Can we justify the continued use of botulinum toxin A in the management of myofascial pain?

We initially conducted a pilot study to evaluate the impact of botulinum toxin A (BtA) on increased masseteric mass associated with pain. After injection we assessed its impact on the muscle mass and the impact, if any, on reported pain, in a group of 10 patients who were refractory to conservative management. Results of this pilot study indicated that clenched and unclenched muscle dimensions showed no significant reduction (-0.82 clenched and -1mm unclenched). However, what did prove to be significant was an improvement in their pain scores as measured on a visual analogue scale (VAS). The mean VAS score before the injection was 8.2, and at six weeks after the injection it was 1.8. Following the pilot study we focused only on patients' pain scores. Our main study included 48 patients (81 muscles) who suffered with pain secondary to increased masseteric size, and had recorded their pain score out of 10 on the VAS before placement of BtA into each affected muscle and again six weeks after the injection. Results showed a mean pre-injection pain score of 7.9 and a mean post-injection pain score of 2.9. Following the results of this study on reported pain alone, our Trust has allowed funding to provide the intramuscular injection of BtA in appropriately selected patients.

An Interesting Association of Cystic Hygroma of the Neck and Lymphangioma Causing a Paediatric Swollen Tongue.

Up to 75% of lymphatic malformations occur in the head and neck region. Of these, cystic hygromas and lymphangiomas have been widely reported; however they rarely occur in the same patient. We report the case of a 5-year-old girl who presented to the Department of Paediatrics of a district general hospital with a short history of recurrent, painful swelling of the anterior one-third of her tongue. She was reviewed under the joint care of the Oral and Maxillofacial Surgery and Otolaryngology Teams. Relevant past medical history included a previously excised cystic hygroma from her right neck when she was aged 2 years. Diagnosis of lymphangioma was made and of the potential management options available active monitoring was favoured due to the patient's age. To our knowledge the occurrence of both tongue lymphangioma and cystic hygroma has not been previously reported in a paediatric patient. This case report therefore shows a rare association between a cystic hygroma of the neck and lymphangioma of the tongue.

Plasma cell cheilitis.

Plasma cell cheilitis is a rare, idiopathic mucosal condition, which has previously been given scant attention among oral and maxillofacial publications. We present a case of plasma cell cheilitis, with the differential diagnosis and options for treatment.

Necrotising fasciitis of the submandibular region; a complication of odontogenic origin.

Inadequate treatment or neglect of odontogenic infections can have serious consequences. The potential for spreading through fascial planes and intracranially can cause compromise of the airway and cavernous sinus thrombosis respectively. On rare occasions this can lead to a rapidly progressing necrotising fasciitis, with destruction of soft tissue, making reconstruction difficult. Antibiotic administration without removal of the cause is inadequate and can complicate subsequent management. We report the presentation and successful management of a 13-year-old boy, who developed necrotising fasciitis in the submandibular region as a result of inadequate initial treatment of a carious, lower molar resulting in significant skin and soft tissue loss.

A 10-year review of the occurrence and treatment of central giant cell granulomas, in a District General Hospital.

BACKGROUND: There is considerable variation in the clinical presentation, behaviour and radiological appearance of central giant cell granulomas (CGCGs), for which multiple treatment modalities have been suggested. METHOD: A 10-year retrospective review of the clinical presentation, radiological features and treatment received was undertaken. RESULTS: The cohort of patients included six males and three females, with an age range of 7-61 years. Six lesions were in the mandible and three in the maxilla. Eight lesions presented with swelling, three in relation to teeth. One case was an incidental finding. Six cases were confined within the cortical plates, one involved soft tissue. Radiological presentation was diverse, but within the existing confines of CGCGs. With one exception, primary treatment was surgical resection with excisional curettage of the remaining bone; to date, none have recurred. CONCLUSION: Diagnosis relies on correct interpretation of clinical, radiographical and histopathological data. Alternative treatments are worthy of consideration, although surgical excision remains the treatment of choice.

Eye safety in operative dentistry - a study in general dental practice.

AIM: In this safety conscious age all general dental practitioners should be promoting the use of eye protection. The aim of this study was to highlight the uptake of eye protection by all clinical staff and patients within the general dental practice setting, with regard to adequate protection and its use at appropriate times. METHOD: Questionnaires were sent to 200 GDPs, chosen at random, to accumulate information on the use of protection, the preferred methods of eye protection and any experience of ocular injury. FINDINGS: Eighty-seven per cent of GDPs wore eye protection routinely, but their choice of protection was not always adequate and not worn for all procedures. Forty-eight per cent of GDPs had experience of ocular trauma or infection which occurred during a variety of procedures; 75% of these injuries resulted from not wearing eye protection. In contrast less than half of the DNs and Hygienists use protection routinely, particularly when cleaning contaminated instruments. However, hygienists did wear eye protection for the majority of their patient work (96%). CONCLUSION: Eye protection use by all staff and patients is currently suboptimal to conform to published guidelines. Risks encountered within the dental environment do cause harm to the unprotected eye, which can be reduced or even eliminated by improving the uptake of suitable eye protection; several choices for eye protection are available. Each individual dentist is responsible for the uptake of eye protection for all persons in their surgery environment.

The pipe bomb: a modern terrorist weapon.

The use of pipe bombs by terrorist organisations around the world has risen dramatically. The pipe bomb is simple and easy to make and details of bomb construction are freely available from the Internet. Components can be found in most hardware stores and thus give little forensic information. Despite the increasing use of pipe bombs, clinicians may be unfamiliar with the type of injuries they cause. This paper describes two incidents of pipe bomb explosions and illustrates the type of injuries sustained by both terrorists and victims.

Post-traumatic orbital cellulitis.

Orbital cellulitis is uncommon. It may arise as a sequel to eyelid infection, or from direct spread of infection from the paranasal sinuses; it may be of odontogenic origin and has been reported after meningitis and after nasoorbital fractures with pre-existing sinusitis. Clinically, orbital cellulitis is of great importance, as it is a severe disease with potentially disastrous consequences. It may lead to optic neuritis, optic atrophy, blindness, cavernous sinus thrombosis, superior orbital fissure syndrome, meningitis, subdural empyema, and even death. We report two cases of severe post-traumatic orbital cellulitis with subperiosteal abscesses. These were managed surgically and vision was preserved. We describe the anatomy, a classification of orbital infection, and the importance of multidisciplinary management of these cases.

Dermatitis artefacta of the breast: a series of case reports.

Dermatitis artefacta of the breast is a common disease process with a psychological basis. Psychiatric assessment is a useful adjunct in the management of these patients who at initial presentation seem to have a strictly surgical dermatological problem.