Pleural Empyema Caused by Streptococcus intermedius and Fusobacterium nucleatum: A Distinct Entity of Pleural Infections.

BACKGROUND: Many community-acquired pleural infections are caused by facultative and anaerobic bacteria from the human oral microbiota. The epidemiology, clinical characteristics, pathogenesis, and etiology of such infections are little studied. The aim of the present prospective multicenter cohort study was to provide a thorough microbiological and clinical characterization of such oral-type pleural infections and to improve our understanding of the underlying etiology and associated risk factors. METHODS: Over a 2-year period, we included 77 patients with community-acquired pleural infection, whereof 63 (82%) represented oral-type pleural infections. Clinical and anamnestic data were systematically collected, and patients were offered a dental assessment by an oral surgeon. Microbial characterizations were done using next-generation sequencing. Obtained bacterial profiles were compared with microbiology data from previous investigations on odontogenic infections, bacteremia after extraction of infected teeth, and community-acquired brain abscesses. RESULTS: From the oral-type pleural infections, we made 267 bacterial identifications representing 89 different species. Streptococcus intermedius and/or Fusobacterium nucleatum were identified as a dominant component in all infections. We found a high prevalence of dental infections among patients with oral-type pleural infection and demonstrate substantial similarities between the microbiology of such pleural infections and that of odontogenic infections, odontogenic bacteremia, and community-acquired brain abscesses. CONCLUSIONS: Oral-type pleural infection is the most common type of community-acquired pleural infection. Current evidence supports hematogenous seeding of bacteria from a dental focus as the most important underlying etiology. Streptococcus intermedius and Fusobacterium nucleatum most likely represent key pathogens necessary for establishing the infection.

Osteomyelitis of the lower jaw. / Osteomyelitt i underkjeven.

BACKGROUND: Chronic non-bacterial osteomyelitis is an inflammatory bone disorder that may affect children and adolescents. Infections, malignancy and other differential diagnoses require consideration. Osteomyelitis of the jaw is a rare condition, but non-bacterial osteomyelitis is probably more common than previously thought, also in the mandible. CASE PRESENTATION: We present four paediatric cases with osteomyelitis of the jaw with no obvious infection source or fever, but mandibular swelling and pain. All the patients were examined clinically, and X-ray, MRI and bone biopsies were performed. Therapeutic measures involved antibiotics, surgical debridement, use of NSAIDS and in one case peroral steroids. INTERPRETATION: Even though all cases started with similar symptoms, the aetiology remained unclear and it was challenging to reach the final diagnosis. The possibility of chronic non-bacterial osteomyelitis was assessed late. The international nomenclature for osteomyelitis is not consistent, and it is in our opinion important to emphasise the aetiology of the condition to avoid terminology misinterpretations which may delay effective treatment.

Temporomandibular joint prosthesis in cancer reconstruction preceding radiation therapy.

Total joint prostheses are a viable treatment option after removal of malignancies invading the temporomandibular joint, even when adjuvant radiation therapy is required.

Complications after mandibular setback with intraoral vertical ramus osteotomies: a retrospective cohort analysis of 133 patients.

OBJECTIVE: In the present study, we assessed the rate of complications and morbidity after mandibular setback with bilateral intraoral vertical ramus osteotomy (IVRO). STUDY DESIGN: In total, 133 patients were included. The prevalence of neurosensory disturbance (NSD), surgical site infection (SSI), and other complications were registered 2 months and 1 year after surgery. The correlations between complications and age, sex, American Society of Anesthesiologists classification, body mass index, blood loss, and operative time were evaluated. RESULTS: NSD was reported for 6.8% of the patients (9 of 133) 2 months after surgery (3.8% of the operated sites). The prevalence was significantly higher in female patients (P < .05). Two patients described persistent unilateral reduced sensibility after 1 year (1.5%). In total, 0.8% of the operated sites (2 of 266) had persistent NSD after 1 year. None of the patients required prolonged hospitalization, and 95.5% (127 of 133) were discharged the day after surgery. None of the patients experienced severe bleeding, and only 1 patient developed SSI. There were no significant correlations between patient-specific or intraoperative parameters evaluated and registered complications. CONCLUSIONS: This study shows that IVRO is a safe surgical technique associated with a low complication rate. IVRO can be an alternative technique for mandibular setback in patients who can tolerate postoperative maxillomandibular fixation.

Hormone spiral in treatment of progesterone-induced stomatitis.

Hormonal changes in the menstrual cycle may cause autoimmune progesterone-induced stomatitis. This case illustrates that insertion of a hormone spiral can be a treatment option to reduce mucosal lesions and symptoms.

Multiple brain abscesses and ventriculitis secondary to chronic periodontitis.

Chronic marginal periodontitis is a common oral disease, but can in rare cases cause severe intracranial infection. This case illustrates that poor dental status can be life threatening, in particular for immunocompromised patients.

Temporomandibular joint function 10-15 years after mandibular setback surgery and six weeks of intermaxillary fixation.

INTRODUCTION: Intermaxillary fixation (IMF) is a classic method for immobilization of the mandible after mandibular fractures and corrective surgery. However, it has been suggested that IMF may be a risk for developing temporomandibular joint (TMJ)-related symptoms, especially when applied for longer periods. OBJECTIVE: To evaluate the clinical function of TMJs and masticatory muscles 10-15 years after mandibular setback surgery and subsequent six weeks of IMF. The patients' self-reported TMJ and masticatory muscle symptoms were also addressed. METHODOLOGY: Thirty-six patients (24 women and 12 men) treated with intraoral vertical ramus osteotomies and subsequent six weeks of IMF, underwent a clinical examination of TMJs and masticatory muscles 10-15 years after surgery and completed a five-item structured questionnaire reporting subjective TMJ-related symptoms. Mean age by the time of clinical examination was 34.1 years (range 27.2-59.8 years). The clinical outcome was registered according to the Helkimo clinical dysfunction index. Descriptive and bivariate statistics were performed and level of significance was set to 5%. RESULTS: Mean maximum unassisted mouth opening 10-15 years after surgery was 50.1 mm, (range 38-70 mm, SE 1.2), statistically significantly greater in men compared to women (p=0.004). Mean Helkimo dysfunction group was 1.5 (range 1-3, SE 0.10). Eighty-one percent experienced pain on palpation in either the masseter muscle, temporal muscle or both, and 31% experienced pain when moving the mandible in one or more directions. Thirty-one percent reported pain from palpating the TMJs. In the questionnaire, none reported to have pain during chewing or mouth opening on a weekly or daily basis, but 22% reported difficulties with maximum opening of the mouth. CONCLUSION: Ten to fifteen years after mandibular setback surgery the patient's mandibular range of movement is good. Despite clinically recognizable symptoms, few patients reported having TMJ- or masticatory muscle-related symptoms in their daily life.

Motor vehicle accidents-related maxillofacial injuries: a multicentre and prospective study.

OBJECTIVES: The purpose of this European multicenter prospective study was to obtain more precise information about the demographic characteristics and etiologic/epidemiologic patterns of motor vehicle accidents (MVA)-related maxillofacial fractures. STUDY DESIGN: Of the 3260 patients with maxillofacial fractures admitted within the study period, 326 traumas were caused by MVAs with a male/female ratio of 2.2:1. RESULTS: The maximum incidence was found in Zagreb (Croatia) (18%) and the minimum in Bergen (Norway) (0%). The most frequent mechanisms were car accidents, with 177 cases, followed by motorcycle accidents. The most frequently observed fracture involved the mandible, with 199 fractures, followed by maxillo-zygomatic-orbital (MZO) fractures. CONCLUSIONS: In all the 3 groups (car, motorcycle, and pedestrian), mandibular and MZO fractures were the 2 most frequently observed fractures, with some variations. The importance of analyzing MVA-related facial injuries and their features and characteristics should be stressed.

Periodontal status at diagnosis predicts non-disease-specific survival in a geographically defined cohort of patients with oropharynx squamous cell carcinoma.

BACKGROUND: The aim of this study was to examine periodontal status with a time-efficient screening method from a cohort of newly diagnosed oropharynx squamous cell carcinoma (OPSCC) patients and to study to what extent dental disease level predicted survival. Aims/objective: Can measuring level of dental pathology based on a blind investigation of a routine orthopantogram (OPG) obtained during diagnostic workup reveal prognostic information? MATERIALS AND METHODS: We included 97 patients diagnosed between 2003 and 2010. Radiographic alveolar bone loss was measured. At least 4 mm bone loss from cement-enamel junction on at least two teeth was registered as periodontal pathology. The number of missing and filled teeth (MFT), residual roots and apical radiolucencies were noted. Clinical data were determined through hospital patient records. RESULTS: The horizontal bone loss discriminated between hr-HPV(+) versus hr-HPV(-) status, but secondary to age and smoking history at diagnosis. Vertical and horizontal bone loss predicted survival directly, and adjusted by gender, patient, smoking history, TN stage and hr-HPV tumor infection at diagnosis. CONCLUSIONS: Degree of periodontal OPG pathology at the time of OPSCC diagnosis to some extent predicted hr-HPV infection, but predicted non-disease-specific long-term survival. SIGNIFICANCE: Degree of periodontal OPG pathology at diagnosis predicts prognosis.

Apnea-Hypopnea Index in Healthy Class III Patients Treated With Intraoral Vertical Ramus Osteotomy: A Prospective Cohort Study.

PURPOSE: The study purpose was to assess whether mandibular setback surgery by intraoral vertical ramus osteotomy (IVRO) induces obstructive apnea and hypopnea in healthy Class III patients without a history of respiratory dysfunction. We hypothesized that the apnea-hypopnea index (AHI) would not exceed 5 events per hour after surgery. PATIENTS AND METHODS: A prospective cohort study was conducted. The sample was composed of healthy Class III patients without a history of obstructive sleep apnea treated with isolated mandibular setback surgery by the IVRO procedure at a university hospital. In-home respiratory sleep recordings (Nox T3; Nox Medical, Reykjavik, Iceland) and self-administered questionnaires were obtained before and at least 3 months after surgery. The AHI was the primary outcome variable. Other study variables were as follows: peripheral capillary oxygen saturation, oxygen desaturation index, snore index, body mass index, Epworth Sleepiness Scale, and Oral Impact on Daily Performance index. Descriptive and bivariate statistics were computed, and the significance level was set at .05. RESULTS: The sample was composed of 8 patients. The mean age at surgery was 23.2 years (range, 18.2 to 33.4 years). The mean amount of surgical setback was 4.3 mm (range, 2.5 to 7.4 mm). The mean body mass index was 24.2 kg/m2 (standard error [SE], 1.3 kg/m2) and 23.9 kg/m2 (SE, 1.4 kg/m2) at the presurgical and postsurgical sleep recordings, respectively. The mean AHI was 1.3 events per hour (SE, 0.3; range, 0.1 to 2.5) before surgery and 1.8 events per hour (SE, 0.4; range, 0.3 to 3.3) after surgery. No statistically significant changes in AHI (P = .412), peripheral capillary oxygen saturation (P = .443), oxygen desaturation index (P = .194), snore index (P = .363), or Epworth Sleepiness Scale (P = .812) were observed. The patients' self-reported oral health-related quality of life was statistically significantly improved after surgery (P = .034). CONCLUSIONS: Mandibular setback surgery with the IVRO procedure in the range of 2.5 to 7.4 mm did not induce obstructive sleep apnea, measured as an AHI above 5 events per hour, in the 8 healthy, young adult Class III patients presented in this study. More studies including larger patient samples are needed.

Temporomandibular joint function 10-15 years after mandibular setback surgery and six weeks of intermaxillary fixation

Abstract Intermaxillary fixation (IMF) is a classic method for immobilization of the mandible after mandibular fractures and corrective surgery. However, it has been suggested that IMF may be a risk for developing temporomandibular joint (TMJ)-related symptoms, especially when applied for longer periods. Objective: To evaluate the clinical function of TMJs and masticatory muscles 10-15 years after mandibular setback surgery and subsequent six weeks of IMF. The patients' self-reported TMJ and masticatory muscle symptoms were also addressed. Methodology: Thirty-six patients (24 women and 12 men) treated with intraoral vertical ramus osteotomies and subsequent six weeks of IMF, underwent a clinical examination of TMJs and masticatory muscles 10-15 years after surgery and completed a five-item structured questionnaire reporting subjective TMJ-related symptoms. Mean age by the time of clinical examination was 34.1 years (range 27.2-59.8 years). The clinical outcome was registered according to the Helkimo clinical dysfunction index. Descriptive and bivariate statistics were performed and level of significance was set to 5%. Results: Mean maximum unassisted mouth opening 10-15 years after surgery was 50.1 mm, (range 38-70 mm, SE 1.2), statistically significantly greater in men compared to women (p=0.004). Mean Helkimo dysfunction group was 1.5 (range 1-3, SE 0.10). Eighty-one percent experienced pain on palpation in either the masseter muscle, temporal muscle or both, and 31% experienced pain when moving the mandible in one or more directions. Thirty-one percent reported pain from palpating the TMJs. In the questionnaire, none reported to have pain during chewing or mouth opening on a weekly or daily basis, but 22% reported difficulties with maximum opening of the mouth. Conclusion: Ten to fifteen years after mandibular setback surgery the patient's mandibular range of movement is good. Despite clinically recognizable symptoms, few patients reported having TMJ- or masticatory muscle-related symptoms in their daily life.

Lymphatic growth factors are expressed in human gingiva and upregulated in gingival fibroblasts after stimulation.

BACKGROUND: The lymphatic growth factors vascular endothelial growth factor (VEGF)-C and -D are important for maintenance and growth of lymphatic vessels (lymphangiogenesis), but their localization in human gingiva is unknown. This study investigated the expression of VEGF-C and -D in human gingiva and isolated human gingival fibroblasts (HGFs). In addition, the localization of their main receptor VEGFR-3 was explored. METHODS: Non-inflamed gingiva from six donors was used for immunohistochemistry or isolation of HGFs. HGFs were stimulated with either E.coli lipopolysaccharide (LPS) or IL-6/soluble IL-6 receptor (sIL-6R) complex for 1, 6, and 24 hours. Quantitative real-time polymerase chain reaction (qRT-PCR) was used to quantify the relative changes in gene expression of VEGF-A, -C, and -D and enzyme-linked immunosorbent assay (ELISA) for quantification of protein levels. RESULTS: VEGF-C, -D and VEGFR-3 were seen in keratinocytes, blood vessels and in scattered single cells in gingiva. VEGFR-3 was also found in lymphatic vessels and VEGF-C in cells with fibroblastic appearance. Gene analysis showed no expression of VEGF-D in the HGFs, but showed constitutive expression of VEGF-C and -A. Stimulation of HGFs with LPS or IL-6/sIL-6R complex was followed by gene upregulation of VEGF-C and -A and increased protein levels in cell culture supernatant (P ≤0.05). CONCLUSIONS: The localization of VEGF-C, -D, and VEGFR-3 expression imply that signaling via VEGFR-3 is linked to vascular homeostasis and keratinocyte function under normal conditions in gingiva. Inflammatory stimulation of HGFs upregulates VEGF-C and -A expression and may contribute to angiogenesis and lymphangiogenesis.

Bisphosphonate associated osteomyelitis of the jaw in patients with bony exposure: prevention, a new way of thinking.

Objective There is strong evidence of a link between the use of systemic bisphosphonates (BPs) and osteonecrosis of the jaw, especially in cancer patients. Among risk factors for BRONJ, tooth extraction and immune suppressive drugs seem to have significant role on bone healing. Therefore, the importance of these parameters in development of BRONJ was reviewed in this retrospective study in two maxillofacial surgery units. Material and Methods From 2007 to 2012, 46 patients on bisphosphonate who had developed oral bony lesions participated in this study. The pharmacological exposure, comorbidities, maxillofacial findings, types of treatment and outcome data were collected from clinical and radiological records. Results The most frequently used BP was alendronate (67%). Tooth extraction was reported in 61% of patients with BRONJ. Systemic corticosteroids were prescribed in 35 cases (76%) as an adjuvant for BP. Patients on corticosteroids had a lower probability of bony lesion healing (p<0.05) than patients without corticosteroids. Of the 46 patients who underwent conservative treatments, only ten were completely healed (21%). Conclusions Beside tooth extraction, corticosteroids were shown to be an implant risk factor for low rate of bone healing and hence the development of BRONJ. The outcome of conservative treatment was uncertain and this emphasizes the importance of prevention.

Bisphosphonate associated osteomyelitis of the jaw in patients with bony exposure: prevention, a new way of thinking

Objective There is strong evidence of a link between the use of systemic bisphosphonates (BPs) and osteonecrosis of the jaw, especially in cancer patients. Among risk factors for BRONJ, tooth extraction and immune suppressive drugs seem to have significant role on bone healing. Therefore, the importance of these parameters in development of BRONJ was reviewed in this retrospective study in two maxillofacial surgery units. Material and Methods From 2007 to 2012, 46 patients on bisphosphonate who had developed oral bony lesions participated in this study. The pharmacological exposure, comorbidities, maxillofacial findings, types of treatment and outcome data were collected from clinical and radiological records. Results The most frequently used BP was alendronate (67%). Tooth extraction was reported in 61% of patients with BRONJ. Systemic corticosteroids were prescribed in 35 cases (76%) as an adjuvant for BP. Patients on corticosteroids had a lower probability of bony lesion healing (p<0.05) than patients without corticosteroids. Of the 46 patients who underwent conservative treatments, only ten were completely healed (21%). Conclusions Beside tooth extraction, corticosteroids were shown to be an implant risk factor for low rate of bone healing and hence the development of BRONJ. The outcome of conservative treatment was uncertain and this emphasizes the importance of prevention. .

Assault-related maxillofacial injuries: the results from the European Maxillofacial Trauma (EURMAT) multicenter and prospective collaboration.

OBJECTIVE: The aim of this study is to present and discuss the demographic characteristics and patterns of assault-related maxillofacial fractures as reported by a European multicenter prospective study. STUDY DESIGN: Demographic and injury data were recorded for each patient who was a victim of an assault. RESULTS: Assaults represented the most frequent etiology of maxillofacial trauma with an overall rate of 39% and the values ranging between 60.8% (Kiev, Ukraine) and 15.4% (Bergen, Norway). The most frequent mechanisms of assault-related maxillofacial fractures were fists in 730 cases, followed by kicks and fists. The most frequently observed fracture involved the mandible (814 fractures), followed by orbito-zygomatic-maxillary complex fractures and orbital fractures. CONCLUSIONS: Our data confirmed the strong possibility that patients with maxillofacial fractures may be victims of physical aggression. The crucial role of alcohol in assault-related fractures was also confirmed by our study.

European Maxillofacial Trauma (EURMAT) in children: a multicenter and prospective study.

OBJECTIVE: The aim of this study is to present and discuss the results of a European multicentre prospective study about pediatric maxillofacial trauma epidemiology during a year. STUDY DESIGN: The following data were recorded: gender, age, etiology, site of fracture, date of injury. Of the 3396 patients with maxillofacial fractures admitted within the study period, 114 (3.3%) were children aged 15 years and younger, with a male/female ratio of 2.6:1. Mean age was 10.9 years. Most patients (63%) were aged 11-15 years. RESULTS: The most frequent cause of injury was fall (36 patients). Sport injuries and assaults were almost limited to the oldest group, whereas falls were more uniformly distributed in the 3 groups. The most frequently observed fracture involved the mandible with 47 fractures. In particular, 18 condylar fractures were recorded, followed by 12 body fractures. CONCLUSIONS: Falls can be acknowledged as the most important cause of facial trauma during the first years of life. The high incidence of sport accidents after 10 years may be a reason to increase the use of mouthguards and other protective equipment. Finally, the mandible (and in particular the condyle) was confirmed as the most frequent fracture site.

European Maxillofacial Trauma (EURMAT) project: a multicentre and prospective study.

The purpose of this study was to analyse the demographics, causes and characteristics of maxillofacial fractures managed at several European departments of oral and maxillofacial surgery over one year. The following data were recorded: gender, age, aetiology, site of facial fractures, facial injury severity score, timing of intervention, length of hospital stay. Data for a total of 3396 patients (2655 males and 741 females) with 4155 fractures were recorded. The mean age differed from country to country, ranging between 29.9 and 43.9 years. Overall, the most frequent cause of injury was assault, which accounted for the injuries of 1309 patients; assaults and falls alternated as the most important aetiological factor in the various centres. The most frequently observed fracture involved the mandible with 1743 fractures, followed by orbital-zygomatic-maxillary (OZM) fractures. Condylar fractures were the most commonly observed mandibular fracture. The results of the EURMAT collaboration confirm the changing trend in maxillofacial trauma epidemiology in Europe, with trauma cases caused by assaults and falls now outnumbering those due to road traffic accidents. The progressive ageing of the European population, in addition to strict road and work legislation may have been responsible for this change. Men are still the most frequent victims of maxillofacial injuries.

Relapse and stability after mandibular setback surgery one year postoperatively: a retrospective study.

PURPOSE: A retrospective evaluation was performed of dentoalveolar and skeletal stability 1 year after mandibular setback surgery using intraoral vertical subcondylar osteotomy (IVSO) combined with intermaxillary fixation. PATIENTS AND METHODS: Twenty-eight patients (16 men, 12 women) with skeletal Angle Class III malocclusions were included. Mean age at start of treatment was 23.9 years. All patients underwent combined surgical and orthodontic treatment. Dental casts and cephalometric measurements were performed for each patient before orthodontic treatment and at 8 weeks and 1 year after surgery. RESULTS: Treatment changes from 8 weeks to 1 year after surgery were small but significant for the angular relationship between the maxilla and the mandible in the sagittal plane (ANB) (mean difference, -0.5 mm; P = .021), Wits appraisal (mean difference, -0.7 mm; P = .044), the inclination of the mandible in relation to the nasion-sella line (ML-NSL) (mean difference, -0.8 mm; P = .010), and the inclination of the lower incisors in relation to the nasion-point B line (Li-NB) (mean difference, -0.6 mm; P < .001). These findings for cephalometric values indicated a small skeletal relapse in sagittal and vertical relations. No significant dentoalveolar relapse occurred according to the dental cast evaluations. CONCLUSION: The results clearly show that orthodontic treatment combined with IVSO provides a stable dental and skeletal result 1 year after treatment.