Reliability of Panoramic Radiography in Evaluating the Topographic

Reliability of Panoramic Radiography in Evaluating the Topographic Relationship Between the Mandibular Canal and Impacted Third Molars JADA The Journal of the American Dental Association March 2004, vol. 135, no. 3, pp. 312 -318(7) Monaco G. [1]; Montevecchi M. [2]; Alessandri Bonetti G. [1]; Gatto M. R. A. [1]; Checchi L. [3] Conclusion: Increased radiolucency, narrowing and interruption of the radiopaque border, as well as the concomitant presence of two or more radiographic markers, on the PR were highly predictive of contact between the third molar and the mandibular canal. An axial CT scan probably is indicated in such cases.

According to various surveys, the rate of neurological complications has varied from 0. 5 to 1 percent for cases involving permanent damage and 5 to 7 percent for cases involving temporary damage. The risk increases dramatically when there is contact between an impacted molar and the mandibular canal (defined as the absence of cortical bone around the alveolar nerve, the point at which the root touches the nerve). In these cases, the incidence of temporary damage to the inferior alveolar nerve rises to about 30 percent of extractions.

“Horizontal inclination is the most dangerous in terms of contact between tooth and canal. ”

Microneurosurgery • Nerves damaged from trauma or from an iatrogenic injury may be helped by microsurgery • Ideally performed 6 -12 months following the trauma • Early (~3 months) referral to specialist indicated if nerve shows no signs of improving

FOR IMMEDIATE RELEASE October 6, 2006 Permanent Injunction of Dental Products Manufacturer Furthers FDA Efforts Against Marketed Unapproved Drugs FDA obtained evidence that Canfield manufactured and distributed adulterated (i. e. , not manufactured according to good manufacturing practice) and unapproved drugs, including D. S. Dressing (20% Eugenol), D. S. Mini-Dressing (20% Eugenol), D. S. Syringe (20% Eugenol), and D. S. Ointment (20% Eugenol). Canfield promoted these products for the treatment of "dry socket, " a condition in which the socket does not heal properly following the extraction of a tooth. The products were available nationwide through dental practices for use by dentists and consumers.

Alvogyl® Dry Socket Alveolar Dressing Alvogyl is a one-step, self-eliminating treatment which rapidly alleviates pain and provides a soothing effect throughout the healing process. Its fibrous consistency allows for easy filling of the socket and good adherence during the entire healing process. The active ingredients of Alvogyl include eugenol for analgesic action, butamben* for anesthetic action, and iodoform for anti-microbial action. *Butamben, a lipophilic local anesthetic of the ester class, produces a differential nerve block of long duration

Odontogenic Infections Dr. J. Bruce Bavitz From Diagnosis and Treatment of Odontogenic Infections, Hooley, JR, Whitacre, RJ editors Stoma Press 1983

Odontogenic Infxts. -Prevention (My heart, artificial joint or jaw are not infected now, and I don’t want them infected after the procedure) Local Site Infxt: • Post-op Infxts • Subperiosteal Infxts • Dry Sockets? Distant Site Infxt: • Heart (endocarditis) • Prosthetic Joints • Shunts “Prevention is better than cure. ” Desiderius Erasmus 1466 -1536

Prevention-Antiseptic Rinse • Chlorhexidine • Alcohol • Iodophors • Cetylpyridinium Chloride

Infect Control Hosp Epidemiol. 2007 May; 28(5): 577 -82. Effect of a chlorhexidine mouthwash on the risk of postextraction bacteremia. Tomás I, Alvarez M, Limeres J, Tomás M, Medina J, Otero JL, Diz P. The chlorhexidine group had 0. 2% chlorhexidine mouthwash administered for 30 seconds before any dental manipulation. Blood samples were collected at baseline, 30 seconds, 15 minutes, and 1 hour after the dental extractions. Subculture and further identification of the isolated bacteria were performed by conventional microbiological techniques. RESULTS: The prevalence of bacteremia after dental extraction in the control and chlorhexidine groups were 96% and 79%, respectively, at 30 seconds (P=. 008), 64% and 30% at 15 minutes (P<. 001), and 20% and 2% at 1 hour (P=. 005). The most frequently identified bacteria were Streptococcus species in both the control and chlorhexidine groups (64% and 68%, respectively), particularly viridans group streptococci. CONCLUSION: We recommend the routine use of a 0. 2% chlorhexidine mouthwash before dental extractions to reduce the risk of postextraction bacteremia.

Prevention-Prophylactic Antibiotics • 2007 AHA Recommendations for Heart • 2003 ADA Recommendations for Ortho • ? results at reducing incidence dry sockets • Do give to immunocompromised patients prior to surgery • Don’t give in a cavalier fashion

Prophylactic Antibiotics. When? • Immunocompromised: Type one diabetes, high dose steroids, immunosuppressive agents, prior infection history, poor protoplasm • “Long” surgical visit • Metastatic/distant site infection risk: (heart valves, orthopedic implants, shunts)

Evidence Base for Duration of Antimicrobial Prophylaxis • “The goal of antimicrobial prophylaxis is to achieve serum and tissue levels of the antibiotic, at the time of incision and for the duration of the operation, that are in excess of the minimum inhibitory concentration needed for the organisms that may be encountered during the operation. The National Surgical Infection Prevention Project recommends the antibiotics not be extended beyond 24 hours of the end of the operation. ” Updated August 2003

Proof Nailed Down that Antibiotics Use Leads to Resistance ANTWERP, Belgium, Feb. 9, 2007 -- For the first time, the unassailable proof that physicians can do harm by indiscriminate use of antibiotics has emerged from a randomized controlled trial. "Physicians should take into account the striking ecological side-effects of antibiotics when prescribing such drugs to their patients, " the researchers concluded. Malhotra-Kumar S et al. "Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers: a randomized, double-blind, placebocontrolled study. " Lancet 2007; 369: 482 -490

2007 AHA The AHA’s latest guidelines were published in its scientific journal, Circulation, in April 2007 and there is good news: the AHA recommends that most of these patients no longer need short-term antibiotics as a preventive measure before their dental treatment. Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE

2007 AHA Preventive antibiotics prior to a dental procedure advised for patients with: 1. artificial heart valves 2. a history of infective endocarditis 3. certain specific, serious congenital (present from birth) heart conditions, including unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits 4. a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure 5. any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device 6. a cardiac transplant that develops a problem in a heart valve.

Prophylactic Antibiotics-Specifics

According to the 2007 AHA guidelines, which patient should receive antibiotics before an extraction? A. Mitral valve prolapse with echocardiogram confirmed murmur B. Recent (less than 6 months) bypass surgery C. History of rheumatic heart disease D. Surgical repair of a heart valve E. Heart transplant recipients

J Am Dent Assoc. 2003 Jul; 134(7): 895 -9. Antibiotic prophylaxis for dental patients with total joint replacements. American Dental Association; American Academy of Orthopedic Surgeons. The statement concludes that antibiotic prophylaxis is not indicated for dental patients with pins, plates or screws, nor is it routinely indicated for most dental patients with total joint replacements. However, it is advisable to consider premedication in a small number of patients who may be at potential increased risk of experiencing hematogenous total joint infection.

Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known risks of antibiotic toxicity; allergy; and development, selection and transmission of microbial resistance

Prevention-Good Surgical Care • Remove infected granulation tissue • Remove bone of questionable vitality • Copious saline irrigation • Rubber dam for endo • No high speed when large flaps reflected • Change needles often

Treatment (My teeth, gums, jaw are infected………. cure me Doctor) 1. Determine etiology 2. Determine how sick patient is 3. Determine if you want to treat 4. Give antibiotics (therapeutic, not prophylactic) 5. Remove etiology 6. Consider I+D with C+S 7. Close follow up

Determine Etiology • Usually non-vital tooth • Rare perio-abscess or pericoronitis • Don’t forget salivary glands/maxillary sinus • Post-op infection? Make sure there isn’t another tooth

How Sick Is Patient? • Airway most important • Mental status • Swallowing/ Secretions • Trismus • Vital Signs • PMH • Speed of onset

Treat? • Your office • Oral surgeon’s office (document referral) • Hospital

Antibiotics • Choose narrowest spectrum • Give in proper dose • More expensive not usually better for odontogenic infections • Not effective for intrapulpal pathology or for walled off abscesses…. need surgery

Antibiotics • Give ASAP-- in office before surgery • PEN Vk 500 mg q 6 h $5 -10. 00 • Clindamycin 450 mg q 8 h $65. 00 • PEN Vk 500 mg + Flagyl 500 mg q 6 h $65. 00 • Big Dog Infection? Then IV antibiotics • Bugs are usually overgrowth of normal flora - both aerobes and anaerobes

Remove Etiology (More important than antibiotics) • Anesthesia challenge? -Akinosi/ V 2 block • Trismus challenge- consider sedation • Endo, Extract • Never faulted for performing I+D • Never faulted for obtaining C+S, but expensive (about $350. 00)

Incision and Drainage 101 • Intraoral more esthetic but not always indicated as most dependent area best • Must contact bone • Obtain cultures without contamination • Suture in drain after copious irrigation • Anesthesia usually challenging • Recall fascial space anatomy

I+D with C+S

Anaerobic Culture Tube

Cellulitis vs. Abscess • Cellulitis • Diffuse • Indurated • Acute • “Body losing” • Abscess • Localized • Fluctuant • Chronic • “Laudable Pus”

Ludwig’s Angina

Which is true concerning odontogenic infections? 1. Identify and remove the etiology as soon as possible 2. Cephalosporins, in general, are superior to penicillins 3. Most serious infections are from periodontal abscesses 4. Can produce death from airway obstruction A. 1, 3 B. 2, 4 C. 1, 4 D. 1, 2, 4

Follow Up • Usually better 3 -4 days post Surg/Abs • Be ready to refer if not (document) • If the patient is not improving, the problem is usually surgical, not antibiotic resistance……. . The etiology remains, pus has not been drained, or dead bone still present

Your patient has developed an infection for which you have prescribed an antibiotic. Three days later, the infection has not responded to your treatment. What may account for this? 1. The patient if noncompliant 2. The etiology has not yet been removed 3. Your empiric therapy is incorrect 4. There are depressed host defenses A. 1, 3 B. 2, 4 C. 1, 2, 3 D. 1, 2, 3, 4

Morbidity and mortality from odontogenic infections is caused most often by: A. Cavernous sinus thrombosis B. Mediastinitis C. Airway compromise D. Endotoxin shock E. Non-working interferences

Questions? jbavitz@unmc. edu