Medication-related osteonecrosis of the jaws: a single centre, Far North Queensland case series.

Medication-related osteonecrosis of the jaws (MRONJ) is a painful debilitating condition which is considered rare in the medical literature available to prescribers. Dentists, however, are likely to trigger this condition through extractions and implants. Anecdotally MRONJ appears more common than first thought. This paper presents 13 cases of MRONJ diagnosed and treated by a single oral and maxillofacial surgeon based in Cairns, Far North Queensland, in a 2-year period. The management of these cases is presented. The two cases where MRONJ resulted in the loss of dental implants are highlighted. © 2022 Australian Dental Association.

A Modified Technique of Temporomandibular Joint Arthroscopic Operative Surgery of the Superior and Inferior Joint Spaces.

PURPOSE: This paper describes in detail the first author's technique of performing arthroscopic surgery in both the superior and inferior joint spaces of the temporomandibular joint. METHODS: The key is careful measurement of sagittal and coronal tomograms to determine the individual size and shape of the joint. The joint is then distracted to allow 3-port video arthroscopy. RESULTS: The detailed steps in the procedure are described and illustrated. CONCLUSION: This modified technique is safe and allows procedures in both joint spaces and surgical access to the fossa, condyle and disc.

Effect of peripheral cryoneurotomy and nerve transection on the trigeminal ganglion in rats.

In this experimental study, we did peripheral neurectomyand peripheral cryoneurotomy of the mental nerve in rats and histologically assessed their effects on the trigeminal ganglion at timed intervals for six months. There were marked irreversible changes in the neurectomy group whereas the cryoneurotomy group made a full recovery. These results help to explain the differing effects of these procedures on trigeminal neuralgia.

The healing of dental extraction sockets in insulin-dependent diabetic patients: a prospective controlled observational study.

BACKGROUND: The aim of this study was to determine whether there was a difference in delayed healing following dental extractions for insulin-dependent diabetics as compared to non-diabetic patients. METHODS: Prospective patients referred to the Adelaide Dental Hospital exodontia clinic for dental extractions were recruited into two groups: Known insulin-dependent diabetics and healthy non-diabetics. All had a random blood glucose level (BGL). Delayed healing cases were identified, and statistical evaluation was performed. RESULTS: There were 56 insulin-dependent diabetic patients (BGL 10.03, range 4.9-26) and 49 non-diabetic, age- and sex-matched patients. Seven patients (12.5%) in the study group showed delayed healing following extraction, while only four patients (8.2%) in the control group suffered delayed healing. This difference was not statistically significant. Two of the study group developed postextraction infections, requiring incision, drainage and antibiotics. CONCLUSION: The study shows that Type 1 and insulin-dependent Type 2 diabetic patients, if well controlled, tend to heal up well following dental extractions but with a small but not statistically different rate of postextraction complications including infection. This is contrary to what is usually taught. Clinicians should take great care with management of insulin-dependent diabetic patients, as compared to non-insulin dependent diabetics or non-diabetic patients.

Arthrocentesis in the management of internal derangement of the temporomandibular joint.

BACKGROUND: Temporomandibular disorders (TMD) cover a wide spectrum of disorder; myalgic, arthralgic and psychogenic. The procedure of TMJ arthrocentesis has a role in managing patients with arthralgic pain and limitation if they fail to respond to non-surgical therapy. METHOD: The patient records of a single private specialist OMS were searched over the 9-year period of 2006-2014 to identify patients who had arthrocentesis as part of their multidisciplinary management. The detailed demographic, diagnosis, pre and post arthrocentesis procedure were identified and put on a database. Appropriate statistics were performed. RESULTS: Seventy-six patients had 115 arthrocentesis procedures performed in the study period. Fifty of 76 had improvement in their pain and 16 of 41 had an increased jaw opening of more than 10 mm. There were no complications or morbidity. Analysis of patient variables generally showed no correlations. CONCLUSIONS: Temporomandibular joint arthrocentesis has a role in the multidisciplinary, multimodality treatment of arthralgic TMD.

Contemporary exodontia.

Exodontia is a cardinal skill of all dentists. Patients expect extractions to be skillfully and painlessly accomplished every time. It's not necessarily so simple and can be challenging. In this paper we explore contemporary issues of the full process of exodontia including diagnosis, technique, complication minimization as well as management of medically compromised patients with appropriate post-operative care, including pharmacotherapy.

The teaching of oral & maxillofacial surgery to dental students in Australia & New Zealand.

The teaching of OMS to dental students in Australia & New Zealand was surveyed. Generally the established schools had well developed curricula with good didactic and clinical experience conducted by specialist OMS educators. There was a much greater array of teaching in some of the newer schools with some appearing to barely meet the current minimalist professional competencies of the ADC. The critical element was whether or not the school was associated with a speciality OMS Unit at a Teaching Hospital. Proposals addressing these deficiencies are presented.

Extractions to reconstruction: The Development of Oral & Maxillofacial Surgery in Australian and New Zealand.

Oral and Maxillofacial Surgery developed initially from Dentistry as exodontia. It then expanded into the surgical management of jaw disorders. As the specialty evolved, it came into increasing conflict with related surgical disciplines. In the 1960s and 1970s these external criticisms were well-founded as training in oral surgery was individual, solely University-based and highly variable. In the 1980s the speciality developed a plan which involved hospital-based surgical training, a mandatory high level college surgical examination and detailed workforce and training studies. These were progressively implemented over the next twenty years with a dual degree (medicine and dentistry) and a final fellowship (FRACDS (OMS)). This resulted in accreditation by the Australian Medical Council and the Australian Dental Council and recognition as a Principal Surgical Speciality by the Commonwealth Department of Health. This development was monitored by published workforce studies over three decades that are important yardsticks to inform the credentialing of dental specialists.

Bisphosphonate-associated osteonecrosis of the external auditory canal.

BACKGROUND: Osteonecrosis is a benign condition characterised by necrotic exposed bone, and is associated with bisphosphonate use. Osteonecrosis of the external auditory canal is rare, with only a few reported cases. METHOD: Two case reports of temporal bone osteonecrosis are presented. RESULTS: A 64-year-old man with a history of immunoglobulin G kappa multiple myeloma developed a right external auditory canal ulcer 6 years after commencement on clodronate. A 72-year-old woman taking alendronate for osteoporosis, initially diagnosed and treated for right-sided otitis externa, was found to have underlying exposed bone in the right external auditory canal, with a computed tomography scan confirming destruction of the temporal bone. CONCLUSION: With increasing use of both oral and intravenous bisphosphonates in the community for benign conditions such as osteoporosis and for malignant conditions such as breast cancer and multiple myeloma, the diagnosis of bisphosphonate-associated osteonecrosis should always be considered in patients with a temporal bone lesion, and a relevant drug history taken.

The healing of dental extraction sockets in patients with Type 2 diabetes on oral hypoglycaemics: a prospective cohort.

BACKGROUND: The aim of this study was to determine whether there is a difference in delayed healing following dental extractions for Type 2 diabetics on oral hypoglycaemics and non-diabetic patients. METHODS: Prospective patients referred for dental extractions were recruited into two groups: known diabetics and non-diabetics with no conditions associated with poor healing. All had a random blood glucose level (BGL). Extractions were performed using local anaesthesia. Delayed healing cases were identified and statistical evaluation performed to identify risk factors. RESULTS: There were 224 Type 2 diabetics on oral hypoglycaemics (BGL 7.51, range 4.1-17.4) and 232 non-diabetics. The diabetic group were older, more males and less smokers than the control group. Twenty-eight patients, 12 (5%) diabetic and 16 (7%) control group, had socket healing delayed for more than one week but all healed in four weeks. There were no statistical differences between delayed healing and age, gender, diabetic state, BGL or smoking. The younger control group had more healing problems. CONCLUSIONS: The traditional view that diabetics have increased delayed healing was not supported. Type 2 diabetics on oral hypoglycaemics should be treated the same as non-diabetic patients for extractions.

Management of severe odontogenic infections in pregnancy.

BACKGROUND: The objective of this study was to review the management of patients presenting with severe odontogenic infections and who are also pregnant. METHODS: A retrospective clinical audit was conducted of all female patients admitted to the Royal Adelaide Hospital by the Oral and Maxillofacial Surgery Unit from 1999 to 2009 with severe odontogenic infections. Pregnant patients were identified and their age, medical history, previous obstetric and gynaecological history, stage of current pregnancy, presenting infection, diagnosis and management were recorded, as well as the outcome of the pregnancy. RESULTS: A total of 346 female patients were admitted to the Royal Adelaide Hospital under the care of the Oral and Maxillofacial Surgery Unit with an admission diagnosis of severe odontogenic infection and five were pregnant. Besides surgical and anaesthetic assessment, mother and foetus were assessed by the Obstetric and Gynaecology Unit. In all, five with severe infection were successfully resolved and four proceeded to a normal delivery with a healthy child. The remaining patient had an already planned therapeutic abortion. CONCLUSIONS: Pregnant patients with severe odontogenic infections require urgent referral to a tertiary hospital with full surgical, anaesthetic and obstetric services. This allows appropriate management of the complex requirements of mother and foetus.

Temporomandibular disorders in patients with mandibular fractures: a preliminary comparative case-control study between South Australia and Oman.

The status of temporomandibular disorders (TMD) in subjects with previously treated mandibular fracture was evaluated in two centres: South Australia (SA) and Oman (O). TMD status was evaluated using Mandibular Function Impairment Questionnaire (MFIQ), Helkimo index for clinical dysfunction (HI), RDC/TMD and Wilkes' classification. Data were retrieved for adult patients treated for mandibular fracture over 3 years from January 2004 to December 2006. Thirty-six subjects participated from SA and 23 from O. Their results were compared with matched controls. The incidence of TMD symptoms in SA injured and control groups was higher compared with the O groups. There was statistically significant difference on all evaluation indices for SA injured subjects compared with controls (MFIQ/P 0.04, HI/P 0.0015, RDC/TMD/P 0.05, Wilkes classification/P 0.03). These TMD symptoms were clinically insignificant for most subjects and all were internal derangement of the temporomandibular joint (TMJ). There was no significant difference in all evaluation indices for O injured subjects compared with controls. For SA injured subjects who reported clinically significant TMD symptoms, assault and bilateral mandibular fractures were predominant features. The study shows that most mandibular injuries fully recover and the associated TMJ trauma usually has low clinical significance in the long term.

Severe adverse reactions to dental local anaesthetics: systemic reactions.

BACKGROUND: Occasionally, patients suffer systemic adverse effects from injections of local anaesthetic solutions. This may range from minor transient vasovagal attacks to life-threatening collapse. METHODS: The suspected adverse reactions reported to the Office of Product Review of the Therapeutic Goods Administration (TGA) were analysed in detail. RESULTS: There was a high incidence (70%) of adverse reactions associated with prilocaine, which is much greater than its market share (less than 20%). There is a tendency to consider all systemic adverse reactions as being 'allergic' reactions although this is rarely the case. Syncope, cardiovascular and central nervous system reactions are much more common. There is also a risk of methaemoglobinaemia to prilocaine and articaine. A small series of cases referred to one of the authors were also reported. CONCLUSIONS: Recommendations are made as to the prevention, acute care and subsequent investigation of adverse reactions. The most important conclusion is not to just label the response as allergic and to use an alternative agent. Detailed investigation and reporting should be made for all cases of suspected severe adverse reaction to local anaesthetic agents.

Severe adverse reactions to dental local anaesthetics: prolonged mandibular and lingual nerve anaesthesia.

BACKGROUND: Prolonged anaesthesia may occur following dental local anaesthetic blocks. This paper reviews the possible mechanisms of injury. Direct injury to the nerve by the needle, although commonly thought to be the mechanism, is unlikely. It is much more likely that the injury is from neurotoxicity and/or interference with the vascularization of the nerve. METHODS: Estimation of the frequency of injury was complicated by the fact that although local anaesthetics are prescription-only (S4) drugs, they are supplied without prescription by dental supply houses. Unlike all other S4 drugs, there is no statutory requirement to record supply. The pharmaceutical and supply houses relied on that and 'commercial confidentiality' to not supply information. RESULTS: An informed estimate of 1 in 27 415 was made but this figure has wide confidence limits. Management of cases of prolonged anaesthesia following local anaesthetic injection is discussed. CONCLUSIONS: Patients who suffer this uncommon complication suffer considerable distress and feel injured, so care must be exhibited in their management. Specialist referral is recommended.

Management challenges in psychiatric patients with severe mandibular pain: a case report.

A 68-year-old man was admitted to the psychiatric unit of a major hospital as he was threatening self-harm due to uncontrolled left mandibular pain. Although he had significant psychiatric issues, psychiatric treatment did not help him. Further review at three weeks post-admission showed that he had had many months of unsuccessful dental treatment and this had triggered his psychiatric crisis. Multidisciplinary investigation and communication showed that he had trigeminal neuralgia secondary to vascular changes in his temporal lobe. He responded well to explanation and anti-neuralgic medication. Simple guidelines on how dental practitioners can cope with such patients are presented.

Biopsy of the oral mucosa and use of histopathology services.

Patients often present with intraoral pathology in the general dental practice setting. Therefore, it is important that dental practitioners are aware of how to deal with pathology when this occurs and have an understanding of investigative techniques that might assist in making a diagnosis. Biopsy and subsequent histological examination of the lesion is an important diagnostic tool. Even if dentists refer the patient to another practitioner for the biopsy, the referring practitioner still needs to be familiar with the procedure and results obtained so that the patient can be appropriately managed. This paper reviews clinical issues that may impact on biopsy procedures and the potential pitfalls and problems that may affect the histological assessment of tissue and therefore affect diagnosis. The medico-legal responsibilities of practitioners are also addressed.

Alveolar bone and the bisphosphonates.

Bisphosphonate associated osteonecrosis of the jaws (ONJ) usually commences at the alveolus. Comparison is made between the structure and function of long bones and alveolar bone and the differing susceptibilities of the bisphosphonates at these different sites are explored. Current concepts of the causation of ONJ are discussed. The clinical implications of these findings to dentists managing periodontal conditions are presented.

A change of heart: the new infective endocarditis prophylaxis guidelines.

New Australian guidelines for the prevention of infective endocarditis were published in July 2008. The guidelines were revised by a multidisciplinary group to reflect recent changes in international recommendations regarding antibiotic prophylaxis for infective endocarditis. The reasons for the changes are explored in this review and the implications for dental practice are discussed.

The oral health status of patients on oral bisphosphonates for osteoporosis.

BACKGROUND: The oral health status of patients on bisphosphonates is the key to the patient's ongoing health and well-being. If they are orally healthy, invasive bone procedures, particularly extractions can be avoided, then the risk of osteonecrosis of the jaws (ONJ) is low. METHODS: The records of 49 consecutive patients on oral bisphosphonates, referred to the Oral and Maxillofacial Surgery Unit (OMSU) for an oral health check and probable extractions, were retrospectively reviewed. The DMFT, periodontal and pathologic state were calculated from the OPG radiographs. An age and gender matched control group, from patients referred to the OMSU but who were not on oral bisphosphonates, were similarly assessed. Community data were also obtained. RESULTS: The DMFT score for the oral bisphosphonate group was 29: Decayed 3, Missing 10, Filled 16. The control group DMFT score was 24: Decayed 5, Missing 11, Filled 8. Both groups had advanced periodontal disease (over 95 per cent) and were medically compromised (over 90 per cent). The DMFT for general community data for age matched government pensioners was 19.1: Decayed 0.8, Missing 10.4, Filled 7.9. With severe periodontal disease 23 per cent. Thus, the oral health of the oral bisphosphonate group was similar to the control group and both had more decayed teeth and periodontal disease than community values. CONCLUSIONS: This study confirms that one cannot assume that a patient on an oral bisphosphonate for osteoporosis has a healthy mouth. It supports the view that all patients on bisphosphonates need to be seen by a dentist either before or soon after commencement of bisphosphonate therapy.