The TMD management dilemma.

As temporomandibular disorders (TMDs) become ever more prevalent in both primary and secondary care settings, successful management is increasingly challenging in both sectors. The authors aim to explore the dilemma of TMD management as the patient journeys through from primary to secondary care and offer educational tools to support practitioners in managing this complex patient cohort, as well as outlining alternative solutions for the delivery of TMD management strategies.

The use of liquid formulation pentoxifylline and vitamin E in both established and as a prophylaxis for dental extractions "at risk" of osteoradionecrosis.

BACKGROUND: Osteoradionecrosis (ORN) of the jaws remains one of the most debilitating complications of radiotherapy (RT) in patients with head and neck cancer (HNC). Liquid pentoxifylline and vitamin E (PVe) presents an alternative formulation to tablets for patients with dysphagia or enteric feeding. OBJECTIVE: This study aimed to assess the clinical outcomes of using a liquid formulation of PVe for both established ORN and as a prophylaxis to avoid its occurrence after dental extractions. A secondary objective was to determine patient-reported side effects in relation to the liquid formulation of PVe. STUDY DESIGN: The clinical records of 111 patients with HNC who were prescribed liquid PVe were reviewed retrospectively (66 with established ORN and 45 as prophylaxis before an invasive dental procedure). RESULTS: In established ORN, 44% healed, and 41% were stable. In the prophylaxis group, 96% of surgical sites healed completely, with 4% (n = 2) developing ORN. Most patients (89%) were able to tolerate liquid PVe. Of the 11% (n = 12) who could not tolerate this regime, the most commonly reported side effect was gastric irritation (n = 5/12), whereas no more than 1 patient reported dizziness, malaise, and bleeding. CONCLUSIONS: This retrospective review suggests that liquid PVe is efficacious for both established ORN and as a prophylaxis. Side effects reported were similar to those recognized for the tablet formulation.

Prophylactic pentoxifylline and vitamin E use for dental extractions in irradiated patients with head and neck cancer.

OBJECTIVE: Osteoradionecrosis (ORN) of the jaw is preceded by dental extractions in up to 10% of cases. We present a case series of post-radiotherapy patients undergoing dental extractions who have received the prophylactic antifibrotic agents pentoxifylline and vitamin E (PVe) to prevent ORN. STUDY DESIGN: A retrospective review was conducted of 219 patients with head and neck cancer (HNC) undergoing 1079 dental extractions between 2009 and 2020. Data regarding oncological treatment, prophylactic drug regimen, dental history, and clinical outcome was collected. RESULTS: Twelve patients developed ORN at 17 extraction sites (ORN rates, 1.6% and 5.5% at tooth level and patient level, respectively). PVe regimen compliance significantly decreased ORN rates at the patient level (3.4% vs 11.5%; P < .03) and the tooth level (1.0% vs 3.5%; P < .01) compared with no PVe. Regimen compliance significantly reduced ORN rates in patients with oropharyngeal cancer (P < .01); in those with mandibular (P < .005) molar (P < .003), and flapless extractions (P < .04); in patients with radiation regions >40 Gy (P < .0009); and in those who underwent primary closure (P < .03). Machine learning analysis identified almost all these factors as influential at a tooth level for ORN. CONCLUSIONS: PVe regimen compliance decreased dental extraction ORN rates more than the literature base rates of 7% at the patient level and 2% at the tooth level. Given its success in managing existing ORN, PVe could be extended prophylactically for dental extractions in irradiated patients with head and neck cancer.

Diffuse sclerosing osteomyelitis: a case series and literature review.

OBJECTIVE: Diffuse sclerosing osteomyelitis (DSO) is a poorly understood chronic inflammatory disease, for which many etiologic theories and treatment modalities have been suggested. We retrospectively evaluated bisphosphonate treatment outcomes in patients with DSO and compared them with those of alternative treatment modalities and those reported in the current literature. STUDY DESIGN: This series was a retrospective analysis of patients diagnosed with DSO of the mandible. We identified a total of 11 DSO cases at Guys Dental Hospital from 1996 to 2017. Data on all treatment modalities attempted during this time were collected, with a focus on patients who underwent management with oral bisphosphonates. RESULTS: Eight of 11 patients who continued to have symptoms after failure of previous interventions were prescribed alendronic acid (70 mg once weekly) for an average of 16 months. All patients reported improvement or resolution of symptoms within 72 hours. Three patients ceased medication at 4 weeks because of medication side effects. The remaining 5 patients reported improved symptom control in comparison with prior treatment regimes. CONCLUSIONS: Oral bisphosphonates appear to provide prolonged symptom relief in patients with DSO compared with previously attempted treatment strategies; however, the exact regimen and length of use is still being debated. The positive impact of bisphosphonates may provide a potential insight into the pathophysiology of DSO.

Coronectomy root retrievals: a review of 92 cases.

BACKGROUND: Coronectomy has become an increasingly prescribed surgical treatment for mandibular third molars that are deemed to pose a risk to the inferior dental nerve. Retention of the roots poses a risk of need for root retrieval in the future if symptoms are present. Long-term outcomes and the symptoms that lead to root retrieval via coronectomy have not been well documented or studied, and this has understandably led to hesitation in some clinicians in offering the procedure. The current series assesses patients who have undergone root retrieval, their reported indications for removal, and the histopathologic status of the removed roots. STUDY DESIGN: A total of 92 cases of root retrievals via coronectomy carried out at Guy's Dental Hospital are included in this analysis. Data were collected retrospectively from patient records regarding patient symptoms, clinical and radiographic findings, function of the inferior dental nerve, and histologic results. RESULTS: The mean age of patients in the study group was 31.6 years (range 19-70 years), with a female-to-male ratio of 62:18 (77.5% female). Mean time to the second surgery for root retrieval was 17 months. In "successfully" performed coronectomies, 75.3% (61 of 81) of root pulps appeared vital histopathologically. Mucosal tenderness (39 of 81 [48.1%]) was the most common symptom leading to root retrieval. CONCLUSIONS: Root retrieval after coronectomy should be based on findings from sound clinical and radiographic examinations. In the presence of obvious indications, such as an unhealed socket resulting from retained enamel or soft tissue infection after eruption of roots, then retrieval should be performed with confidence that resolution would occur. However, if the coronectomy root appears an unlikely culprit, then the clinician should consider and investigate alternative diagnoses, such as overerupted upper third molars causing trauma, temporomandibular dysfunction, and the dental status of the adjacent tooth as potential causes of symptoms.

Congenital Epidermoid Cyst Presenting as Isolated Painful Trigeminal Neuropathy: Indications for Neuroimaging in the Diagnostic Process.

This article reports a case of a cerebellopontine angle epidermoid cyst presenting as isolated painful trigeminal neuropathy. The indolent nature of these uncommon benign tumors leads to frequent delays in their presentation and diagnosis, with patients often initially undergoing dental procedures. This is illustrated in the present case reported here, which highlights the difficulties in identifying trigeminal neuralgia (TN), particularly in its early phases, and supports current recommendations for routine neuroimaging in suspected cases of painful trigeminal neuropathy, which, unlike classic TN, is caused by a disorder other than neurovascular compression (even in the absence of additional neurologic symptoms or signs) and is present particularly in younger patients with atypical features. Additionally, this case report offers a unique patient perspective of living with TN, with a detailed description by one of the authors of the nature of the pain and its impact.

Methotrexate-associated osteonecrosis of the jaw: A report of two cases.

There has been a rise in medication-related osteonecrosis of the jaw (MRONJ) predominantly related to antiresorptive and antiangiogenic medications. More evidence is revealing that MRONJ is not limited to these drug groups. With the introduction of newer and varied medications used in the treatment of cancer and autoimmune diseases, reports of possible related osteonecrosis of the jaw (ONJ) are also on the rise. We present 2 cases of ONJ in patients with long-standing arthritis treated with methotrexate in the absence of a lymphoproliferative disorder and antiresorptive or antiangiogenic medications.

Axitinib-related osteonecrosis of the jaw.

Tyrosine kinase inhibitors (TKIs) are oral chemotherapy drugs used primarily to treat leukemias, renal cell carcinomas, gastrointestinal stromal tumors, and neuroendocrine tumors. Within this group, a number of drugs have already been implicated in jaw necrosis. Axitinib (Inlyta) is a novel TKI currently licensed for the treatment of renal cell carcinoma. We report the first case, to our knowledge, of jaw necrosis solely related to this medication and review the literature surrounding TKIs and their implication in osteonecrosis of the jaw.

Coronectomy and dentigerous cysts: a review of 68 patients.

OBJECTIVE: This large case series retrospectively reviewed the outcomes of coronectomy in conjunction with dentigerous cyst removal in 68 patients at the oral surgery department of Guy's Hospital. STUDY DESIGN: A retrospective review of 68 patients was undertaken in a single department where 73 teeth with associated dentigerous cysts were treated by coronectomy to reduce the risk of inferior alveolar nerve injury or mandibular fracture. RESULTS: One patient experienced permanent injury of the inferior alveolar nerve. There were no intraoperative mandibular fractures in this series. Four coronectomy roots required retrieval at 2, 4, and 20 months and 10 years after the initial surgery due to persistent surgical site infection and incomplete coronectomy with retained enamel and associated cystic tissue leading to symptoms. The longest follow-up in this series was 10 years for 2 patients, and 30 of 68 patients were reviewed between 1 and 3 years postoperatively. CONCLUSION: Coronectomy in conjunction with dentigerous cysts is an effective treatment, with minimal morbidity seen in both short- and long-term periods.

Osteoradionecrosis following treatment for head and neck cancer and the effect of radiotherapy dosimetry: the Guy's and St Thomas' Head and Neck Cancer Unit experience.

OBJECTIVES: To analyze clinical features, dosimetric parameters, and outcomes of osteoradionecrosis (ORN). STUDY DESIGN: Thirty-six patients with ORN who had been previously treated with radiotherapy (RT) were retrospectively identified between January 2009 and April 2014. ORN volumes were contoured on planning computed tomography (CT) scans. Near maximum dose (D2%), minimum dose (Dmin), mean dose (Dmean), and percentage of bone volume receiving 50 Gy (V50) were examined. Clinical and dosimetric variables were considered to compare ORN resolution versus ORN persistence. RESULTS: Median interval time from end of RT to development of ORN was 6 months. Of the ORN cases, 61% were located in the mandible. Dmean to affected bone was 57.6 Gy, and 44% had a D2% 65 Gy or greater. Smoking was associated with ORN persistence on univariate analysis, but no factors were found to impact ORN resolution or progression on logistic regression. CONCLUSIONS: Prevention strategies for ORN development should be prioritized. Dose-volume parameters could have a role in preventing ORN.

Prophylactic use of pentoxifylline and tocopherol in patients who require dental extractions after radiotherapy for cancer of the head and neck.

Osteoradionecrosis (ORN) is a complication seen intermittently in patients who have had radiotherapy to the head and neck, and results of treatment with pentoxifylline and tocopherol (PVe) have been encouraging. As a consequence, some argue that this should be used prophylactically to lower the risk of ORN after dental extractions in this group. We retrospectively analysed data on 390 dental extractions in 82 patients who had had radiotherapy for cancer of the head and neck. Each had been given PVe prophylactically. Only one patient (1.2%) developed ORN (rate/tooth 0.26%). Patients had taken PVe for a mean (SD) of 11 (23) weeks preoperatively and 13.6 (18) weeks postoperatively. The incidence we found was lower than that normally associated with dental extractions in irradiated patients (7%).

Use of pentoxifylline and tocopherol in the management of osteoradionecrosis.

Osteoradionecrosis (ORN) is a complication of radiotherapy, and is difficult to manage once established. However, its pathogenesis has been reinvestigated, and it is now thought to be potentially amenable to treatment with pentoxifylline and tocopherol (vitamin E). We made a retrospective analysis of 62 patients with established ORN who were treated in this way. When only pentoxifylline and vitamin E was used ORN resolved in 14/25 (56%) but paradoxically, when it was combined with antibiotics, only 6/22 resolved (27%). The next stage would ideally be to incorporate the treatment in a randomised clinical trial against both standard antibiotic treatment and hyperbaric oxygen.

Spontaneous Osteonecrosis of the Maxilla.

In the past decade there has been a rise of osteonecrosis of the jaws (ONJ) predominately related to bisphosphonate therapy and osteoradionecrosis secondary to radiotherapy. However, osteonecrosis can occur in the absence of these agents. A case of idiopathic osteonecrosis of the maxilla is reported and the literature discussed. Clinical relevance: It is not always possible to make a definitive diagnosis.

Primary Extranodal Non-Hodgkin Lymphoma in the Infra-Orbital Region ­ A Diagnostic Challenge.

Lymphomas within the head and neck region (HNR) are relatively uncommon; however, they can mimic common odontogenic conditions leading to diagnostic delays and subsequently the implementation of treatment. We report a case of a chronic infra-orbital swelling which, following excision, was diagnosed as an extranodal low grade Non-Hodgkin lymphoma. This paper explains the mode of presentation of extranodal lymphomas in the HNR, so that dental practitioners may consider it as a potential diagnosis when presented with a lump in the HNR. Clinical relevance: Extranodal lymphomas presenting within the head and neck region can have a multitude of clinical presentations, which may often resemble odontogenic conditions. This can cause confusion, resulting in diagnostic delays and treatment. This case highlights the importance of being aware of the features of extranodal lymphoma in the head and neck region, and the diagnostic challenges that may be encountered.

Histological evaluation of mandibular third molar roots retrieved after coronectomy.

There is a resurgence of interest in coronectomy for the management of mandibular third molars because it has a low risk of injury to the inferior dental nerve. However, there is concern that the root that is left in place will eventually become a source of infection. We describe the histological evaluation of 26 consecutive symptomatic coronectomy roots in 21 patients. All roots had vital tissue in the pulp chamber and there was no evidence of periradicular inflammation. Persistent postoperative symptoms related predominantly to inflammation of the soft tissue, which was caused by partially erupted roots or failure of the socket to heal.

To retrieve or not to retrieve the coronectomy root--the clinical dilemma.

UNLABELLED: Coronectomy of mandibular third molars is a well established technique that is going through a resurgence as it seems to reduce the risk of inferior dental nerve (IDN) injury. The reservation with the technique arises because of fear that the retained root will become infected and symptomatic over time. General dental practitioners will be responsible for the long-term review and care of these patients and, consequently, it is important that they are aware of the technique and its sequelae. CLINICAL RELEVANCE: Coronectomy of mandibular third molars to avoid nerve injury is becoming increasingly popular. It is important that general dental practitioners (GDPs) are aware of the immediate and later sequelae of treatment and the implication of the retained root.

Unerupted teeth associated with dentigerous cysts and treated with coronectomy: mini case series.

There is a resurgence of interest in coronectomy, but its appropriate application in the management of third molar teeth has yet to be defined. Dentigerous cysts associated with unerupted teeth are most commonly associated with mandibular third molars. In this case series we evaluate outcome after coronectomy of teeth with associated dentigerous cysts in cases where the inferior dental nerve was thought to be at risk, or there was an increased risk of mandibular fracture. We retrospectively studied 21 consecutive patients treated by coronectomy for dentigerous cysts at the Oral Surgery Department at Guy's Hospital. The most commonly affected teeth were mandibular third molars (20/21). One patient had permanent injury to the inferior dental nerve, but no mandibular fracture or recurrence of cyst was reported. One patient required secondary retrieval of the retained root because of eruption. Coronectomy of unerupted teeth associated with dentigerous cysts is an effective treatment when there is high risk of injury to the inferior dental nerve injury or potential for mandibular fracture. Further work with larger numbers and longer follow-up is required to discover the long-term outcome of the electively retained root.

Coronectomy practice. Paper 2: complications and long term management.

Coronectomy was developed to reduce the incidence of iatrogenic injury to the inferior dental nerve, which can be a result of routine mandibular third molar surgery, but it is not widely accepted despite early studies that all showed positive results. This two-part paper looks at the technique in more detail to help clinicians gain a better understanding of the procedure. The first part dealt in detail with technical aspects. This one will consider the management of common complications.

Coronectomy practice. Paper 1. Technique and trouble-shooting.

Coronectomy is a technique that reduces morbidity of the nerve after operation on high-risk mandibular third molars. This two-part paper aims to give an overview of the technique and a description of common problems that can be encountered during and after operation. In this paper we discuss the technique as an overview and then each type of impaction more specifically. We also explore common problems encountered during the procedure and their subsequent management.