Paradoxical masseteric bulging after botulinum neurotoxin type A injection.

Paradoxical masseteric bulging refers to an unexpected occurrence of masseter muscle bulging or protrusion following the administration of botulinum toxin injections, contrary to the anticipated muscle weakening effect. It may occur secondary to toxin failing to diffuse through the entire masseter muscle due to the presence of an inferior tendon structure within the superficial masseter that divides it into a superficial and deep belly. We report a clinical case of paradoxical masseteric bulging in a female in her late 40s who developed this adverse effect within a week of her masseter botulinum neurotoxin type A injections. We also describe the masseter two-site injection technique for the management of this complication.

Centers for Disease Control and Prevention Clinical Practice Guideline for Prescribing Opioids: United States, 2022: What dentists need to know.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) published the Clinical Practice Guideline for Prescribing Opioids for Pain-United States, 2022 (CDCCPG) to replace the 2016 guideline. This guideline was designed to serve as a clinical tool to improve communication between clinicians and patients and empower them to make informed, person-centered decisions regarding pain management and the prescribing of opioids. It is intended for primary care and other clinicians, including dentists, who provide pain management for adults with acute, subacute, and chronic pain. TYPES OF STUDIES REVIEWED: This article summarizes the CDCCPG, with an emphasis on information of relevance to dentistry. RESULTS: For dentists, the most important recommendations for pain management are that nonsteroidal anti-inflammatory medications are first-line medications for acute dental pain, interdisciplinary care for chronic orofacial pain is indicated, and opioids should only be prescribed for acute dental pain for a maximum of 3 days after risk assessment. PRACTICAL IMPLICATIONS: The CDCCPG contains a great deal of relevant information that can help dentists and dental specialists make safe, effective, and evidence-based decisions in providing pain control for their patients.

Burnout in oral medicine and orofacial pain residents.

BACKGROUND: The authors sought to identify the prevalence of burnout in oral medicine (OM) and orofacial pain (OFP) residents and investigate potential contributing factors. METHODS: A cross-sectional questionnaire-based study was conducted. An anonymous 22-item online survey was emailed to the residents of all Commission on Dental Accreditation-accredited OM and OFP residency programs in the United States. Abbreviated Maslach Burnout Inventory was included to gauge the following details of burnout: emotional exhaustion (EE), depersonalization (DP), and personal accomplishment. Questions also addressed the impact of residency program characteristics, work-life balance, and possible discrimination or abuse on burnout. RESULTS: Six OM and 12 OFP programs (72 residents) were contacted, and 46 residents responded (response rate, 64%). Overall prevalence of burnout was 35% (29% in OM residents, 40% in OFP residents). High EE burnout was noted in 57% of residents, high DP burnout in 11% of residents, and high personal accomplishment burnout in 59% of residents. Working for fewer than 40 hours per week was significantly associated with low DP burnout (P < .05). Moderate to high DP burnout was more prevalent in men and unmarried residents (whether in a relationship or not) were more likely to experience moderate to high EE burnout (P < .05). CONCLUSIONS: Burnout among OM and OFP residents is an emerging concern due to its detrimental effect on the physical and mental well-being of the residents. To the authors' knowledge, this study is the first to report burnout prevalence in the 2 most recent dental specialties recognized by the American Dental Association in 2020. PRACTICAL IMPLICATIONS: Early detection of signs of burnout among residents would allow program faculty and administrators to provide required support and resources.

Pathology Mimicking Orofacial Pain.

A case of a 64-year-old woman is reported, who developed new-onset pain over a preexisting area of right mandibular fullness. Clinical examination, MRI, and fine-needle aspiration cytology confirmed the diagnosis of a benign parotid gland tumor-pleomorphic adenoma, which was treated by total parotidectomy with complete removal of the tumor. When evaluating a patient with orofacial pain, oral health care providers should be cognizant of all potential differential diagnoses, especially in the setting of red flags such as persistent or enlarging facial swelling/fullness.

Oral lichen planus: comparative efficacy and treatment costs-a systematic review.

OBJECTIVE: To compare the reported efficacy and costs of available interventions used for the management of oral lichen planus (OLP). MATERIALS AND METHODS: A systematic literature search was performed from database inception until March 2021 in MEDLINE via PubMed and the Cochrane library following PRISMA guidelines. Only randomized controlled trials (RCT) comparing an active intervention with placebo or different active interventions for OLP management were considered. RESULTS: Seventy (70) RCTs were included. The majority of evidence suggested efficacy of topical steroids (dexamethasone, clobetasol, fluocinonide, triamcinolone), topical calcineurin inhibitors (tacrolimus, pimecrolimus, cyclosporine), topical retinoids, intra-lesional triamcinolone, aloe-vera gel, photodynamic therapy, and low-level laser therapies for OLP management. Based on the estimated cost per month and evidence for efficacy and side-effects, topical steroids (fluocinonide > dexamethasone > clobetasol > triamcinolone) appear to be more cost-effective than topical calcineurin inhibitors (tacrolimus > pimecrolimus > cyclosporine) followed by intra-lesional triamcinolone. CONCLUSION: Of common treatment regimens for OLP, topical steroids appear to be the most economical and efficacious option followed by topical calcineurin inhibitors. Large-scale multi-modality, prospective trials in which head-to-head comparisons interventions are compared are required to definitely assess the cost-effectiveness of OLP treatments.

Detection of circulating tumor human papillomavirus DNA before diagnosis of HPV-positive head and neck cancer.

Human papillomavirus (HPV), most commonly HPV16, causes a growing subset of head and neck squamous cell carcinomas (HNSCCs), including the overwhelming majority of oropharynx squamous cell carcinomas in many developed countries. Circulating biomarkers for HPV-positive HNSCC may allow for earlier diagnosis, with potential to decrease morbidity and mortality. This case-control study evaluated whether circulating tumor HPV DNA (ctHPVDNA) is detectable in prediagnostic plasma from individuals later diagnosed with HPV-positive HNSCC. Cases were participants in a hospital-based research biobank with archived plasma collected ≥6 months before HNSCC diagnosis, and available archival tumor tissue for HPV testing. Controls were biobank participants without cancer or HPV-related diagnoses, matched 10:1 to cases by sex, race, age and year of plasma collection. HPV DNA was detected in plasma and tumor tissue using a previously validated digital droplet PCR-based assay that quantifies tumor-tissue-modified viral (TTMV) HPV DNA. Twelve HNSCC patients with median age of 68.5 years (range, 51-87 years) were included. Ten (83.3%) had HPV16 DNA-positive tumors. ctHPV16DNA was detected in prediagnostic plasma from 3 of 10 (30%) patients with HPV16-positive tumors, including 3 of 7 (43%) patients with HPV16-positive oropharynx tumors. The timing of the plasma collection was 19, 34 and 43 months before cancer diagnosis. None of the 100 matched controls had detectable ctHPV16DNA. This is the first report that ctHPV16 DNA is detectable at least several years before diagnosis of HPV16-positive HNSCC for a subset of patients. Further investigation of ctHPV16DNA as a biomarker for early diagnosis of HPV16-positive HNSCC is warranted.

Effect of COVID-19 on training and mental health of oral medicine residents in North America.

OBJECTIVE: The objective of this study was to assess resident and faculty perception of the effect of the coronavirus disease 2019 pandemic on the training experience, education, and psychological well-being of oral medicine (OM) residents. STUDY DESIGN: An anonymous 16-item online questionnaire was e-mailed to faculty and residents of all Commission on Dental Accreditation-accredited OM residency programs in North America. Survey questions asked about the pandemic's effect on resident educational, clinical, and research activities and the well-being of the residents. Survey data were collected using Qualtrics XM. RESULTS: Forty participants (52.5% residents and 47.5% faculty members) responded to the survey. Regarding the effect on clinical activities, 67.5% reported 50% or less reduction in patient volume seen by residents at its worst during the pandemic. With respect to educational activities, most reported a complete switch of didactic training (85.3%), academic examinations (60%), and off-site resident rotations (45%) to a virtual platform. Research activities were affected the most; 55% reported complete cessation for some time. Thirty-three percent perceived a negative effect, 18% perceived no effect, 11% perceived a positive effect, and 38% were unsure regarding the effect of coronavirus disease 2019 on resident morale. Despite the interruptions in the clinical, research, and educational activities, 62.5% expected on-time resident graduation. CONCLUSION: Despite constraints due to the pandemic, OM residency programs successfully continued clinical activities, didactic training, and research productivity through virtual means and a hybrid delivery care model while supporting their residents' morale.

Osteonecrosis of the jaw secondary to haematopoietic stem cell transplantation.

Osteonecrosis of the jaw (ONJ) is necrosis of mandibular or maxillary bone, which sometimes leads to bone exposure and sequestration. There is evidence that the microenvironment of the marrow stromal system is severely and irreversibly damaged after haematopoietic stem cell transplantation (HSCT) leading to a deficit in the quantity and quality of osteoblastic progenitors, compromising the ability to regenerate a normal osteogenic cell population and abnormality in bone remodelling/turnover. While osteonecrosis of the appendicular skeleton is a common complication after HSCT, there have been no reports of an association with ONJ. This is a report of the first case of ONJ secondary to HSCT in a 69-year-old woman who developed a unique pattern of osteonecrosis involving all four quadrants of the jaw 2 months after allogeneic stem cell transplantation.

Osteonecrosis of the jaw and dental extractions: A single-center experience.

OBJECTIVE: The aim of this study was to investigate the frequency of osteoradionecrosis/medication-related osteonecrosis of the jaw (ORN/MRONJ) after dental extraction with use of postextraction antibiotic coverage without prophylactic hyperbaric oxygen (HBO) in patients who received radiotherapy to head and neck (RT-HN) or antiresorptive medications and to determine possible associated factors. STUDY DESIGN: A retrospective study was conducted in patients who had a history of RT-HN or exposure to antiresorptives and who underwent dental extractions from 2003 to 2019. According to the clinical protocol, patients received amoxicillin 500 mg, 3 times daily (TID) for at least 14 days, and chlorhexidine 0.12% rinses, 2 times daily (BID), after extraction (or an alternative antibiotic if allergic to amoxicillin). HBO was not used for patients with RT-HN. RESULTS: Ninety patients underwent a total of 243 extractions. Fifty patients (55.5%) received a median of 54.1 Gray to the extraction site and 40 (44.4%) were on antiresorptives. None of the patients received both RT and antiresorptives. Of 40 patients, 3 (7.5%) developed MRONJ, and of 50 patients, 1 (2%) developed ORN. Among those at risk for MRONJ, male gender and concomitant immunosuppressant medications were associated with MRONJ development (P < .05). CONCLUSIONS: In our patient cohort, the rate of postextraction ORN/MRONJ was lower and comparable with the rates reported in the literature. Larger prospective studies are required to validate the efficacy of postextraction antibiotics in reducing ONJ.

Bleeding risk in thrombocytopenic patients after dental extractions: a retrospective single-center study.

OBJECTIVE: The aim of the present study was to assess the clinical safety profile of dental extractions in patients with thrombocytopenia and explore the effectiveness of platelet transfusion before dental extractions. STUDY DESIGN: This is a retrospective cohort study of patients with moderate to severe (≤100,000/µL) thrombocytopenia who underwent dental extractions in the Oral Medicine and Dentistry Clinic at Brigham and Women's Hospital from 2003 to 2019. Patients with a platelet count <30,000/µL received prophylactic preprocedure platelet transfusion. Risk and type of bleeding complication (prolonged postoperative bleeding requiring intervention with topical hemostatic agents and/or therapeutic platelet transfusions) was assessed. RESULTS: Eighty-nine thrombocytopenic patients were identified. Postextraction bleeding complications occurred in 4 patients (4.4%). Surgical extractions and multiple number of extractions were significantly associated with an increased bleeding risk (P < .05), whereas prophylactic platelet transfusion and post-transfusion platelet count were not. CONCLUSIONS: Dental extractions in patients with thrombocytopenia may be performed with a positive safety profile by following a comprehensive medical evaluation, thorough treatment planning, adequate surgical management, use of local hemostatic measures, and, importantly, coordination of care with the patient's medical team.

Progression of Self-Assembly of Amelogenin Protein Supramolecular Structures in Simulated Enamel Fluid.

Mechanisms of protein-guided mineralization in enamel, leading to organized fibrillar apatite nanocrystals, remain elusive. In vitro studies reveal recombinant human amelogenin (rH174), a matrix protein templating this process, self-assembles into a variety of structures. This study endeavors to clarify the self-assembly of rH174 in physiologically relevant conditions. Self-assembly in simulated enamel fluid was monitored up to 2 months. At alkali (7.3-8.7) and acidic (5.5-6.1) pH ranges, a distinct progression in formation was observed from nanospheres (17-23 nm) to intermediate-length nanorods, concluding with the formation of long 17-18 nm wide nanoribbons decorated with nanospheres. Assembly in acidic condition progressed quicker to nanoribbons with fewer persistent nanospheres. X-ray diffraction exhibited reflections characteristic of antiparallel ß-sheets (4.7 and 9.65 Å), supporting the model of amyloid-like nanoribbon formation. This is the first observation of rH174 nanoribbons at alkaline pH as well as concurrent nanosphere formation, indicating both supramolecular structures are stable together under physiological conditions.