hence, no effect of
amoxicillin when used at "real world" dosages. The evidence does not support a cause-and-effect relationship
between exposure of infants to amoxicillin and permanent molar hypomineralization.
Reviewer's Comments: Amoxicillin and other penicillins remain important therapeutic agents for patients in all
age groups. While hypomineralization is a significant risk factor for severe caries and eventual extraction,
amoxicillin should not be withheld from young patients based on a risk of hypomineralization alone. (ReviewerArthur H. Jeske, DMD, PhD).
© 2010, Oakstone Medical Publishing
Keywords: Antibiotics, Amoxicillin, Hypomineralization, Permanent Molars
Print Tag: Refer to original journal article
Onset of BRONJ in Implant Patients May Be Delayed for Years
Oral Bisphosphonate-Associated Osteonecrosis of the Jaw After Implant Surgery: A Case Report and Literature Review.
Bedogni A, Bettini G, et al:
J Oral Maxillofac Surg 2010; 68 (July): 1662-1666
Even though oral bisphosphonate therapy represents a low risk for jaw osteonecrosis in implant patients,
there may be significant variations in success from patient to patient.
Background: The risk of bisphosphonate-related osteonecrosis of the jaw (BRONJ) associated with the
placement of dental implants in patients who have taken oral bisphosphonates is real, and while oral
bisphosphonate use is not an absolute contraindication to implants, the actual risk and severity of
complications have not been firmly established.
Objective: To present a case of BRONJ in a patient with a history of oral bisphosphonate use and to describe
the potential etiologic factors of this complication.
Design: Case report of a single patient.
Participants/Methods: Postoperative surgical observation and management of BRONJ was carried out in 1
female patient aged 63 years.
Interventions: 2 dental implants placed in 2006 (one of which was placed immediately in an extraction site), in
a patient with a 6-year history of taking alendronate for osteoporosis, which was continued.
Results: Following integration of 2 root-form dental implants, a fixed-partial restoration was placed in
November 2006. In June 2008, the patient presented with sudden-onset swelling and gingival bleeding, for
which a 1-week course of amoxicillin/clavulanate was prescribed, and then 7 subsequent but unsuccessful
courses of antibiotics. The patient finally presented to an oral surgery service in June 2009 and a diagnosis of
BRONJ was confirmed.
Conclusions: Multiple factors may contribute to development of BRONJ, as in this case, and the interference
of nitrogen-containing bisphosphonates with bone turnover may reduce peri-implant resistance of bone to
bacterial infection, so that poor oral hygiene may be a significant risk factor as well. Reinforcement of excellent
oral hygiene is very important in such cases.
Reviewer's Comments: Development of BRONJ associated with 2 dental implants in a patient with a history
of oral bisphosphonate use probably comes as no surprise to most readers, but the impressive message from
this case report is the delayed onset after apparently good osseointegration, which underscores the need for
oral hygiene management. (Reviewer-Arthur H. Jeske, DMD, PhD).
© 2010, Oakstone Medical Publishing
Keywords: Oral Bisphosphonates, Osteonecrosis of the Jaw, Implants
Print Tag: Refer to original journal article
Implants Can Be Immediately Placed Into Infected Areas
Immediate Placement of Implants Into Infected Sites: A Systematic Review of the Literature.
Waasdorp JA, Evian CI, Mandracchia M:
J Periodontol 2010; 81 (June): 801-808
Evidence suggests that implants can be placed into sites with periodontal and periapical infections, and
sites must be thoroughly debrided prior to placement.
Background: Immediate placement of implants into fresh extraction sites has shown to be both predictable
and successful when proper clinical protocols are followed. Placement into infected sites was often considered
taboo.
Objective: To review the literature regarding treatment outcomes of immediate implant placement into sites
exhibiting pathology.
Methods: The authors did a Medline/PubMed systematic search with the following questions guiding their
path: does the presence of infection compromise the osseointegration of immediately placed implants? Does
the presence of infection compromise immediately placed implant success? What protocols have been used to
address the infection prior to immediate implant placement? Is the use of guided bone regeneration necessary
to fill bone-implant gap and/or socket deficiencies? It is also important to point out that all periapical lesions
that present radiographically do not necessarily indicate similar clinical situations. They may represent a range
of clinical situations including periapical granuloma, periapical abscess, periapical cyst, or periodontal abscess.
Each of these represents divergent clinical entities requiring differing clinical modalities of treatment.
Results: The authors searched for articles from 1982 through November 2009. Initially, they included 6 animal
and 9 human studies from 417 references and then excluded 1 human and 2 additional animal studies. All
studies used thorough debridement, most used either sterile saline rinses or chlorhexidine rinses, and most
used antibiotic therapy prior to and following surgery. One study even used a cortisone injection into the site
while another used plasma-rich growth factors. Human studies suggest that periodontitis as a reason for
extraction may adversely affect implant survival.
Conclusions: Evidence suggests implants can be placed into sites with periapical and periodontal infections.
The sites must be thoroughly debrided prior to placement.
Reviewer's Comments: If an implant can be immediately placed into a fresh extraction site, there are several
advantages including a reduction of treatment time and numbers of procedures and the ability to place the
fixture in an ideal axial position. Although clinical studies on both human and animal subjects have shown a
high degree of success in the immediate placement of implants in infected sites, this is in no way an exact
science. Thorough debridement is an absolute necessity and oftentimes aggressive antibiotic regimens need
to be given concurrently. Much further study is required with strict study control guidelines to determine if the
use of antibiotics is always a necessity, and to determine what will provide the correct formula to achieve
clinical success. (Reviewer-Ralph J. Bozza, DDS).
© 2010, Oakstone Medical Publishing
Keywords: Immediate Placement, Protocol, Pathology, Tooth Socket
Print Tag: Refer to original journal article
Still No Definitive Guidelines for Antibiotic Prophylaxis
Decisions and Antibiotic Use: More Questions and Some Answers.
Miller C:
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010; 110 (July): 1-3
Practice guidelines based on strong evidence should be established to aid clinicians on proper use of
antibiotics.
Background: Strong guidelines need to be established to address the controversy regarding proper use of
antibiotics for infection, as well as prophylaxis. Multiple questions arise regarding proper antibiotic regimens.
For example, "What is the magical dose and time frame?" Also, "Is the immune status of a healthy patient a
factor when determining the minimum inhibitory concentration (MIC) or minimum lethal concentration (MLC) of
a particular antibiotic?" "If the source of infection (tooth, for example) is eliminated, should the antibiotic dose
be adjusted?" In addition, "Oral flora may cause bacteremias, but do they directly cause a late prosthetic joint
infection?"
Objective: To present thought-provoking questions regarding the use of antibiotics in dentistry.
Design: Literature review, including data from clinical studies. Discussion: Bacteremias may be caused by
oral flora; however, it is still difficult to prove the direct relationship between an oral organism causing a late
prosthetic joint infection (LPJI). No study has cultured flora in the mouth before and after a late prosthetic joint
infection, and multiple LPJI case reports clearly show that infections are rarely caused by microorganisms from
the oral cavity. In addition, a recent case-control study done at the Mayo Clinic showed that dental procedures
were not risk factors for hip or knee infections. And, finally, in the Waldman report, 1 patient of 9 "dentally
related" joint infection cases still developed an infection even after receiving prophylaxis.
Conclusions: There are still a lot of data and controversy concerning antibiotic use in the field of dentistry.
Strong scientific evidence is needed for clinicians to properly dispense the correct antibiotic regimen for their
patients.
Reviewer's Comments: This article presented multiple thought-provoking questions and data regarding the
need for stronger evidence in the current antibiotic regimens for infections and prophylaxis in dentistry.
(Reviewer-Gargi Mukherji, DDS).
© 2010, Oakstone Medical Publishing
Keywords: Antibiotic Prophylaxis, Prosthetic Joints
Print Tag: Refer to original journal article
Don’t Assume That a Submandibular Swelling Is Odontogenic
Rapidly Growing Neck Swelling in the Submandibular Triangle.
Chigurupati R, Connelly ST, et al:
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010; 110 (July): 4-10
Tuberculous lymphadenitis of the neck is often difficult to diagnose due to its varied physical signs and
symptoms and inconsistent lab results.
Background: A 38-year-old East Indian male patient presented to the oral surgery department at University of
California, San Francisco with the chief complaint of progressive swelling (3.5 x 3.5 x 2.5 cm) on the left lateral
neck by the submandibular triangle. Signs and symptoms over the past 3 weeks included intermittent lowgrade fever and difficulty swallowing. No pain, difficulty breathing, night sweats, productive coughs, weight
loss, or toothache was noted. Patient did make frequent trips to India and recently, a family member was
treated for pulmonary tuberculosis (TB). The patient was given a 1-week dose of tetracycline by his physician
as well as 1 week dose of augmentin by emergency department physicians, but the swelling did not resolve.
Objective: To correctly diagnose with the appropriate lab tests and scans the progressive submandibular
swelling.
Design: Case report.
Methods: Multiple lab tests were ordered to aid in diagnosis of the patient's swelling. These tests included:
complete blood count, electrolyte panel, urine analysis, fine needle aspiration cytology (FNAC), Rapid Plasma
Reagin (RPR), panorex of jaws, chest films, tuberculin skin test (TST), and neck CT scans. An excisional
biopsy was also done.
Results: CBC and electrolyte panel were WNL. C-reactive protein was slightly elevated and urine analysis
showed positive nitrites with 4+ bacteria. FNAC showed abundant neutrophils, histiocytes, and granulomas.
RPR was negative and HIV tests were negative as well. TST showed positive 22-mm skin induration at 72hour follow-up. Neck CT showed enlarged lymph nodes with focal necrosis and edema. Lungs were clear.
After histopathologic exam of the biopsy (matted lymph nodes along with the submandibular gland), multiple
granulomas surrounded by lymphocytes as well as a well-formed granuloma with multiple giant cells were
revealed.
Conclusions: A definitive diagnosis of cervical tuberculous lymphadenitis was made due to the patient's
recent medical history, signs and symptoms, radiology, FNAC, TST, and histopathologic results. The patient
was put on a 4-drug regimen, including isoniazid, rifampin, pyrazinamide, and ethambutol for 6 months.
Reviewer's Comments: The article depicts the various illnesses that can cause swelling in the submandibular
triangle. These can range from Hodgkins and non-Hodgkins lymphoma, sarcomas, cysts, carcinoma
metastases, salivary gland tumors, sarcoidosis, systemic lupus erythematosus, actinomycosis, tuberculous
lymphadenitis, brucellosis, infectious mononucleosis, cat-scratch disease, etc. The article also stresses the
importance of lab tests, scans, and a thorough medical history to differentiate and appropriately diagnose TB
lymphadenitis because treatment will vary if the disease is caused by atypical mycobacteria (responds to
surgical therapy) or tuberculous mycobacteria (responds to medication therapy). (Reviewer-Gargi Mukherji,
DDS).
© 2010, Oakstone Medical Publishing
Keywords: Swelling, Submandibular Triangle, Tuberculous Lymphadenitis
Print Tag: Refer to original journal article