Some Interesting Information!

I'd like to start off by discussing an interesting article that I came across, and essentially, this patient presented to the emergency room and they had this left TMJ joint pain in a 28-year-old man, and he, obviously, presented to a dental clinic, and he was an active duty infantry soldier in the US army.

He had intense throbbing to his left TMJ, specifically during physical activities and weight lifting. On exam by his general dentist, all of his vitals were unremarkable. He had great mobility of 45-plus millimeters. No pain. He did have some deviation and some crepitus, but he had a full range of motion without any restrictions or provocation of pain.

A night guard was fabricated despite these finding, and muscular physical therapy instructions were given. He was given this night guard and he was referred to OMS, but before his appointment, he had collapsed during physical training in cardiac arrest.

He had an 80% occlusion of his left anterior descending artery, and a one vessel coronary artery bypass graft was completed. After his cardiac surgery, he was seen and evaluated by OMS, and his TMJ symptoms had completely resolved.

During the differential diagnosis of oral facial pain, we got to consider non-facial sources of pain, particularly referred cardiac pain that can mimic TMJ, odontogenic, and myofascial pain. I think the fact that all of the standard findings for what you would expect for a TMJ problem were not there with the chief complaint of left jaw pain is the key and the tip off in this situation.

I ran across another article that discusses uses a C-arm guidance to improve the reduction of the zygomatic arch fractures in a randomized controlled trial, and the bottom line is, using some kind of intraoperative imagining, obviously, is helpful, and with the advent of intraoperative CT scans, this can become much more helpful and much more useful in the middle of complex facial fractures, and perhaps some of the more routine fascial fractures where there's any sort of question.

I also ran across an interesting approach for a sinus lift in an otherwise wide maxillary edentialist ridge, where they made an osteotomy on the superior aspect of the ridge, and then in fractured and pushed this bone superiorly, elevating the sinus floor, and then packed bone grafting, just your standard particular bone grafting material, in the defect.

Pretty interesting. It does not look like particularly technique sensitive anymore so than, just say a standard sinus lift type procedure. Perhaps a little bit easier, but something that I thought was interesting that you guys would like to think about and to know.

The final article that I want to chit chat to you guys about today is about non-surgical management of medication-related osteonecrosis of jaws using local wound care, and this was done out of the UCLA school of dentistry in LA, and it was a retrospective cohort study where they had 117 patients with medication-related osteonecrosis of the jaws, and for those that were amenable to conservative treatment, which included aggressive debridement by the patient using ... or a mechanical cleaning is probably a better term rather than debridement.

Mechanical cleaning of the exposed bone, chlorhexidine mouth rinses. If they should either get infected or appear and present initially infected, they were given a round of antibiotics, and a significant number of patients resolved spontaneously. The number was approximately 70%, so keep that in mind that conservative therapy is worthwhile and helpful, and some of these patients will get better.

They did follow the AAOMS practice guidelines strictly. All right, as a little bonus for those of you that held on tight through all of this, I have this article that talks about increasing use of intensive care unit for odontogenic infections over one decade, the incidents and predictors, and this is by Benjamin Fu out of Melbourne, Australia.

And so, what they did with this study is they took data from patients undergoing surgery for odontogenic infections that were over a 20 month period from January 2003 to December 2004 and compared that to January 2013 to December 2014. They did some statistical analysis to make sure that the data was worthwhile.

And the rate of ICU admission increased significantly from seven to 24% during the decade. That is an over three times increase in admission to the ICU. The mean number of days spend in the ICU increased significantly from approximately 1.7 to 3.24 days, so roughly one and a half to three days, so basically double, and the overall length of stay increased, again, from 1.7 to 3.5 days.

The use of a preoperative CT scan increased significantly over this time from 43% roughly to 93% roughly. That's almost a doubling in the use of CT scans. The most significant predictors of ICU admission were lower third molar involvement, dysphagia, and c-reactive protein levels exceeding 150 milligrams per liter, with a confidence interval of .039.

So, in conclusion, the use of the ICU in the management of odontogenic infections has increased significantly in Australia over the last decade, and having dysphagia or difficulties in swallowing, have lower third molars as the source of the infection, and an elevated c-reactive protein increases your likelihood of admission to the ICU.                                       

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