Country data on AMR in Saudi Arabia in the context of community-acquired respiratory tract infections: links between antibiotic susceptibility, local and international antibiotic prescribing guidelines, access to medicine and clinical outcome.

BACKGROUND: Antimicrobial resistance (AMR) is one of the biggest threats to global public health. Selection of resistant bacteria is driven by inappropriate use of antibiotics, amongst other factors. COVID-19 may have exacerbated AMR due to unnecessary antibiotic prescribing. Country-level knowledge is needed to understand options for action. OBJECTIVES: To review AMR in Saudi Arabia and initiatives addressing it. Identifying areas where more information is required will provide a call to action to minimize a further rise in AMR within Saudi Arabia and improve patient outcomes. METHODS: National AMR initiatives, antibiotic use and prescribing, and availability of susceptibility data, particularly for the key community-acquired respiratory tract infection (CA-RTI) pathogens Streptococcus pneumoniae and Haemophilus influenzae, were identified. National and international antibiotic prescribing guidelines commonly used locally for specific CA-RTIs (community-acquired pneumonia, acute otitis media and acute bacterial rhinosinusitis) were also reviewed, plus local antibiotic availability. Insights from a clinician in Saudi Arabia were sought to contextualize this information. CONCLUSIONS: Various initiatives are underway in Saudi Arabia, including a National Action Plan for AMR, which was published in 2017. However, AMR is rising and knowledge about appropriate antibiotic use seems to be lacking among physicians and the general public. Various international guidelines are utilized by clinicians in Saudi Arabia, but a more standardized inclusive approach in developing local guidelines, using up-to-date surveillance data of isolates from community-acquired infections in Saudi Arabia could make management guideline use more locally relevant for clinicians. This would pave the way for a higher level of appropriate antibiotic prescribing and improved adherence. This would, in turn, potentially limit AMR development and improve patient outcomes.

Evaluation of bone regenerative capacity in rats claverial bone defect using platelet rich fibrin with and without beta tri calcium phosphate bone graft material.

AIM: To compare bone regeneration in noncritical rat calvarial bone defects filled with platelet-rich fibrin (PRF), alone or combined with beta-tricalcium phosphate (ß-TCP), using micro-computed tomographic (MCT) evaluation. ANIMALS AND METHODS: Two calvarial bone defects were created in each of 45 male Sprague-Dawley rats (age: 20-22 weeks, weight: 350-450 g), using a dental trephine with an external diameter of 3 mm. The 90 defects were randomly allocated among three groups, each containing 30 unilateral defects in a total of 30 rats. Defects in the control group were allowed to heal spontaneously. Defects in the PRF group received PRF alone. Defects in the PRF/ß-TCP group received PRF mixed with ß-TCP in a 50⧹50 percentage. Nine animals (three per group) were killed after 1, 2, 3, 4, and 6 postoperative weeks, and 18 calvarial defects from each period were analyzed for new bone formation and bone mineral density using MCT. Results were compared by a one-way Analysis of Variance with the POST HOC Least Significant Difference test. RESULTS: The volume and mineral density of bone formed in the control group were significantly different from those of the other two groups. Greater bone regeneration was observed in defects receiving PRF with ß-TCP compared to defects receiving PRF alone in the first 2 weeks (P < 0.001). However, differences in the volume and density of newly formed bone between the PRF and PRF/ß-TCP groups were not significant at 3, 4, and 6 postoperative weeks (P > 0.005). CONCLUSION: The addition of ß-TCP to PRF significantly improved bone regeneration in the first 2 weeks after surgery. Although the differences between results with and without the addition of ß-TCP to PRF were statistically insignificant from weeks 3 to 6, it was nevertheless apparent that the group receiving the combination showed better results. We suggest a synergistic mechanism for this effect.

Changes in quality of life after orthognathic surgery in Saudi patients.

AIM: This study was conducted to measure the impact of orthognathic surgery on quality of life in Saudi patients. MATERIALS AND METHODS: Patients with a discrepancy of 5 mm or more who underwent orthognathic surgery either single jaw or bimaxillary at the Department of Oral and Maxillofacial Surgery, College of Dentistry, King Saud University, between September 2007 and June 2013 were included in the study. They were asked to complete the Arabic version of the 22-item Orthognathic Quality of Life Questionnaire (OQLQ) preoperatively and postoperatively. Responses at these two timepoints were compared using paired t-tests, with the significance level set to P < 0.05. RESULTS: Seventeen patients participated in the study. Total OQLQ scores and those in the instrument's four domains (oral function, facial aesthetics, awareness of dentofacial aesthetics, and social aspects) indicated that quality of life was significantly improved by orthognathic surgery (all P < 0.001). The social aspect domain was shown to be more important for patients than were facial aesthetics and oral function. CONCLUSION: The present study revealed highly significant improvement in Saudi patients' quality of life following orthognathic surgery. This improvement was evident in all four OQLQ domains.

Dental extraction in patients on warfarin treatment.

BACKGROUND: Warfarin is one of the most common oral anticoagulants used to prevent thromboembolic episodes. The benefits of discontinuation of this drug before simple surgical procedures are not clear and this approach could be associated with complications. The aim of this study was to evaluate the risk of bleeding in a series of 35 patients (in cases where the international normalized ratio [INR] is less than 4) following simple tooth extraction without modification of the warfarin dose given to patients. METHODS: Thirty-five patients taking warfarin who had been referred to the Oral and Maxillofacial Department, College of Dentistry, King Saud University, for dental extractions were included in the study. Exclusion criteria included patients with an INR of ≥4 or with a history of liver disease or coagulopathies. No alteration was made in warfarin dose, and the CoaguChek System was used to identify the INR on the same day of dental extraction. Bleeding from the extraction site was evaluated and recorded immediately after extraction until the second day. RESULTS: A total of 35 patients (16 women and 19 men) aged between 38 and 57 years (mean =48.7) were included in the present study. All patients underwent simple one-tooth extraction while undergoing warfarin treatment. Oozing, considered mild bleeding and which did not need intervention was seen in 88.6% of patients. Moderate bleeding occurred in 11.4% of all cases. The INR of the patients ranged from 2.00 to 3.50, with 77.2% of patients having INR between 2.0 and 2.5 on the day of extraction. No severe bleeding which needed hospital management was encountered after any of the extractions. The patients who suffered moderate bleeding were returned to the clinic where they received local treatment measures to control bleeding. Moderate bleeding occurred only in four patients, where three had INR between 3.1 and 3.5, and one with INR less than 3. CONCLUSION: In the present study, we have shown that simple tooth extraction in patients on warfarin treatment can be performed safely without high risk of bleeding, providing that the INR is equal or less than 3.5 on the day of extraction. A close follow-up and monitoring of patients taking warfarin is mandatory after dental extraction.

The effects of surgicel and bone wax hemostatic agents on bone healing: An experimental study.

BACKGROUND: The biological effects of hemostatic agends on the physiological healing process need to be tested. The aim of this study was to assess the effects of oxidized cellulose (surgicel) and bone wax on bone healing in goats' feet. MATERIALS AND METHODS: Three congruent circular bone defects were created on the lateral aspects of the right and left metacarpal bones of ten goats. One defect was left unfilled and acted as a control; the remaining two defects were filled with bone wax and surgicel respectively. The 10 animals were divided into two groups of 5 animals each, to be sacrificed at the 3(rd) and 5(th) week postoperatively. Histological analysis assessing quality of bone formed and micro-computed tomography (MCT) measuring the quantities of bone volume (BV) and bone density (BD) were performed. The results of MCT analysis pertaining to BV and BD were statistically analyzed using two-way analysis of variance (ANOVA) and posthoc least significant difference tests. RESULTS: Histological analysis at 3 weeks showed granulation tissue with new bone formation in the control defects, active bone formation only at the borders for surgicel filled defects and fibrous encapsulation with foreign body reaction in the bone wax filled defects. At 5 weeks, the control and surgicel filled defects showed greater bone formation; however the control defects had the greatest amount of new bone. Bone wax filled defects showed very little bone formation. The two-way ANOVA for MCT results showed significant differences for BV and BD between the different hemostatic agents during the two examination periods. CONCLUSION: Surgicel has superiority over bone wax in terms of osseous healing. Bone wax significantly hinders osteogenesis and induces inflammation.

Evaluation of bone regenerative capacity following distraction osteogenesis of goat mandibles using two different bone cutting techniques.

PURPOSE: To compare the regenerative capacity of goat mandibles following sagittal split osteotomy and distraction osteogenesis with a vertical body osteotomy. ANIMALS AND METHODS: Bilateral vertical and sagittal body osteotomy was performed on the left and right sides of the mandibles in 18 goats. The distraction period lasted for 10 days at 1 mm/day. Animals were sacrificed at 0, 10, and 35 days post-distraction. Bone mineral density (BMD) and bone volume (BV) were analysed by microcomputed tomography (MCT). Types of bone and cells present in the regenerated defect sites were analysed histologically. RESULTS: At 0, 10, and 35 days, BMD was 0.358 ± 0.012, 0.410 ± 0.012, and 1.070 ± 0.019, respectively, for vertical osteotomy and 0.420 ± 0.013, 0.421 ± 0.009 and 1.182 ± 0.030, respectively, for sagittal osteotomy. BV was 973.310 ± 5.048, 1234.589 ± 4.159, and 2121.867 ± 6.519, respectively, for vertical osteotomy and 995.967 ± 2.781, 1755.938 ± 4.379, and 2618.441 ± 21.429, respectively, for sagittal osteotomy at these three time points. BMD and BV differed significantly at all three times. Histological analysis shows that sagittal splitting was characterized by more robust lamellar bone formation bridging the distraction gap than vertical body osteotomy. CONCLUSION: Both MCT and histological analyses showed that distraction using the sagittal osteotomy technique resulted in significantly higher BV and BMD than using vertical body osteotomy.

Modifying gummy smile: a minimally invasive approach.

AIM: Excessive gingival display is a problem that can be managed by variety of procedures. These procedures include non-surgical and surgical methods. The underlying cause of gummy smile can affect the type of procedure to be selected. Most patients prefer minimally invasive procedures with outstanding results. The authors describe a minimally invasive lip repositioning technique for management of gummy smile. MATERIALS AND METHODS: Twelve patients (10 females, 2 males) with gingival display of 4 mm or more were operated under local anesthesia using a modified lip repositioning technique. Patients were followed up for 1, 3, 6 and 12 months and gingival display was measured at each follow up visit. The gingival mucosa was dissected and levator labii superioris and depressor septi muscles were freed and repositioned in a lower position. The levator labii superioris muscles were pulled in a lower position using circumdental sutures for 10 days. Both surgeon's and patient's satisfaction of surgical outcome was recorded at each follow-up visit. RESULTS: At early stage of follow-up the main complaints of patients were the feeling of tension in the upper lip and circum oral area, mild pain which was managed with analgesics. One month postoperatively, the gingival display in all patients was recorded to be between 2 and 4 mm with a mean of (2.6 mm). Patient satisfaction records after 1 month showed that 10 patients were satisfied with the results. Three months postoperatively, the gingival display in all patients was recorded and found to be between 2 and 5 mm with a mean of 3 mm. Patient satisfaction records showed that 8 patients were satisfied with the results as they gave scores between. Surgeon's satisfaction at three months follow up showed that the surgeons were satisfied in 8 patients. The same results were found in the 6 and 12 months follow-up periods without any changes. Complete relapse was recorded only in one case at the third postoperative month. CONCLUSION: This study showed that the proposed lip repositioning technique is an acceptable minimally invasive procedure in managing gummy smile. CLINICAL SIGNIFICANCE: A non-invasive procedure to avoid other complicated surgical procedures.

Patterns and etiology of maxillofacial fractures in Riyadh City, Saudi Arabia.

OBJECTIVE: The aim of the present study was to study the etiologies and patterns of maxillofacial fractures in patients treated in Riyadh City, Saudi Arabia, between 2007 and 2011. PATIENTS AND METHODS: Data were obtained through a retrospective review of 237 patients admitted to the King Saud Medical City Dental Department with a diagnosis of maxillofacial trauma. After excluding patient files with incomplete or unclear records, and cases in which computed tomography showed no evidence of fracture, the files of 200 patients with a diagnosis of maxillofacial fracture were included in the study. For each case, patient's sex and age, pattern of facial fractures, and cause of injury were recorded on a data sheet. The data were transferred to an SPSS (ver. 16.0; SPSS Inc., Chicago, IL, USA) spreadsheet for statistical analysis. The chi-square test was used to test the association between two categorical variables or factors (age group, cause) with p value set at p<0.05, and t-test value at <0.05 and independent. RESULTS: Motor vehicle accidents were the most common cause of maxillofacial fractures in most age groups, especially in males. Within the study sample, mandibular fractures were significantly more common than middle-third facial fractures (56.4% vs. 43.6%; p=0.006). Among mandibular fractures, parasymphyseal fractures were most common (47%), followed by condylar fractures (35.3%). Most (77.2%) middle-third facial fractures involved the zygomatic complex, and the incidence of such fractures differed significantly between male and female patients. p=0.72, not significant. CONCLUSION: Males were more prone to maxillofacial fractures, perhaps as a result of the conservative nature of Saudi society, as the rules of Saudi Arabia do not allow the females to drive. Motor vehicle accidents were the most common cause of maxillofacial fractures in patients aged 10-29 years, indicating the high demand for the application of stricter traffic rules to reduce the rate of such accidents.

Anesthetic management of a patient with Bartter's syndrome undergoing bilateral sagittal split osteotomy.

Bartter's syndrome is an unusual (estimated incidence is 1.2 per million people) but important congenital form of secondary hyperaldosteronism; due to abnormalities in renal handling of electrolytes. It is associated with hypertrophy and hyperplasia of the juxtaglomerular cells, normal blood pressure, and hypokalemic alkalosis withoutedema.We present a 22-year-old woman with Bartter's syndrome underwent bilateral sagittal split osteotomy to correct mandibular prognathic. The anesthetic management of Bartter's syndrome should be relevant to the pathophysiology of the syndrome. Therefore, it should be directed toward maintaining cardiovascular stability, control of associated fluid, electrolyte and acid-base derangements, and the prevention of renal damage.

Surgical treatment of keratocystic odontogenic tumour: A review article.

KCOT is one of the most aggressive odontogenic cysts with a high recurrence rate, this was explained histopathologically as it typically shows a thin, friable wall, which is often difficult to enucleate from the bone in one piece, and have small satellite cysts within the fibrous wall. Multiple surgical approaches were introduced including decompression, marsupilization, enucleation with or without adjunct (Carnoy's solution, enucleation) and resection. Depending on other studies KCOT can be conservatively treated with enucleation and application of Carnoy's solution or cryotherapy. This can be used specially in the large lesions that when treated with resection, the continuity of the jaw will be interrupted. This technique shows comparable results to other more aggressive techniques.

The use of a single titanium microplate in displaced pediatric parasymphysial mandibular fractures.

OBJECTIVE: The objective of this study was to evaluate the use of one titanium microplate in the fixation of displaced pediatric parasymphysial mandibular fractures. MATERIALS AND METHODS: The study was conducted on 7 children in the mixed dentition stage with displaced parasymphysial fracture. Patients' age ranged between 5 years 9 months and 8 years 4 months with an average of 7 years 1 month. Fractured bone segments were exposed, reduced and then fixed using 1.5 linear microplates at the inferior border of the mandible using monocortical screws, with 1.5 mm in diameter and 5 mm in length. Stainless steel wire was used as a tension band by ligating the teeth around the fracture line. Patients were followed up for occlusion and stability clinically and radiographically (panoramic X-ray and CT). RESULTS: According to clinical and radiographic post-operative follow-up, none of the patients showed displacement of the fixed bony segments. CONCLUSION: The present study concluded that using one microplate with 1.5 monocortical microscrews and dental tension band by a stainless steel wire could be adequate for fixing displaced pediatric parasymphysial mandibular fractures. This technique has the following advantages: decreases the amount of titanium used, decreases the risk of injury of the roots and teeth buds, and decreases the cost and time of surgery.