Clinical Questions in Dentistry IJCP Š Copyright 2010 IJCP Publications Pvt. Ltd. All rights reserved. The copyright for all the editorial material contained in Clinical Questions in Dentistry, in the form of layout, content including images and design, is held by IJCP Publications Pvt. Ltd. No part of this publication may be published in any form whatsoever without the prior written permission of the publisher. Published, Printed and Edited by Dr KK Aggarwal on behalf of IJCP Academy of CME, as part of their Social Commitment for upgrading the knowledge of Indian doctors. Published: Daryacha, 39 Hauz Khas Village, New Delhi - 110 016 Website: www.ijcpgroup.com, E-mail: editorial@ijcp.com, emedinews@gmail.com, Ph.: 011-26965874/75, HIP/IN/MUMBAI/1149 Disclaimer: Although great care has been taken in compiling and checking the information given herein to ensure that it is accurate, the publisher shall not be in no way directly or indirectly responsible for any error, omissions or inaccuracy in this publication whether arising from negligence or otherwise. IJCP Publications Pvt. Ltd. does not guarantee, directly or indirectly, the quality or efficacy of the product or service described in the advertisements or other material which is commercial in nature in this publication.
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Dear Colleague The past years have brought dramatic changes in the field of dentistry, many of which have helped to make a visit to the dentist a pleasant experience. Scientific knowledge of the relationship between dental health and overall health has improved a lot now. Although, modern day dental practice focuses on prevention, treatment and interventions are still needed. Most dental treatments are carried out to prevent or treat the two most common oral diseases, namely dental caries and periodontal disease. Currently dentistry is moving around new issues. Recent advances in dentistry now focus on the conversion to digital X-rays. Improved instruments like microscopes and reciprocating sawdrills now make it possible to complete some root canal procedures in a single appointment. Advanced techniques and drugs like local anesthetics and IV sedation make dental procedures more comfortable and safer for the patient. Some orthodontic treatment can now be completed without the use of traditional bands and wire and improvements in dental restorative materials (fillings) have made the use of amalgam fillings almost unnecessary. All these advances compel the dental surgeon to update his knowledge of the subject. Recognizing this need of the dental practitioner, IJCP Group of Publications has brought out ‘Clinical Questions in Dentistry’. Presented in a question and answer format, this compilation addresses major situations frequently encountered in clinical practice ranging from dental infections to pain management to dental surgery. The questions have been formulated and answered by dental practitioners. I hope that this compilation would save valuable time expended in searching and looking for updated information and be useful in your practice. I welcome feedback and suggestions from all readers.
Lincomycin Spectrum of activity Lincomycin has good in vitro activity against many gram-positive pathogenic microbes. This antibiotic is active against gram-positive microbes regardless of whether these organisms were aerobic or anaerobic. Lincomycin is active against L-forms of gram-positive cocci. In general, its action is feeble against most gram-negative pathogens. Lincomycin is the most effective antimicrobial with a low range of minimum inhibitory concentration (MIC) values when compared to cephalosporins. The mean MIC for lincomycin towards S. aureus was 0.2-3.2 µg/ml which is 10-fold lesser when compared to cefpodoxime, cefixime and ceftriaxone whose MICs were 2->16 µg/ml, 4->16 µg/ml and 2->16 µg/ml, respectively. Therefore, lincomycin is a preferred drug of choice against infections caused by aerobic and facultative anaerobic gram-positive bacteria. The bacterial eradication efficiency of lincomycin increases with increasing concentration, whereas increasing concentration of the b-lactam antibiotics such as cefixime, cefotaxime cause minimal decrease in bacterial counts. Antimicrob Agents Chemother 1988;32(12):1896-8.
Lincomycin is active against the following anaerobic organisms: Anaerobic gramnegative bacilli such as Bacteroides spp. and Fusobacterium spp.; anaerobic gram-positive nonspore-forming bacilli such as Propionibacterium, Eubacterium and Actinomyces spp.; anaerobic and microaerophilic gram-positive cocci such as Peptococcus spp., Peptostreptococcus spp. and microaerophilic streptococci and Clostridium spp. Infection 1974;2(3):152-9.
Mechanism of action Lincomycin is bacteriostatic and inhibits protein biosynthesis by irreversibly binding to the 50S subunit of the bacterial ribosome. This prevents translocation of the peptidyl-tRNA from the A site to the P site, causing early chain termination and inhibition of bacterial growth.
Lincomycin enhances PMN function Not all antibiotics posses host defense enhancement capabilities. Some may even inhibit function. However, lincomycin enhances polymorphonuclear (PMN) leukocyte chemotaxis, phagocytosis and bactericidal activity against organisms. Preincubating some gram-positive organism in the presence of lincomycin significantly enhances the PMN leukocyte chemotaxis, phagocytosis and bactericidal activity against these organisms. In contrast to lincomycin, for example, in vitro penicillin, cephalosporins, aminoglycosides and tetracycline either penetrate the PMN minimally or not at all. J Antimicrob Chemother 1981;8(Suppl C).
Pharmacokinetics With a single oral dose of 500 mg a blood level of 3.5 µg/ml is obtained within two hours, decreasing to 2.2 µg after six hours. A 600 mg IM dose produces a peak level of 14.6 μg/ml within 30 minutes, falling to 5.5 µg/ml in six hours and to 2.5 µg/ml in 12 hours.
Factors affecting its activity pH: Lincomycin shows maximal activity at an alkaline pH. The compound nevertheless retains its activity in the presence of hydrochloric acid, this clearly shows that gastric acidity does not impair its activity. Organic fluids: In vitro tests show that the presence of organic fluids in no way reduces its activity, even at concentrations of upto 50% of serum, pleural fluids or urine. Lincomycin penetrates healthy tissue, necrotic tissue and pus, and is not inhibited by bacterial enzymes.
Lincomycin in Dental Infection Efficacy of lincomycin over amoxycillin A clinical and microbiological study was carried out to assess the therapeutic efficacy of two different antibiotics, lincomycin and amoxycillin, in the treatment of patients suffering from odontogenic abscesses. Microbiological analyses revealed that the majority of infections were supported by mixed aerobic and anaerobic bacterial flora. The assessment of clinical parameters clearly showed that patients receiving pharmacological treatment with lincomycin achieved a more rapid and efficacious recovery from disease in comparison to patients treated with amoxycillin. Minerva Stomatol 1991;40(3):129-37.
Lincomycin in root channel filling The efficiency of preventive oral antibiotic therapy before the root channel filling was evaluated in 78 patients with granulating and granulomatous chronic periodontitis. Positive clinical changes were observed after lincomycin or rondomycin therapy (p = 0.017). The number of complaints was also less in the latter group (p > 0.05). The incidence of X-ray restoration of periapical foci of bone tissue destruction during 6 and 12 months was significantly higher (p < 0.05 and p < 0.01) after preventive treatment with lincomycin or rondomycin, characterized by potent osteotropic effects (decontamination with rondomycin 81.8%, with lincomycin 70.3% vs 31.0% without decontamination therapy). Stomatologiia (Mosk) 2003;82(5):16-9.
Lincomycin applied to the alveolus on TCP (Beta-tricalcium phosphate) carrier reduces complications in the form of pain and trismus. Lincomycin on TCP can be used to prevent alveolar periostitis. Ann Acad Med Stetin 2009;55(2):59-64.
Clinical Questions in Dentistry
1
What is the treatment of apical infection in molars with calcified canals? KMK Masthan*, Anitha Nagrajan**
*Professor and Head, Dept. of Oral and Maxillofacial Pathology **Postgraduate Student Sree Balaji Dental College and Hospitals, Chennai
Tooth with apical infection can be treated by root canal treatment (RCT). Method: Cavity preparation is done and extended toward the assumed location of pulp chamber. At this phase of treatment, the clinician must attempt to provide maximum visibility of roof of pulp chamber. So all caries, discolored dentin should be removed. Using long shanked No. 4 or No. 6 round burr, the assumed location of main pulp chamber should be explored. An endodontic explorer is used to explore the pulpal floor. It is both an examining instrument and a chipping tool, often used to flake away calcified dentin. A slight tug back in the area of canal orifice often signals the presence of a canal. If access does not occur at this point in the search, the clinician should be concerned about the loss of important tooth structure, which could lead to vertical root fracture. The burr may be removed from the handpiece and placed in excavation site. Radiograph exposed at right angles through the tooth reveals the depth and angulation of the search. At first indication of space, the smallest file should be introduced. Gentle passive movement, both apical and rotational, often produces some penetration. Access to canal orifice can be widened using Gates-Glidden drills until orifice is identified. Large files may be used to prepare the canal. Finally, the prepared canals are obturated. vvv
Clinical Questions in Dentistry
2
What is the treatment of a fractured mandible during surgical extraction of a tooth? Rajesh Chandna
Dr Chandnaâ&#x20AC;&#x2122;s Dental Centre, New Delhi
E
xtraction force, if applied in excess, can result in fracture of jaws. In the mandible, third molar region is a common site which fractures during extraction with excess force. Such fractures of mandible can be treated by three methods. One method is by using mini plates to approximate the fractured ends. Monocortical wiring of fractured site and intermaxillary fixation (IMF) are other techniques of managing such fractures. The IMF should be removed six weeks later. The mini plates and monocortical wiring can be retained provided it is not causing any infection. vvv
Clinical Questions in Dentistry
3
What anesthetic techniques should be used in an uncooperative patient or in case of acute pain while opening root canal, extraction or surgeries? US Krishna Nayak
Dean Academics and Head, Dept. of Orthodontics and Dentofacial Orthopedics AB Shetty Memorial Institute of Dental Sciences, Mangalore
P
ain is the unpleasant sensory and emotional condition caused by the valid or possible damaging influence on a tissue. The choice of the best analgesic to help manage pain from a dental emergency is influenced by a number of factors. These include:
Severity of the pain Clinical judgment is required to determine the patient’s anticipated level of pain following the management of the dental emergency. A very arbitrary and subjective classification is: Mild, moderate, moderate-to-severe or severe.
Medical history of the patient Factors that would contraindicate nonsteroidal anti-inflammatory drugs (NSAIDs) include gastric ulceration, bleeding concerns, severe asthma, late-term pregnancy and significant renal disease. Avoid NSAIDs in patients taking drugs which can interact, such as lithium, anticoagulants or antineoplastic doses of methotrexate. NSAIDs should only be used for ≤4 days if the patient is taking an antihypertensive (angiotensin-converting enzyme [ACE] inhibitors, diuretics or b-blockers). Significant liver disease would also require a reduction in doses of any analgesic selected.
Consider these general guidelines
Eliminate the source of pain when possible. Individualize regimens based on the patient’s level of pain and medical history. Maximize the nonopioid (NSAID or acetaminophen) analgesic before adding the opioid. Avoid chronic use of any analgesic.
Acute pain while opening root canal, extraction or surgeries Analgesics most commonly prescribed in dentistry for acute pain relief include the NSAID, acetaminophen and various opioid-containing analgesic combinations. The NSAIDs and presumably acetaminophen act by inhibiting cyclo-oxgenase enzymes responsible for the formation of prostaglandins that promote pain and inflammation. Opioids such as codeine, hydrocodone and
Clinical Questions in Dentistry oxycodone stimulate endogenous opioid receptors to bring about analgesic and other effects. Numerous clinical studies have confirmed that moderateto-severe pain of dental origin is best managed through the use of ibuprofen or another NSAID whose maximum analgesic effect is at least equal to that of standard doses of acetaminophen-opioid combinations. If an NSAID cannot be prescribed because of patient intolerance, analgesic preparations that combine effective doses of an orally active opioid with 600-1,000 mg of acetaminophen are preferred in the healthy adult. On occasion, prescribing both an NSAID and an acetaminophen-opioid combination may be helpful in patients not responding to a single product. In all cases, however, the primary analgesic should be taken on a fixed schedule, not on a â&#x20AC;&#x2DC;prnâ&#x20AC;&#x2122; (or as needed) basis, which only guarantees the patient will experience pain.
If this does not work go for conscious sedation What is conscious sedation? Conscious sedation induces an altered state of consciousness that minimizes pain and discomfort through the use of pain relievers and sedatives. Patients, who receive conscious sedation usually are able to speak and respond to verbal cues throughout the procedure, communicating any discomfort they experience to the provider. A brief period of amnesia may erase any memory of the procedure. Some common reasons to use conscious sedation include biopsies and minor surgeries, along with dental procedures. Conscious sedation dentistry is offered to young children who may have trouble complying with requests from the dentist and the staff, and to adults who experience significant anxiety about dental appointments. Some dentists actively advertise conscious sedation as an option, to appeal to patients who dread visits to the dentist. Patients are carefully reviewed before being selected as candidates for conscious sedation, and the doctor also goes over the risks, advantages and alternatives with the patient. Once the determination to use conscious sedation is made, the patient is given sedatives which cause him or her to relax, along with painkillers which are designed to eliminate pain from the procedure. During the period of conscious sedation, an anesthesiologist or certified nurse anesthesiologist monitors the patient at all times, looking at heart rate, breathing and dissolved oxygen levels in the blood, so that adverse reactions can be quickly identified and addressed. In some cases, patients are also given drugs which are supposed to help them forget the procedure. Medical procedures can be traumatizing and these drugs are designed to reduce bad memories which could cause nightmares, panic attacks and other unpleasant symptoms. After the procedure is over, the patient is taken into recovery and monitored until he or she is fully alert. 10
Clinical Questions in Dentistry It usually takes around 48 hours to fully recover from conscious sedation, during which the patient should not drive, make critical decisions or engage in tasks which require a high level of concentration or fine motor skills.
If this still does not work then the next level of analgesia is narcotic analgesia Narcotic analgesics are combined with psychotropic drugs for carrying out of special kinds of anesthesia: ď Ź
ď Ź
Neuroleptanalgesia: Anesthesia by fentanylum combination (strong, 3040 minutes react) and droperidolum (a soft neuroleptic). Droperidolum has soft sedative, antiemetic, antishock effect, eliminates any emotional reaction, reduces a tonus of skeletal musculation. Doses: 1:50. The combined preparation - thalamonalum. neuroleptanalgesia use in non traumatic operations, neurosurgery, myocardial infarction, etc. Analgesia or trankvilon analgesia: Fentanylum plus a strong tranquilizer of a type of sibazonum, phenazepamum. The basic disadvantage - a strong respiratory depression.
Using long-acting local anesthetics It is extremely important to achieve profound anesthesia prior to initiating treatment. It is equally important to ensure that the anesthesia is of adequate duration. Adequate anesthesia not only ensures comfortable treatment but also reduces post-treatment pain. Research has shown that when dental procedures are performed without complete anesthesia, patients are likely to report greater and longer lasting post-treatment pain. One method for controlling postoperative or postendodontic pain is to use long-acting local anesthetics, when indicated. In addition to ensuring patient comfort throughout a procedure, long-acting local anesthetics have exhibited an extended duration of analgesia, beyond the period of anesthesia. Both etidocaine and bupivacaine are available in dental cartridges and are effective in reducing pain after dental procedures. Etidocaine may have a slight advantage over bupivacaine since it often demonstrates a faster onset for anesthesia. However, cost differences between these local anesthetics may be a consideration. Combining NSAID pre-treatment with long-acting local anesthetics can result in nearly 70% of patients reporting pain as either none or slight, even at seven hours after surgical removal of impacted third molars. Of course, case selection is important when considering the use of longacting local anesthetics. Patients, especially children, may be prone to biting 11
Clinical Questions in Dentistry Dosing regimens for orofacial pain Adult
Dose (mg)
Frequency
Daily maximum (mg)
Acetaminophen
500-1,000
q 4-6 h
4,000
Acetylsalicylic acid
325-1,000
q 4-6 h
4,000
Ibuprofen
400
q 4-6 h
2,400
Flurbiprofen
50
q 4-6 h
300
Diflunisal
500
q 1-2 h
1,500
Naproxen
275/250
q 6-8 h
1,375
Drug
Ketorolac
10
q 4-6 h
40
Ketoprofen
25-50
q 6-8 h
300
Floctafenine
200-400
q 6-8 h
1,200
Etodolac
200-400
q 6-8 h
1,200
Celecoxib
200
q 1-2 h
400
Codeine (with acetaminophen or an NSAID)
30-60
q 4-6 h
â&#x20AC;&#x201D;
Oxycodone
5-10
q 4-6 h
â&#x20AC;&#x201D;
10-15 mg/kg
q 1-6 h
65 mg/kg
10 mg/kg
q 6-8 h
40 mg/kg
0.5-1 mg/kg
q 4-6 h
3 mg/kg
Pediatric Acetaminophen Ibuprofen
their lips following inferior alveolar nerve block anesthesia. Some patients dislike the sensation of a fat lip or anesthetized tongue and may elect not to have long-acting local anesthetics. In addition, there have been some reports of increased cardiac risk with the use of long-acting local anesthetics in certain patients. vvv
12
Clinical Questions in Dentistry
4
What is the surgical technique to treat a patient with subluxation of TMJ (mandibular dislocation)? KMK Masthan*, Anitha Nagrajan**
*Professor and Head, Dept. of Oral and Maxillofacial Pathology **Postgraduate Student Sree Balaji Dental College and Hospitals, Chennai
D
islocated condyle can be usually repositioned without the use of muscle relaxants or general anesthetics. If muscle spasms are severe and reduction is difficult, the use of intravenous diazepam can be beneficial. The clinician should stand in front of seated patient and place the thumb lateral to mandibular molars on the buccal shelf of bone, the remaining fingers of each hand should be placed under the chin. Condyle is repositioned by a downward and backward movement. This is achieved by simultaneously pressing down on the posterior part of mandible while raising the chin. As the condyle reaches the height of eminence, it can usually be guided posteriorly to its normal position. vvv
13
Clinical Questions in Dentistry
5
What is the emergency management of patients with maxillary anterior alveolar fracture due to traumatic injury as in sports? Rajesh Chandna
Dr Chandna’s Dental Centre, New Delhi
T
he alveolar bone, which supports the teeth, may be fractured at the alveolar socket wall, the alveolar process or as a comminuted (shattered) fracture of the supporting bone. Segmental fractures involve multiple teeth and their supporting alveolar process.
First-aid Primary tooth Rinse with cold water, and keep an ice pack over the lip and mouth to reduce swelling. Give acetaminophen (paracetamol) for pain relief.
Permanent tooth Rinse with cold water, and keep an ice pack over the lip and mouth to reduce swelling. Give acetaminophen (paracetamol) for pain relief.
Dental office treatment Primary tooth For any severe luxation injury: An anti-inflammatory agent (ibuprofen), an analgesic (paracetamol) and an antibiotic (amoxycillin), are prescribed. Treatment of alveolar process fractures requires manually repositioning the segment of displaced teeth back into proper arch alignment. A very rigid splint is applied for two months.
Permanent tooth For severe luxation injury: An anti-inflammatory agent, an analgesic and an antibiotic are prescribed. Treatment of alveolar process fractures requires manual repositioning of the segment of displaced teeth back into proper arch alignment. A very rigid splint is applied for two months. vvv
14
Clinical Questions in Dentistry
6
How is syncope during a dental procedure managed? US Krishna Nayak
Dean Academics and Head, Dept. of Orthodontics and Dentofacial Orthopedics AB Shetty Memorial Institute of Dental Sciences, Mangalore
W
hen the presyncopal or syncopal symptoms are recognized, all dental procedures should be suspended and all objects should be removed from the oral cavity. Presyncopal symptoms indicate a 50-70% decrease in blood flow to the brain. If consciousness is lost, the patient should be placed in a Trendelenburg position so that the legs are above the level of the heart to facilitate blood return. The position of the patient should assure an open airway circulation. Tight-fitting clothing (e.g., ties or belts), which can decrease blood flow to the brain should be loosened. Oxygen should be administered at 4-5 liters/ minute. If the patient is breathing and has a pulse but remains unconscious, aromatic ammonia can be administered by crushing an inhalant between the fingers and allowing the patient to breathe the vapors. The noxious vapors will stimulate breathing and muscle movement. A syncopal episode can last anywhere from a few seconds to several minutes. All vital signs should be monitored during the entire episode. If bradycardia continues, 0.6 mg of atropine can be administered to block vagal stimulation. Following the syncopal episode, patients should remain in a supine position until they feel well enough to be slowly returned to a seated position and their pulse rates return to normal. An attempt should be made to determine the cause of the syncope to avoid future recurrence of the condition. All dental treatment should be suspended for the day, and since syncope can recur, arrangements should be made to have an emergency contact to escort the patient home. If a condition other than neurocardiac syncope is suspected, the patient should be transported to the nearest hospital, where he or she will undergo a complete physical examination. The report made in the dentist office should include the circumstances preceding the event, the duration of unconsciousness, a description of the signs and symptoms and manner of recovery, this report will aid the physician to make a correct diagnosis. Electrocardiography (EKG), exercise testing and Holter monitoring (e.g., the use of a device for prolonged EKG recording while the patient conducts normal daily activities) may be necessary to determine the exact etiology of the syncopal episode. 15
Clinical Questions in Dentistry
7
How are broken files from root canal removed during RCT? Sana Wadhwa
Postgraduate Student, Dept. of Orthodontics, New Delhi
A
fter locating the file, careful ultrasonic instrumentation is used to remove dentin around the file. This is done carefully without touching the file itself. The file should be exposed upto 2-3 mm before we begin vibrating the file itself. Too much contact with the file in this early stage can cause a coronal piece of the file to break off, making retrieval even more difficult. Once the coronal 2-3 mm of the file has been accessed, the ultrasonic is placed on the most apical part of the file to begin vibrating it. This should loosen the file and vibrate it out. If the file breaks again, then repeat step one. Use of an operating microscope is essential in effective removal of a separated instrument. vvv
16
Clinical Questions in Dentistry
8
How is a perforation of the root treated while doing a filling or RCT? KMK Masthan*, Anitha Nagrajan**
*Professor and Head, Dept. of Oral and Maxillofacial Pathology **Postgraduate Student, Sree Balaji Dental College and Hospitals, Chennai
P
erforations represent pathologic or iatrogenic communications between root canal space and the attachment apparatus. Perforation is an invasion into supporting structures and causes inflammation and loss of attachment.
Method Hemostatics Many perforation defects exhibit massive bleeding upon re-entry. A dry field enhances vision creating an environment for predictable placement of restorative agent. Two or three applications of placing and then removing calcium hydroxide begins to control the bleeding. If hemostasis is not achieved, the calcium hydroxide is left in canal until future appointment.
Barrier materials These help to produce a dry field and also provide an ‘internal matrix’ or ‘back stop’ to condense restorative materials against. Barrier materials can be divided into ‘resorbable’ and ‘nonresorbable’.
Resorbable barrier materials are passed through access cavity and are intented to be placed in the bone, not left within tooth structure. Collagen and calcium sulfate materials are best employed because of ease of handling, research and observed clinical result. Collagen material is biocompatible, supportive of new tissue growth, resorbable in 10-14 days and left in situ. Nonresorbable barriers such as mineral trioxide aggregate (MTA) exhibit excellent tissue biocompatibility. It has many clinical applications and represents an extraordinary breakthrough for managing radicular repairs. MTA is barrier of choice when there is potential moisture contamination or when there are restrictions in technical access and visibility. MTA can be used as sole restorative material radicularly, or it can be used as a barrier against which to pack another material. vvv
17
Clinical Questions in Dentistry
9
What is the treatment of Bell’s palsy? Rajesh Chandna
Dr Chandna’s Dental Centre, New Delhi
Questions to be addressed while treating a case of Bell’s palsy
What tests need to be done to adequately diagnose the condition?
What treatment do you recommend?
Will any medication be prescribed?
What are the side effects?
If severe, is surgery recommended?
What is the procedure?
What can be expected from the surgery?
What is the prognosis? Or what is the chance of a full recovery?
Are there any special measures that need to be taken to protect the eye, face or even to cope with eating difficulties?
Are there any facial exercises which are beneficial?
Is there any benefit from electrical stimulation to the facial muscles?
Treatment The prognosis for Bell’s palsy is generally very good. With or without treatment, most patients begin to get significantly better within two weeks, and about 80% recover completely within three months. For some, however, the symptoms may last longer. In a few cases, the symptoms may never completely disappear. Only one in 10 patients never experience a complete disappearance of symptoms. The extent of nerve damage determines the extent of recovery. There is no specific treatment for Bell’s palsy. The most important part of treatment is to keep the eyes healthy and moist. One of the purposes of blinking the eyes is to keep the eyes wet. If a person can’t close their eyes, because the muscles that control the eyelids are paralyzed, it is important to keep the eyes moist and prevent itching. Eye drops are prescribed for the day and an eye ointment for the night to prevent drying of the surface of the eye cornea. Diminished blinking and the absence of tearing together can reduce or eliminate the flow of tears across the eyeball, resulting in drying, erosions and ulcer formation on the cornea and possible loss of the eye. Closing the eye with a finger is 18
Clinical Questions in Dentistry an effective way of keeping the eye moist. Use the back of the finger to ensure that the eye is not injured with the finger tip. Protective glasses or clear eye patches are often used to keep the eye moist, and to keep foreign materials from entering the eye. If infection is the cause, then an antibiotic to fight bacteria (as in middle ear infections) or antiviral agents (to fight syndromes caused by viruses like herpes simplex virus, Ramsay Hunt) may be used. If simple swelling is believed to be responsible for the facial nerve disorder, then corticosteroids (prednisone) can be administered to relieve swelling and to prevent an early condition from getting worse. It is usually given for one week, though it shouldnâ&#x20AC;&#x2122;t be prescribed if there are any signs of infection or other problems that are known to cause complications with short-term steroid use. A pain reliever may be necessary to relieve pain. Some have used electrical stimulation to stimulate the facial nerve. There is no scientific evidence of its effectiveness. Some researchers have found that electrical stimulation might have caused further nerve damage and delayed healing. Sometimes physiotherapy can help to strengthen the facial muscles. Patients with Bellâ&#x20AC;&#x2122;s palsy should find ways to reduce the stressful situations in their lives in order to speed recovery and avoid recurrence. Massage muscles of the forehead, cheek, lips and eyes using cream or oil. Exercise the weak muscles in front of a mirror. Open and close the eye, wink, smile and bare your teeth. Perform the massage and exercise for 15 or 20 minutes several times a day. Some patients may benefit from a special form of physical therapy called facial retraining. Brush and floss teeth more often to keep the mouth healthy. Patients with permanent facial paralysis may be rehabilitated through a variety of surgical procedures including eyelid weights or springs, muscle transfers and nerve substitutions. Other medical treatments for complications of facial paralysis including excessive motion of the face (twitching) or muscle spasm may involve surgical division of overactive muscles or weakening them by chemical injection. In certain circumstances, surgical removal of the bone around the nerve (decompression) may be done. vvv
19
Clinical Questions in Dentistry
10
How does one suspect inadvertent injection of the local anesthetic solution into cavernous sinus in maxillary region? KMK Masthan*, Shyam Sundar Behura**
I
*Professor and Head, **Postgraduate Student Dept. of Oral and Maxillofacial Pathology Sree Balaji Dental College and Hospitals, Chennai
t has been suggested that the local anesthetic solution, after an inadvertent entry into the venous system, will drain into the pterygoid venous plexus and thereby into the cavernous sinus through emissary veins traversing the bony foramina. It will be more vulnerable when the patient is in the supine position. The abducent nerve may be more susceptible than other cranial nerves because it travels through the cavernous sinus. Therefore, it has been suggested that the venous spread of the local anesthetic solution will explain the isolated ocular complications of diplopia resulting from the paralysis of lateral rectus muscle which is innervated by abducent nerve. Other symptoms include temporary pupillary dilatation and ptosis of eyelids. vvv
20
Clinical Questions in Dentistry
11
How is excessive salivation during dental procedures controlled? Eldo Koshy
Associate Fellow, The American Academy of Implant Dentistry Professor, Dept. of Prosthodontics and Implantology Royal Dental College, Kerala, Cochin
T
he following may be used to control excessive salivation that may occur during dental procedures:
Antisialagogue drugs
♦ Methantheline bromide 50 mg tablet taken one hour before the dental procedure.
♦ Propantheline bromide 15 mg tablet taken one hour before the treatment. Also by injecting 2-6 mg intraorally. It gives a dry working environment for 1.5 hours.
Both drugs are contraindicated in patients with a history of hypersensitivity to the drugs, glaucoma, asthma, congestive heart failure, obstructive conditions of gastrointestinal (GI) or urinary tract.
♦ Clonidine hydrochloride 0.2 mg taken one hour before the procedure.
Rubber dam
High volume vacuum
Saliva ejector
Svedopter vvv
21
Clinical Questions in Dentistry
12
How is cardiac resuscitation done? KMK Masthan*, Anitha Nagrajan**
*Professor and Head, Dept. of Oral and Maxillofacial Pathology **Postgraduate Student, Sree Balaji Dental College and Hospitals, Chennai
Cardiopulmonary resuscitation
Lay the patient on the floor.
Clear the airway.
Look into the mouth and throat to ensure the airway is clear.
If any objects are present, try to sweep them out with fingers.
If the person is not breathing, pinch the nostrils closed with thumb and index finger, and tilt the head back to open the airway. To carry out cardiac massage kneel at the person’s right side and interlock the fingers of the two hands to give external cardiac compression. With elbows straight, push down the lower sternum briskly with the heel of hand 15 times over about 10 seconds. Depress sternum 2 inches at each compression. Let the chest rise after each compression and two breaths, repeated multiple times. Defibrillation may also be indicated if there is ventricular fibrillation or asystole. vvv
22
Clinical Questions in Dentistry
13
What is the approach to the anesthetic solution being injected into the parotid gland while giving an inferior alveolar block? Rajesh Chandna
Dr Chandnaâ&#x20AC;&#x2122;s Dental Centre, New Delhi
D
entists administer thousands of local anesthetic injections everyday with few reports of serious complications. However, misjudging the anatomy involved during local anesthetic administration can result not only in inadequate or incomplete anesthesia, but in other complications such as paresthesia, bleeding or hematoma formation or in serious systemic complications. Most complications associated some are persistent or have do occur, it is incumbent on and act swiftly to manage the minimize the consequences.
with anatomy are transient in nature, but permanent ramifications. If complications the dentist to make the proper diagnosis problem, inform and assure the patient and
Paresthesia resulting from nerve trauma during dental anesthetic injection can last for weeks or months. These paresthesias commonly involve the tongue and lower lip. In these cases, mechanical (biting) and thermal trauma can occur without the patientâ&#x20AC;&#x2122;s awareness and can result in significant pathology. When the lingual nerve is involved, the chorda tympani branch of the facial nerve also may be traumatized, resulting in dysgeusia (impaired sense of taste) and xerostomia (reduced salivation). In some instances, dysesthesia may accompany paresthesia. If the injection is made too far posteriorly, the anesthetic solution may be injected into the substance of the parotid gland and could involve the facial nerve. If this happens, the patient will complain immediately of an inability to blink the eye, followed by an awareness of a sense of paralysis on the same side of the face. The dentist should quickly recognize the problem and assure the patient that the ensuing paralysis is transient and will disappear with the absorption of the anesthetic. vvv
23
Clinical Questions in Dentistry
14
What is the approach to manage a patient with dry socket and acute pain? Sana Wadhwa
Postgraduate Student, Dept. of Orthodontics, New Delhi
I
manage dry socket by thorough curettage of socket and packing with collagen (colla-plug) with sutures, or repeated dressings over a few days to close the wound. My choice of antibiotic is amoxycillin + metronidazole. 1. Medicated dressings: This is the main way to treat dry socket. The socket is packed with medicated dressings. The dressings need to be changed several times in the days after treatment starts. The severity of pain and other symptoms determines how the need for dressing changes or other treatment. 2. Flushing out the socket: The socket should be flushed to remove any food particles or other debris that have collected in the socket and that contribute to pain or infection. 3. Pain medication: Talk to your doctor about which pain medications are best for your situation. vvv
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Clinical Questions in Dentistry
15
How is excessive bleeding during surgeries managed? KMK Masthan*, Shyam Sundar Behura**, Jayasri Krupaa
*Professor and Head, **Postgraduate Student Dept. of Oral and Maxillofacial Pathology Sree Balaji Dental College and Hospitals, Chennai
T
he various methods to control bleeding during surgeries can be broadly categorized into the following headings:
Mechanical method Direct pressure (packs), clamps, ligating clips, staples, sutures, bone wax, digital pressure and external bandages can be used to arrest excessive bleeding.
Cauterization method Thermal cautery and electrocautery
By use of Laser, cryosurgery, vessel sealing device
Chemical method Topical absorbable hemostats Local hemostatic agents and techniques include pressure surgical packs, vasoconstrictors, sutures, surgical stents, topical thrombin and use of absorbable hemostatic materials. Sutures can be used to stabilize and protect packing.
Oxidized regenerated cellulose: Surgicel - binds platelets and chemically precipitates fibrin. Gelatin sponge/powder: Gelfoam, surgifoam - Surgifoam is an absorbable gelatin sponge with intrinsic hemostatic properties. Microfibrillar collagen - stimulates platelet adhesion, stop venous ooze. Hemostasis time 1-5 minutes. Thrombin: Topical thrombin which directly converts fibrinogen in the blood to fibrin, is an effective adjunct when applied directly to the wound. Fibrin glue - concentrated fibrinogen and factor VIII, thrombin and calcium, aprotinin to prevent clot dissolution. Surgical acrylic stents may be useful if carefully fabricated to avoid traumatic irritation to the surgical site. vvv
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Clinical Questions in Dentistry
16
How are broken anterior teeth dentures repaired in an emergency? Rajesh Chandna
Dr Chandnaâ&#x20AC;&#x2122;s Dental Centre, New Delhi
D
entures should always be repaired with denture acrylic by a dental professional. The dental surgeon may use acrylic or denture repair kits to join the broken denture after properly positioning the joint of the broken denture accurately. Self repair by patients using different adhesives are to be avoided completely and not recommended. vvv
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Clinical Questions in Dentistry
17
What is the management of a patient who has swallowed a root canal file during a RCT? Eldo Koshy
Associate Fellow, The American Academy of Implant Dentistry Professor, Dept. of Prosthodontics and Implantology Royal Dental College, Kerala, Cochin
A
n endodontic file may pass through the gastrointestinal (GI) tract asymptomatically and apparently atraumatically within three days. Timely treatment and referral is required.
The patient may be reviewed with serial chest and abdominal radiographs to locate the instrument, and stool tests for occult blood. Endoscopic removal may be required some time. If aspirated into lungs, there are reports of open surgery for instrument retrieval.
Simple measures like using Rubber dam while performing a root canal treatment (RCT), tying a floss/suture thread at the rear end of the RCT instrument can prevent an accidental aspiration and/or swallowing of the RCT instruments. vvv
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Clinical Questions in Dentistry
18
How is mandibular block administered to a patient with trismus? KMK Masthan*, Shyam Sundar Behura**
*Professor and Head, **Postgraduate Student Dept. of Oral and Maxillofacial Pathology Sree Balaji Dental College and Hospitals, Chennai
I
n a patient with trismus, the target area for the block is the mandibular sulcus, which is at the level of the coronoid notch and above the mandibular foramen. When the mouth opening is not adequate, the inferior alveolar nerve, which descends from above, is relaxed and away from the medial wall of the ramus. Consequently, it is at a distance from the target area, which leads to inadequate anesthesia. When the mouth opening is adequate, the nerve is flush against the medial wall of the ramus and at the target area. Hence, the patient reports experiencing almost immediate onset of anesthesia. This is why the block does not work in cases of trismus and the closed-mouth block needs to be administered.
Closed-mouth block (Vazirani/Akinosi block) This technique is most useful when the patient cannot open the mouth completely, as is the case with trismus. It is a simple technique that is comfortable for the patient. After the patient closes his or her mouth, the clinician advances a syringe fitted with a 35 mm needle parallel to the maxillary occlusal plane at the level of the cervical margin of the maxillary molars. The needle is inserted medial to the anterior border of the ramus and buccal to the maxillary alveolus. The clinician then advances the needle until the hub is level with the distal surface of the maxillary second molar. After performing aspiration, he or she then deposits a 1.8 ml cartridge of local anesthetic solution. This technique does not block the buccal nerve in some cases, so a separate buccal nerve block may be required to achieve anesthesia of the tissues buccal to the mandibular molars. No bony landmark is available when performing this technique. Hence, a small chance exists of overinserting the needle and injuring the vessels in the pterygoid plexus. However, the closed-mouth block is a reasonably safe technique. vvv
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Clinical Questions in Dentistry
19
How do you bandage a patient with a fractured mandible? Rajesh Chandna
Dr Chandnaâ&#x20AC;&#x2122;s Dental Centre, New Delhi
I
n mandibular fracture without displacement, the Bartonâ&#x20AC;&#x2122;s bandage is secured with a pin or strip of adhesive tape at the crossing on top of the head. It may be used for fractures of the lower jaw and to retain and compress the chin.
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Clinical Questions in Dentistry
20
How can inadvertent injections into the inferior alveolar artery be avoided? KMK Masthan*, Shyam Sundar Behura**
*Professor and Head, **Postgraduate Student Dept. of Oral and Maxillofacial Pathology Sree Balaji Dental College and Hospitals, Chennai
E
ven when clinicians use the utmost care, by aspirating before the injection and noting anatomical landmarks, intra-arterial injections can occur during inferior alveolar nerve blocks. Fortunately, permanent damage to nerves, facial and oral tissues and eyes is rare. Injection of the local anesthetic into the inferior alveolar artery would account for the deviation of the eye, with temporary anesthesia of the lateral rectus muscle. The epinephrine works peripherally on the -adrenergic receptors of the skin and mucosa, resulting in constriction of the blood vessels. This would account for the blanching of the skin localized to the infraorbital foramen area, resulting from decreased blood flow. Steps to prevent injecting into the inferior alveolar artery
Know the anatomical landmarks correctly. Aspirate frequently to avoid injecting into a blood vessel. Use an aspirating-type syringe, which has a tiny harpoon that engages the rubber stopper of the anesthetic carpule. Avoid needles <25 gauge. Slow injection and aspiration in two different planes can minimize incidence of injection into the vessels. vvv
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