Assessment of palliative approach in the pain management in endodontic emergencies during Covid-19 outbreak: Retrospective cohort study

Aim: During the coronavirus disease, a palliative approach was recommended for the management of endodontic emergencies. This retrospective cohort study was conducted to investigate the effectiveness of dexamethasone or ibuprofen-acetaminophen combination for pain management in endodontic emergencies. Material(s) and Method(s): One hundred and eight records of patients who presented to the emergency department with dental pain were evaluated retrospectively. Since interventional procedures were not performed during the pandemic period, Specific analgesics/antibiotics for the management of pain were preferred. A follow-up protocol with a questionnaire was developed to observe the effectiveness of palliative treatment and make changes if necessary. All participants received a questionnaire to rate the pain levels 6, 12, 18, 24, 48, and 72 hours after taking the drug. All data were collected from the patient file and assessed. After inclusion and exclusion criteria, 32 patients were included (n = 19, ibuprofen + acetaminophen;n = 13, dexamethasone). Data were analyzed using the chi-square test (P = 0.05). Result(s): In both groups, a significant decrease in pain was experienced immediately after medication and at 6, 12, and 18 hours, with no significant difference (P >.05). However, dexamethasone (Group II) resulted in lower pain levels than ibuprofen\acetaminophen (Group I) at 24 and 48 hours (P <.05) Discussion: Both dexamethasone and ibuprofen-acetaminophen can be good palliative choices in endodontic emergencies in pandemic conditions. However, at 24 and 48 hours, dexamethasone resulted in lower pain levels.Copyright © 2022, Derman Medical Publishing. All rights reserved.

Absence of Supportive Periodontal Treatment during the Covid-19 Pandemic - Recurrence of Periodontal Inflammation

Case presentation: Supportive periodontal care (SPC) is defined as step IV by the 2020 and 2022 EFP Guidelines for the treatment of periodontitis stages I-IV. SPC aims to maintain periodontal stability after active periodontal treatment is finished and the endpoints of periodontal therapy are achieved. SPC presumes preventive and therapeutic procedures performed at individualised, patient-based intervals. This case report describes a patient, 43 y/o female, with diagnoses of generalised periodontitis stage IV, grade C and periodontal health on reduced periodontium who was enrolled in longterm SPC provided at 3 - 4-monthly intervals. During the COVID-19 pandemic, the patient did not report for regular SPC due to personal fears of the contagion. After 20 months of absence, the patient was admitted for SPC. The comprehensive periodontal exam showed excellent oral hygiene (FMPS=7%), the presence of five 4 and 5 mm pockets and relapse of periodontal inflammation (FMBS=42%). The affected areas were mostly in the lower jaw. As periodontitis is a chronic disease, patients need to be continuously monitored. SPC reduces the probability of disease progression and tooth loss, as timely re-treatment can be provided in cases of disease recurrence. Various factors can contribute to disease relapse. In terms of the described patient, despite good oral hygiene, factors such as psychological stress and unhealthy living habits experienced during the COVID-19 pandemic might have negatively impacted the innate host response and led to disease relapse.

Odontogenic Osteomyelitis in Healthy Individualscomplications in the Sars-Cov-2 Pandemic

Introduction: Osteomyelitis is an infection of the bone that usually affects immunocompromised individuals with multiple comorbidities. Maxilla and the mandible are at risk because of close contact with primarily contaminated spaces of the oral cavity and maxillary sinus that can harbor subclinical infection and a thin mucosal layer that adheres to the periosteum. Recently, odontogenic osteomyelitis has become rare due to better oral hygiene, stomatological care, and the widespread use of antibiotics. During the pandemic of the SARS-CoV-2 virus, the availability of medical care was limited, and the number of complicated infections rose. Case report: We present two cases of odontogenic osteomyelitis of the mandible in healthy individuals that were complicated with relapses and SARS CoV-2 coinfection. The first patient was a 30-year-old otherwise healthy female who developed localized osteomyelitis after extraction of the tooth 38. She was asymptomatic but tested positive for SARS-CoV-2. The second patient was a COVID-19-positive 29-year-old male with no previous illnesses, whose odontogenic abscess and neck edema compromised the airway, requiring urgent tracheotomy. After two weeks he developed a relapse of the infection and osteomyelitis of mandibular ramus with the formation of sequestrum. Coinfection with SARS CoV-2 virus could aggravate osteomyelitis by causing immune dysfunction and depletion of CD-4 and CD-8 lymphocytes. The osteomyelitic site is hypoperfused because of tissue edema and the inability of intraosseal spaces to expand. Endothelial le-sions and increased coagulation in COVID infection could contribute to hypoperfusion and the spread of the infection. Currently, it is impossible to claim that SARS CoV-2 infection aggravated the clinical status of our patients, but further studies are needed about the impact of SARS CoV-2 infection on other organs and illnesses, especially in mild and asymptomatic cases.

Concomitant Presence of Mandibular Mucormycosis in a COVID Positive Patient: Report of A Rare Case

Reports of COVID-19 associated mucormycosis has exponentially increased in recent times, especially in patients with uncontrolled diabetes. It is reported to be associated with high mortality and morbidity rates and hence has emerged as a public health crisis. Covid-19 associated mucormycosis poses a diagnostic challenge for the Dentists as the clinical and radiological featuresare largely non-specific. The most common variant of mucormycosis in general is rhino-orbital and involvement of mandible is a rather uncommon presentation. Here we document a rare case of mucormycosis affecting the mandible with the concomitant presence of COVID19 infection in a diabetic patient.

How London maxillofacial units faced the demands of COVID lockdown and lessons learnt

Introduction: In the UK between the March 23, 2020 and May 10, 2020, the government enforced a lockdown. This, combined with COVID, caused OMFS hospitals across London to experience a change in staffing, resources and patient presentations. This study examines these changes, how patient care was adapted during this period and what can be learnt for the future. Method(s): Data was collected from OMFS units attached to all 4 level 1 trauma centers in London. Prospective data was collected from March 23, 2020-May 10, 2020 (1st period). Retrospective data was collected from hospital coding records for 23rd of March - May 10, 2019 (2nd period). Data was collected on all referrals to the OMFS team including diagnosis, patient demographics and treatment received. Result(s): There was an 84% reduction in patients presenting with mandible fracture. 2 units with dental emergency services experienced no change in dental abscess presentations whilst the other 2 units saw a decrease of 70-75%. There was a trend towards reducing admission and general anaesthetic treatments. Most mandible fractures were treated in the outpatient setting with 1 unit discharging 100% of mandible fractures that presented to A&E. Only 13 of 72 paediatric lacerations were treated with general anaesthetic. Conclusion(s): The COVID lockdown period, like war time, posed great challenges to healthcare provision. This paper presents the changes experienced and how patients were managed. Aiming to allow reflection and learning to guide changes in management to be adopted for the future.Copyright © 2022

Lesion Sterilization and Tissue Repair of Laterally Luxated Primary Mandibular Incisor: A Case Report

Lateral luxation injuries are common during childhood and in young adolescence. These injuries involve the surrounding tissues that could lead to extensive clinical treatment problems with a risk of pulpal complications such as pulp necrosis. A case of a healthy 4-year-old Malay boy visiting the paediatric dental clinic after seven months of laterally luxated injury on the lower right lateral incisor (tooth 82) was reported. The traumatic tooth was splinted by a private practitioner three days after the trauma, however, the splint dislodged less than 24-hour after placement. In view of the mother's fear of bringing her child to the dentist due to the COVID-19, no follow-up and further treatment were carried out. This has resulted in the development of discolouration and pulpal necrosis to the injured tooth. Lesion sterilization and tissue repair technique (LSTR) was performed. This report highlights the rare occurrence of lateral luxation injury on tooth 82 and the management of pulp necrosis as a complication via lesion sterilization and tissue repair technique due to the uncooperative behaviour of the child.Copyright © 2022, Faculty of Medicine, University of Malaya. All rights reserved.

Osteomyelitis of the mandible in patients with a history of COVID-19 infection: clinical, histologic, and radiographic presentations.

COVID-19 is a serious global infectious disease impairing the quality of life of people across the world. SARS-CoV-2 may reside in nasopharyngeal and salivary secretions of COVID-19-infected patients and spreads mainly through respiratory droplets and fomites. It has presented a challenge to dentistry, as many dental procedures generate aerosols that could lead to cross-contamination. It also presents many post-infection complications that may continue to debilitate patients, even after successful management of the virus. One such complication may be osteomyelitis of the jaw. Two cases of post-COVID-19 osteomyelitis of the jaw are presented that were determined to be unrelated to mucormycosis in otherwise healthy individuals with no prior dental complaints. An attempt is made to shed light on clinical signs in post-COVID cases that may point to a diagnosis of the condition. The pathophysiology is also discussed, which may help in formulating guidelines to prevent and manage post-COVID osteomyelitis of the jaw.

Role of Duplex scans in surgical planning of fibula free flaps - A retrospective study

Introduction/Aims: Fibula free flaps remain the workhorse flap for composite reconstruction in Maxillofacial surgery. The peroneal vessels demonstrate anatomical variance and susceptibility to atherosclerosis. Assessing perfusion to ensure adequate blood supply to the remaining lower limb following flap harvest is paramount. We aim to assess and analyse the role and limitations of Duplex scans in surgical planning, as these are being increasingly replaced by alternative methods. Material(s) and Method(s): A retrospective review of 30 consecutive patients was undertaken. These patients underwent bony reconstruction following oral cancer ablation, for which an osteocutaneous fibula flap was our first choice. Data collection included demographics, cancer staging, investigations and details of surgery. These results were compared with current practice and a review of the literature. Results/Statistics: Out of 30 patients, 27 had a Duplex scan. In 21 cases, a Duplex alone allowed for surgical planning, while in 6 cases it led to the surgical plan being altered. Twice, the Duplex was deemed inconclusive and further MRA was obtained. 3 patients only had an MRA. Conclusions/Clinical Relevance: Duplex scans are an accurate, reliable and safe way to assess vascular supply prior to flap harvest. They cost less than angiography and eliminate radiation risk. Their use can relieve pressure within radiology departments as waiting lists are shorter than for alternative scans, especially following increased demand resulting from the Covid-19 pandemic. Duplex scans diminish the need for MRA/CTA scans. If digital 3D planning is essential, an additional CT mandible and CT fibula may be preferred. Copyright © 2022

Antibiotic Guidance for OMFS inpatients

Introduction/Aims: Implementation of local antimicrobial guidelines is essential for optimal use of antibiotics and reduction of antibiotic resistance. The aims are: * To assess current antibiotic use for inpatients. * To assess which antibiotics are commonly prescribed in OMFS. * To assess dose/duration of antibiotics. * To assess second line antibiotic options for allergies. Material(s) and Method(s): Retrospective data was collected for elective and emergency admissions from October 2018 - October 2019. Data collection included: Antibiotic prescribed, clinical reason for antibiotics, dose, duration, administration method, discharge antibiotics, alternatives for penicillin allergic patients and microbiology swab results if applicable. Results/Statistics: Elective procedures included osteotomies, salivary gland surgery, TMJ surgery, cysts and major resections. 92% of osteotomies received prophylactic IV co-amoxiclav. 26% of salivary gland patients received antibiotics, majority co-amoxiclav. 58% of cyst patients received IV co-amoxiclav (43%), amoxicillin (43%) or amoxicillin and metronidazole (14%) and all major resection patients received IV antibiotics, majority amoxicillin and metronidazole (45%) 70 dental abscesses received IV antibiotics. 30% received amoxicillin and meronidazole, 22% received benzylpenicillin and metronidazole and the remaining 48% were prescribed a variety of combinations. 65% of abscesses had a microbiology pus swab taken. 48% were sensitive to penicillin, metronidazole or both. 33% had no growth. 91% of fractured mandibles received IV antibiotics, with co-amoxiclav and metronidazole the most common (30%). Conclusions/Clinical Relevance: Current practice was extremely varied. A guidance document was created for the department by a multidisciplinary team. A further round of data collection will be completed in due course following lifting covid restrictions to assess compliance. Copyright © 2022

Change in management of zygomatic fractures

Introduction/Aims: The impact of COVID on elective operating is well documented and far-reaching. What has not been reviewed is the impact on trauma surgery. The indications for the surgical treatment of zyggomatic fractures are primarily aesthetic, with only a small percentage of patients with this injury having significant functional problems Material(s) and Method(s): Operative records between April 2015 and December 2021 held in the theatre database of Swansea Hospital were exported to Excel and processed using Winstat. Results/Statistics: Over the time studied the mean zygoma fractures treated per year was 41 (SD 20.6, max 61, minimum 11). The two years since COVID 2020 and 2021 had 11 and 16 cases requiring operative intervention. These were significantly different to that observed in any of the preceding years. [Formula presented] Conclusions/Clinical Relevance: Early in COVID there was a contraindication to general anaethesia for anything but emergency cases. Zygomatic surgery did not qualify as an emergency during this initial phase and the frequency of facial trauma was also reduced because of lockdown. When lockdown ceased in Wales, facial trauma in Swansea (as indicated by operated mandibular fractures) returned almost to normal. However, a combination of limited access to semi-elective theatre and a change in approach by clinicians and patients to the management of cheekbone fractures has completely altered the approach in the Swansea Unit. The impact of this change on training and patient care will be discussed. Copyright © 2022

Impact of COVID Pressures on Delays to Theatre of Mandibular Fractures. A Service Evaluation of Mandibular Fracture Admissions at a UK Tertiary Maxillofacial Unit and Major Trauma Centre

Introduction/Aims: Dedicated OMFS trauma theatre sessions were suspended through the initial lockdown through a combination of reassigned resources, and extreme reduction in trauma cases. These sessions were not restarted when lock-down ended because of ongoing COVID pressures and access to elective OMFS operating was not possible because these theatres were 'silver'. This service evaluation is aimed at assessing the time taken from admission/diagnosis of mandibular fractures requiring surgery at Aintree University Hospital (AUH) and comparing this to BAOMS Trauma Group national standards i.e. 80% of patients operated by the end of the next working day. Material(s) and Method(s): Operative records were obtained within a 6-month period from June-November 2021. Data was collected retrospectively from electronic clinical/radiographic records. All patients with mandibular fractures requiring operative intervention were included. Results/Statistics: 98 patients were identified. The mean time from diagnosis to operation was 47 hours (median=39, max=276 min=5). 41% of patients were treated by the end of the next working day - falling short of the minimum standard (80%). When stratified by day of the week admitted, patients were noted to have significantly increased waiting time to operation on days where there was no available elective trauma list. (median 47 hours on a Wednesday versus 15 on Thursday) 96% of patients were discharged within one day of operation i.e. they were day cases. Conclusions/Clinical Relevance: In addition to the elective surgery backlog, there is an ongoing impact of COVID on emergency provision. Both could be addressed by access to day surgery. Copyright © 2022

Mucormycosis of the Mandible Following Sars-Cov- 2 Infection - a Case Report with a Brief Review of Literature

Mucormycosis is a rare fungal infection of the craniofacial region and lungs. An upsurge in the cases of mucormycosis was observed in the patients who had a history of SARS-CoV-2 infection.Infact in India, mucormycosis was declared an epidemic during the second wave of the COVID-19 pandemic. Rhino-orbital and cerebral regions were most commonly involved and very few cases of mandibular involvement have been reported in Post-COVID-19 Mucormycosis in India. Herewith, we report a case of isolated mandibular mucormycosis in a COVID-19 patient. A 47-year-old patient who recently recovered from COVID-19 presented with typical symptoms of osteomyelitis which was confirmed by radiological findings. An incisional biopsy followed by histopathologic examination confirmed mucormycosis of the mandible. Mucormycosis is an aggressive fungal infection thatrequires prompt diagnosis and treatment. Judicious management of osteomyelitis with secondary fungal infections involving the maxilla or mandible in patients with a history of SARS-CoV-19 infection can improve prognosis.

Co-existence of Head and Neck Squamous Cell Carcinoma with Sinonasal Mucormycosis: Therapeutical Challenges

Pandemic was new experience for entire humanity. Medical fraternity was no exception. The cases of mucormycosis were on the rise during the second wave of the pandemic. Presented here are two cases which were combination of two diseases, one of which was squamous cell carcinoma of head and neck region and other one was sinonasal mucormycosis. Both patients were diabetics and had history of Coronavirus Disease-2019 (COVID-19) infection in past. Our literature search doesn't reveal any previously reported cases of this rare combination. There were certain challenges in management. Both diseases were lethal and treatment of one cannot be prioritised over other. Challenges in managing those cases were, reconstruction planning, perioperative management and postsurgery adjuvant therapy. In absence of previous experience to treat this combination or any literature available new treatment protocol were formulated. Cases were discussed in multidisciplinary team meetings and treatment plans were formulated. Mucormycosis and oral squamous cell carcinoma both were operated and reconstructed in same sitting. In one patient revision endoscopic debridement had to be done. Amphotericin B was started once diagnosis was confirmed. Patients were followed-up on weekly basis during first month and imaging was done every 15 days. Both patients had satisfactory recovery without any sign of progression of mucormycosis. Adjuvant radiation was given in both cases at appropriate time. At follow-up both patients were free from disease for six months. From these unique experiences it can be recommended that combination of sinonasal mucormycosis and squamous cell carcinoma of head and neck is very rare. Both diseases can be treated simultaneously. Excision and reconstruction can be done in single sitting. There is no need to delay or avoid adjuvant radiation. Multidisciplinary team approach is the key for treatment.

Post-COVID Mucormycosis of Mandible: A Conundrum of Management.

Mucormycosis is an acute invasive infection of paranasal sinuses, with the propensity to spread from paranasal sinuses to intra-orbital and cranium. It is usually associated with immunocompromised states like diabetes mellitus, hematological malignancies, long-term steroids, neutropenia, and other multiple systemic disorders. Mucormycosis cases had been upsurging following COVID-19 infection. Due to the rampant use of steroids, pulmonary involvement secondary to cytokine upsurge, and deranged blood sugar levels in diabetic patients, mucormycosis of paranasal sinuses and neighboring anatomical structures has occurred at an unprecedented rate. The isolated involvement of the mandible is infrequent, and very few cases have been reported in the literature. We report one such case of post-COVID-19 isolated mandibular mucormycosis and its management. Generally, surgical excision and reconstruction of defect followed by a course of broad-spectrum antifungals are described as the appropriate line of management for this condition. However, on the contrary, we followed conservative management as the sole treatment because of the various challenges concerning undesirable postoperative consequences and reducing morbidity for the patient.

“Incidence, Clinical Profile, Treatment Protocol and Outcome of Rhino-Maxillary Orbital Mucormycosis in Government Medical College Hospital, Nizamabad, Telangana, India: A Prospective Study and Mini – Review of Literature”

Introduction: mucormycosis (ROCM) is a aggressive infection and in patient with co-morbidities, the mortality rises upto 50%. Rhino-orbitocerebral mucormycosis (ROCM) is the more common in patients with poor diabetic control and usually manifests itself as nasal stuffiness, nasal discharge, facial pain. Eye signs involve opthalmoplagia, proptosis and in advanced stages loss of vision. Material & Methods: This is a prospective, cross-sectional study involving patients who reported to our centre and those patients who were referred from other hospital for treatment of mucormycosis during the second of COVID-19 during april – june 2021. Results:Majority of the patients were above 50 years of age and the most common co-morbidity was diabetes. Maxilla was more commonly involved than mandible. Posaconazole along with surgical debridement effectively controlled the disease process. All the patients were disease free at 6 months follow up Discussion: Combined team work, creating a task force team for mucormycosis, effective anti-fungal therapy along with surgical debridement played a key role in management of mucormycosis with no recurrence. Control of co-morbidities remained as part of the patient care and has helped in control of the disease process and prevention of secondary infections.

TECHNOPATHIES IN WIND MUSICIANS AND SARS-COV-2

Objectives:To study the impact of SARS-CoV-2 infection, technopathies and associated pathologies in a cohort of wind musicians with respect to the general population paired by age and gender. Material and Method: Review of medical records with record: blood pressure, heart rate, dyslipidemia, smoking, respiratory, cardiovascular, traumatological, other pathologies, exposure and disease by SARS-CoV-2: duration, clinical, hospitalization, UVI, persistence symptomatology. The RR and 95% CI are calculated Results: Sick 6 cases and 3 controls. (RR 2.0;95% CI [0.56-7.1], with fewer days of illness (p<0.003). The traumatological pathologies of upper extremities (p<0.001) and lower extremities (p<0.04) stand out in the controls Hernial pathology in musicians (p<0.002), with three cases of mandibular temporalgia (TMJ). Conclusions: Musicians recovered before SARS-CoV-2 and Consult less for ostheomuscular pathology. Hernias and TMJ stand out, probably due of their professional activity.

ANTIMICROBIAL PHOTODYNAMIC THERAPY: AN ALTERNATIVE FOR THE TREATMENT OF OSTEORADIONECROSIS

Introduction Osteoradionecrosis (ORN) is a side effect after head and neck radiotherapy (RT) that is difficult to control. Antimicrobial photodynamic therapy (aPDT) promotes bacterial lysis through photosensitization, aiming at stimulating the affected area, promoting healing of the oral mucosa. Methods We performed a retrospective cohort analysis of patients with head and neck cancer, treated with RT, who developed ORN after RT and who underwent the treatment with aPDT concomitant with irrigation with 0.12% chlorhexidine digluconate and surgical debridement. Results Thirty-six patients who had lesions by ORN in the mandible or maxilla, with a mean development time of 30.9 months, were included. Of them, 77.8% were male, with a median age of 58 years. All of them were diagnosed with malignant neoplasms of oral cavity and oropharyx that received local RT as part of cancer treatment. In 22 patients, chemotherapy was used as part of the treatment. The main etiologie of ORN was prosthetic trauma (61.2%). All patients underwent the proposed protocol and 75% of patients were successful in treatment with total healing of the affected area and presented with no symptoms. Conclusions The protocol used suggests successful healing of the area in 75% of cases. The others suffered some complication of the ORN, such as pathological fracture, oro-cutaneous fistula and bucosinusal fistula and 16.6% patients treatment were affected by the COVID-19 pandemic and had the continuity of treatment impaired, still maintaining, a chronic ORN.

Cranial nerve involvement in mucormycosis in post-COVID patients: a case series

Background: One of the largest outbreaks of rhinosinocerebral mucormycosis (RSCM) occurred in India close to the second wave of the SARS-CoV-2 infection. RSCM is a rare infection caused by several fungal species occurring in immunocompromised subjects. Mucor shows a high propensity to invade the central nervous system. There have been limited studies, mostly isolated case reports, on the neurological manifestations of RSCM. The outbreak of mucormycosis infection was thus the most opportune to study the neurological manifestations and cranial nerve involvement in mucormycosis in greater depths. Aim of the study: The purpose of the study was to investigate and review the involvement of cranial nerves in a series of cases of rhinosinocerebral mucormycosis associated with the novel coronavirus disease caused by SARS-CoV-2. Results: It was a retrospective cross-sectional study of seven patients who were undergoing treatment of RSCM with a recent history of coronavirus disease caused by SARS-CoV-2 infection within the last 3 months. Patients with cranial nerve involvement were identified by magnetic resonance imaging (MRI) at a single institution. Demographic details of the patients, clinical presentation, imaging, microbiological and pathological findings were recorded. All subjects had two or more cranial nerves affected by fungal infection. The most commonly involved cranial nerve was found to be the optic nerve followed by the trigeminal nerve and its branches. We document three cases with extensive involvement of the inferior alveolar branch of the mandibular division of the trigeminal nerve (V3), a previously unreported finding. In one case, in addition to the second and fifth cranial nerves, the third, fourth, sixth, seventh, eighth, and twelfth cranial nerves were involved without any sensory or motor long tract involvement, suggestive of Garcin syndrome secondary to intracranial abscesses and skull base osteomyelitis due to invasive fungal infection. This case is of rare occurrence in the literature, and our study provides one such example. Conclusion: Cranial nerve involvement in patients of mucormycosis tends to have a poor prognosis, both cosmetic and functional. Radical surgeries and aggressive medical management is needed in such cases to improve the outcome.