PAUL E. LEVY,  DMD,  Fellow, AAOMS

 

          Doctors’ Continuing Education Forum

 

 

                                                        

 

Index to Doctors’ C.E. “Blog”-table of contents

(listings are from top to bottom, as below)

 

2009, Nov.- Oroantral communication Discovery during Extraction

2009, Oct.- TMJ Joint- Differential Dx and Tx

2009, March- Wisdom Teeth and  Adolescent patients

2009- Dental Implants- Current Trends & Time Proven Princicples

Oct. 2008- Odontogenic Infections and Antibiotic Therapy

Sept. 2008- Extractions and Bony Spicule Management

June 2008- Sinus Perforation therapy

March 2008- Wisdom Teeth and Older Patients

 

 


                                                                                    Clinical Questions to: info@drlevyoralsurgery.com

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    WELCOME TO THE C.E. COMPONENT OF OUR WEB SITE!  DOCTORS ARE INVITED TO SUBMIT QUESTIONS OF GENERAL INTEREST  TO  E-MAIL,  ABOVE.

 

please note: The educational discussions contained on this page are for the benefit of the dentist and physician community.** Your unique knowledge of your own diagnostic, clinical and surgical skills is the ultimate guide of whether YOU should perform any particular surgical procedure or therapy offered as part of our commitment to contributing to the knowledge-base of our colleagues.  Some oral surgeons or other dentists in a different specialty/ or with different practical experience may have suggestions which are different but still equally valid.  Dr. Levy strives to have this publication in keeping with current literature is his field, as well as his personal patient care. It is the combination of his 25-plus years of experience, with a devotion to continued learning which he hopes will be of benefit to you.

 

Nov. 2009

Oroantral Communication discovered during Extraction

 

You just finished extracting a fairly “simple” maxillary tooth, and a large sinus perforation appears just superior to your site.  What went wrong, and what do you do?

 

As in the accompanying case, frequently you did every thing right. The large inflammatory mass, which  frequently can’t be appreciated on x-ray, has eroded through the very thin bony lamina between the maxillary sinus and the

extraction site. Perhaps some purulence drips down when you remove the tooth and its mass.   If you are in doubt, a “Valsalva Maneuver” will confirm your suspicions: Tell your patient that you’ll gently squeeze the nostrils,

and the patient should blow against your fingers (patient’s nose) but not through the mouth. ‘Blow like a scuba diver” usually works.  Air being forced through the socket is confirmation of a sinus opening.

 

Remember your anatomy: The normal outflow for the sinus is the Middle Meatus on the lateral side of the nose. It is above the maxillary dental alveolar bone. Closure must withstand gravity, therefore. If your closure isn’t very

good  (and sometimes even if it is) the repair will break down due to sinus secretions . A good closure will have a very good flap thickness, and suturing which leaves no gap- what surgeons sometimes refer to as a “watertight

closure”. Even a quite small sinus perforation will often break down if closure is not thick and well-sewn.  I use a fat flap from the infratemporal fossa if the communication is in the 2nd or 3rd molar area.

 

Antibiotics: 7 to 10 days of an antibiotic with good coverage for sinus is often used. Augmentin (amoxicillin plus clavulonic acid) or Cleocin is appropriate. The patient should expect a bit of blood from the nostril, and you should

tell them in advance how to place a small lubricated dressing to apply anterior intranasal pressure, if needed. The non-resorbable sutures are removed no sooner than 7 days post-repair.

 

This sinus opening was associated with a failed endo-treated tooth. The communication was 8mm A-P by 5mm buccal to palatal.. It was successfully closed with a broad based flap with a basement interior flap sewn into place.

The infraorbital nerve needs to be taken into consideration. You can visualize how an opening in such a dependent position on the alveolar bone floor could be susceptible to breaking down. This one did not, by applying careful

technique.

 

Anterior

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               


                                                                                                                                                            

                                                                                                                                                                                                             Posterior

 

 

 

Questions on how to treat this common but rather hard to care problem?  Call or e-mail me at info@drlevyoralsurgery.com.

 

 

 

 

 

 

Oct. 2009

TMJ: TEMPEROMANDIBULAR JOINT

PCP DIFFERENTIAL DIAGNOSIS and INITIAL THERAPY

WHEN TO TREAT, WHEN TO REFER

 

As a Primary Care Provider, you’ve encountered numerous patients with pain near the ear, not of otologic origin.  Symptoms included limited jaw opening, clicking and popping, pain upon chewing, and the jaw getting briefly “stuck” before opening.  What can you do for these patients?

 

I can offer a few suggestions on therapy. I’ve treated TMJ patients from all corners of N.H.  Since my residency in Oral and Maxillofacial Surgery at     Mass. General Hospital, TMJ therapy has been an area of interest for me.  Most of my specialty colleagues have familiarity with joint problems. However, it seems that most Oral Surgeons in N.H. prefer not to treat TMJ patients, for a variety of reasons.  In addition, the general dentist of your patient usually doesn’t wish to treat these patients either. The result is that many TMJ patients get referred to Boston, which is inconvenient.

 

You can help someone with myofascial spasm of the jaw.  TMJ intraarticular disease most often requires surgery; this subset you would refer.  I’m happy to assist you via phone consult, or referral, if you’d like.  However, initial phase diagnosis and treatment is within your expertise.

 

Differential Diagnosis:

·          A PCP has a fairly straightforward algorithm after ear infection, and other standard medical etiology is ruled-out.

·          The problem is generally primarily myofascial, of the masticatory/chewing muscles, with secondary effect upon the TMJ itself; OR the reverse- intrarticular TMJ disease with reactive muscle spasm.

·          A good clinical hint: ask the patient: “With one finger, touch the exact spot which is MOST painful.”

·          Muscle/myofascial primary will almost always have the patient pointing to the external lateral side of the jaw, where the masseter muscle runs.

·          A second location, which requires a gloved hand to examine, is to palpate the insertion of the temporalis muscle- lateral to the back of the upper jaw (maxilla). Here, the tendon of the temporalis inserts on the mandibular coronoid process.

·          Significant tenderness or a reproducing of the patient’s pain is a good indication that you can begin with myofascial therapy. This is similar to your initial therapy for treating a presenting low-back pain patient.

 

There almost always is some muscular component to TMJ. You can suggest:

·          Heating pad to jaw at affected area in a.m. and p.m.

·          Do they use chewing gum? Stop, or at least cut to a minimum.

·          Medications: (lacking contraindications): NSAID- I prefer ibuprofen, 600-800mg t.i.d.

·          Muscle relaxant: either robaxin / methemcarbamol (500 or 250 mg.), or flexeril, again t.i.d.

·          Consider Physical Therapy referral if the muscular component is evident. Work with a Therapist who has head and neck training and an interest in facial muscle.

 

I ask patients to follow this regimen for a month, even if they don’t perceive immediate relief. A lack of response will shift the diagnosis towards the intrarticular joint as the primary etiology.

 

INTRARTICULAR TMJ DISEASE:

 

A lack of significant improvement with the above therapies means it’s time to refer.  Joint disease or true intrarticular TMJ etiology is likely.

 

I’d suggest that you do NOT obtain a MRI as part of your initial workup. Initial treatment based on a masticatory myofascial symptom pattern is adequate for primary care therapy, as above. An MRI maps out intrarticular pathology, and doesn’t alter initial therapy. I rarely order an advanced study unless the patient has “failed” initial-phase therapy, and the patient and I agree that the situation is intolerable. A MRI is then ordered if we are actively considering surgical correction.

 

In my experience, about 80% of presenting TMJ pain is improved with the above masticatory myofascial therapy.  If you wish to confer with me, or refer a patient who isn’t improving, please don’t hesitate to call me at 228.9050, or e-mail me at:  info@drlevyoralsurgery.com.

 

Many PCPs who’ve contacted me and initiated the above recommendations have obtained good results.  I hope that this brief overview of therapy is helpful.  In addition, please share this letter with your associates, as that they might find it helpful for their next patient with a painful TMJ.

 

 

June, 2009

 

IT’S WISDOM TOOTH TIME FOR YOUR HIGH SCHOOL AND COLLEGE PATIENTS

Peer Reviewed Facts to Help You in Wisdom Tooth Assessment

 

AAOMS recently published a “Wisdom Tooth White Paper” to evaluate the volumes of data regarding 3rd molars.

The document is rich with hundreds of literature citations of studies on the evaluation of who benefits from the removal of wisdom teeth, and related surgical protocols. This data was evaluated for accuracy by academicians using rigorous statistical and epidemiologic parameters.

 

You may benefit, this summer, by this brief summary of the Paper’s findings. When counseling your 20-ish patients on third molar removal versus retention, being able to refer to proven facts and studies will likely make life a little easier on you.

 

I and my staff are happy to provide our popular “Lunch and Learn” to you and your staff at your office. “Running time is 30 minutes, plus questions, making it convenient to fit into your lunch schedule. My staff and I seek to get across key points which you might wish to know, so that you can move on to aspects of dental care which are the focus of your practice.

 

Continuing Education credit is available, under the auspices of the NH Dental Society.

 

THE LITERATURE SUPPORTS THE FOLLOWING:

 

1- Asymptomatic impacted wisdom teeth have an increased load of associated pathologic bacteria if a portion of the

     tooth has approached the gingival surface.

 

2- Most impacted 3rds, although asymptomatic, can be shown to have the chemical mediators of chronic inflammation

    within their bony cavities.

 

3- Removal before 25 years of age carries far less risk of morbidity than those removed later in life. This finding ranges                   post-op perio defects, to sinus continuities which require repair, to rarer issues such as pathologic fractures.

 

4- Orthodontic overcrowding is a multifactorial problem. No study has been able to isolate 3rds as the sole cause of overcrowding, or post-treatment relapse. Third molar removal should therefore be presented as one of a number of issues

relating to maintaining the stability of the dentition.

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NOT IN THE WHITE PAPER, BUT OF CONSEQUENCE

 

Third molars are frequently at the junction of the various nearby anatomic fascial spaces. This is why infected 3rds can

pose a significant danger when infected. The Sublingual, Submandibular, Buccal, Masticator and Parapharyngeal fascial

spaces are amongst those readily involved by a fulminant 3rd molar infection.  Taking you back to Dental School, the

involvement of multiple spaces can yield the infrequent, but very serious Ludwig’s Angina.

 

 

Consider our Lunch and Learn on wisdom teeth. Your staff benefits from the information as well. A good indication or two from you will reflect better on you and your office than telling the student/ parent that the child should “get your wisdom teeth out”. Please call soon if you would like the advantage of this- our lunchtime availability diminishes as

Spring turns to Summer.

 

Also important in the current economy: we at Central NH Oral Surgery, P.A. try very hard to make care affordable to

your patients’ families. We accept / participate in most significant health insurance programs in our area- so that

your patient/ student can afford the care which you’ve diagnosed as being necessary.

 

Have a good Spring / early Summer!

 

Paul / Paul E. Levy, DMD, Diplomate, Amer. Board of OMFS 

 

 

 

 

 

 

 

 

 

March, 2009           PE  Levy, DMD, Fellow-AAOMS

 

 

 

 

 

DENTAL IMPLANTS- TIME PROVEN METHODS AND CURRENT TRENDS

 

 

 

 

 

 

 

     Since 1982, I’ve placed a wide variety of both dental and endosteal implants (ex: Staple Implants- for edentulous mandibles).  That, plus tons of Cont Ed and literature

    review permit me to offer some observations and suggestions to obtain superior results:

 

    In this film, we see a number of systems spanning 12 years duration. They’ve all been functionally and esthetically successful- not including the nice one at #12 site

    which I placed this week.  Naturally, the skill of my restorative colleague is equally responsible for both nice AND long-term success.

 

    1- BONE- thickness, and quality is very crucial. Almost any system will work if the bone is adequate- both in thickness (buccal- lingual) and in height ( does a sinus lift

        procedure need to be done to place implants in an atrophic maxilla?).  Please look at the available bone when considering implant restoration.  If it’s clear that bone will

        need to be grafted, the patient hearing that true thought from you, whom they’ve known longer and trust, as well as me reinforces the concept that we’re working on                    

        the same wavelength.

 

        Socket preservation- I can often avoid more complex grafting procedures by grafting into the socket at the time of failed tooth removal.  For technical ease and the best

        possible result, please consider letting me remove a tooth where an implant is treatment-planned.

 

   2- IMMEDIATE LOADING- show me the long-term, peer-reviewed proof!

       Implants have about a forty year record of development and improvement in design and technique.  The vast majority of these have been done in he old-fashioned way

       which takes maximum advantage of our knowledge of bone healing and physiology.  The implant is permitted to heal, or lock with the bone for some months- as a cast

       does for a broken bone- complete immobility.  Motion, or even micromotion contributes to malunion in bone. The vast balance of valid studies which I’ve reviewed

       indicate that loading an implant increases the complication or failure rate. No good long-term studies exist to show otherwise.

      

       As dentists, we know that making a temp, and taking it “out of occlusion” doesn’t eliminate the forces imparted to it by chewing, eccentric motion, etc.  The premise

       runs counter to everything we’ve learned about what makes osseointegration succeed.  Your patients expect that our implant will last for a very long time. Research

       based on classical healing times (3 to 4 months in uncomplicated cases- longer in grafting situations).  I have not yet seen valid research to permit me, in good

       conscience, to immediately load- and I’ve seen some negative results from other doctors to make me content with the standard timetable.

 

   3- CLOSE RESTORATIVE- SURGEON INTERACTION- optimal placement, occlusion and esthetics requires that we confer.  This is especially so as the number of

       units to be placed increases.  If you cannot be certain that your colleague fully understands your needs in restoring a case, that communication problem can cause

       all manner of non-optimal results. Your discussion should be during treatment planning- not once the units have been placed.

 

   4- Implant Company Technical Rep- Each implant has its own little oddities. The reps whom I work with, and therefore the implant products which I use, are available to

       be at your chairside at impression / restoration time should you desire. We pay quite a bit for implant components- I consider the availability of the rep. to be an

       important part of the “value-added” part of the implant.  I can say that I’ve changed primary systems which I’ve used when a company rep became too busy to

       be available to help my colleagues. If you’re not comfortable torquing that screw, then the rep ( or I) should be there with you.

 

       Dental Implants are quite sophisticated now, and we can obtain some very gratifying results with them.  As with most areas of dentistry, the basics of planning and

       support are the foundations of our success.

 

      TO MY MEDICAL-SIDE COLLEAGUES:

       Sorry for all the dental-speak.

       Dental Implants are generally inert titanium “screws” which promote the growth of bone without a fibrous interface- the definition of a surgically successful implant.

       My restorative dental colleagues can then treat my surgical result much like a tooth- for placement of a cap, to help hold in a lower denture and the like.

       Risk factors from a medical perspective are generally additive:  smoking and IDDM is much more troubling than either alone.  Poorly controlled diabetes, significant

       anticoagulation, a prosthetic heart valve would be considered a contraindication by most of my specialty colleagues.

       Please let me know if you have specific questions, or wish references.

 

 

Questions? / Please e-mail me at: info@drlevyoralsurgery.com

I look forward to your thoughts and suggestions

       

 

 

 

 

 

 

 

Oct. 14, 2008          P.E. Levy, DMD, Fellow AAOMS

 

ANTIBIOTIC THERAPY for ODONTOGENIC INFECTIONS

REVIEW of BASIC GUIDELINES

 

Antibiotic (antibx) therapy for standard “dental” infections should have a reasoned-out rationale for our selection. General principles and from published research

clinical experience is presented:

 

CAPSULE:

1-Barring contraindications, primary antibx of choice treat anaerobes:

*Penicillin (PCN) class

*Clindamycin (Cleocin)

*Erythromycin (including EES tabs)

 

2- Don’t change your antibx for a patient without a good reason

 

3- Always be looking and feeling for an abscess, especially if patient isn’t getting better

 

Most dental infections are treated empirically- it works for me. Thought may be given to these issues:

  • Fever, combined with your clinical suspicion and exam, including deep palpation, have been shown to have the best statistical correlation with antibx therapy     

and the ultimate need for drainage.

  • PCN class drugs have been found to have efficacy in at least 90% of dental infections. Penicillin itself probably has one of the highest sensitization/ allergenic

properties of any antibx. Amoxicillin is much less allergenic.

  • Most of the “worst’ bacteria are Anerobes, such as Bacteroides and Peptostrptococcus.
  • Clindamycin is an excellent drug for most oral infections. We recall the possibility of its altering bowel flora, to cause Pseudomembraneous Enterocolitis-            

which itself requires antibx for treating. Have your patients STOP the drug at the first sign of diarrhea, and call you to switch drugs.  Cleocin 150mg.

QID is sufficient for most dental infections.

  • Cephalsporins (such as Keflex) have little scientifically-proven value over the PCN-class in the oral environment. They do have better activity against

Staph.- something which is rarely dealt with by us, unless there was a through-and-through skin laceration, or the like. Although favored by some in endodontic infections, this is not supported by the literature.

  • Erythromycin (including EES tabs- macrolide class)- about as good as PCN for standard oral flora. I do not prescribe it unless the patient has used it

before- it has a very high rate of gastric upset, which causes one to change it when the patient just can’t keep it down.

 

Please Remember:

  • Frequent switching of antibx on your patient due to lack of response, and continued severe pain often means that an abscess is present. From a societal

POV, antibx switching may hasten bacterial resistence to antibx, as the bacteria get to “see” short courses of several drugs, and can become antibx-resistant

Select a good one and stick with it on a given patient, barring specific reasons.

  • Antibiotic-loading…Numerous studies indicate that having a good “load” of antibx before a procedure, with a much briefer course afterwards yields superior protection to the standard post-treatment rx.
  • Birth Control Pills- PCN-class drugs can dramatically affect the efficacy of bcp’s. Cleocin, as an example, does not. I almost always try to find  an alternative to the PCN-class for women in their child-bearing years who are on bcp’s. An alternative is to stress (and document) the need for supplemental

protection. This can, of course, easily be forgotten by someone who is used to not thinking of such concerns,

  • Abscess- palpate deeply to feel for the beginnings of a fascial space abscess if your patient is still in severe pain despite several days of an appropriate

antibiotic and analgesic. A sublingual abscess, for example, is not always easily seen at first. Bimanual palpation- one hand in the floor of mouth and the other pushing upwards from the skin will be helpful in this location.

  • I & D- either upon a new presentation, or after an appropriate course of antibiotics, a standard alveolar abscess may exist or form. You probably know

that you will need to drain the abscess at this point. Awareness of relevant nearby anatomy is “key”- the branches of the mental nerve in mid facial mandible

and the very high on the lingual mandible-run of the lingual nerve if # 18 or 31 has a seemingly easy abscess, are good examples. Don’t work in anatomically

sensitive areas that are outside your comfort-zone

  • Address the Etiology- not to state the evident- but as soon as reasonable, do the endo, extract the tooth or whatever caused the infection initially. Neither

you nor your patient want to go through that again!

 

QUESTIONS / COMMENTS: info@drlevyoralsurgery.com         Thanks for the input. Will publish again soon…….

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 Sept. 14, 2008      P.E. Levy, DMD, Fellow AAOMS

 

EXTRACTIONS AND BONY SPICULES / SEQUESTRA

MANAGEMENT

 

Any dentist who does extractions should be prepared to treat the bone spicules which can appear up to months after the tooth removal.  They can occur no matter how “smooth” you left the bone at the time of extraction.

 

Bone physiology, healing and the remodeling inherent in bone healing is the issue which we deal with. Bone maturation, and therefore the possibility of spicules can occur up to six months after the initial surgery.  Patients often think that “you left a piece of tooth in there, Doc”.

 

This occurs in thin mucosa areas especially – the 2nd to 3rd molar areas and the mylohyoid ridge beneath this area being especially prone. Many of these spicules work there way through the mucosa, as osteoclastic/ osteoblatic activity progresses. Some spicules are sharp and annoying enough to your patient that more direct treatment must be given.

 

CASE REPORT:


This healthy male had #31 removed 4 months previously, and uneventfully, with normal healing and smooth lingual bone for 3 months postop:

 

 

 

 

 

#30 is seen with a small but annoying sequestrum/ bone chip to the lingual of the 4 month old #31 extraction site.  As it bothered the patient’s tongue, and he did not want to try massage, hot rinse, etc----I removed the excess bone, TAKING EXTREME CARE AS TO THE UNDERLYING LINGUAL NERVE. A nice result and a happy patient was the result.

 

COMMENTARY:  If you elect to do this in an anatomically sensitive area, excellent visualization is recommended.  I do procedures such as this with loupe magnification.

Some patients have bone genetics such that they are prone to form sequestra, as was the case with this patient. At the time of the extraction, one should not leave sharp bony edges, as palpated over the soft tissue.  Maxillary bone, being relatively pliable, may be deformed laterally with an extraction. You might attempt to manually compress a buckled area inward, or develop a flap to smooth the sharp edges if needed.

 

Bone is metabolically active, even if it is slower in healing than, say, gingival. As above, a decision to surgically recontour versus supportive care is based on patient preference informed by your experience and advice.

 

Questions /Comments: info@drlevyoralsurgery.com                 Hope to hear from you soon

 

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 June. 5, 2008      P.E. Levy, DMD, Fellow AAOMS

 

YOU’RE IN THE SINUS – NOW WHAT?

 

 

 

    As most any OMFS knows, the maxillary sinus may be encountered during an extraction of any tooth from the canine to the third- and whether it seems like a “simple” or a surgical, or difficult removal.  Inflammatory tissue frequently erodes the thin bone lamina, when an upper posterior has a periapical lesion. The sinus, or

Scheiderian membrane may also have been eroded, or the root may have simply grown into the sinus- it’s hard being certain of the three dimensions around the root

from a 2-dimensional film.

   Hopefully, you informed the patient of this possibility before the procedure. The simple fact that there is an OROANTRAL COMMUNICATION (OAC)

does not mean that you “did something wrong”. We all know that patients don’t like unexpected surprises, however.

 

   DIAGNOSIS: aside from a visually-obvious OAC,  an easy post-tx test is the Valsalva Maneuver:  gently, but firmly squeeze the patient’s nostrils, and ask him/ her

to “blow air against your nose like a scuba diver”. ? Air leak through the extraction site = sinus communication. You can confirm this, if you wish, by instilling

some sterile saline into the socket/ site. If it goes into the nose/ runs down the back of the throat- same proof.

 

   TREATMENT: an OAC  of any reasonable size will not granulate in on its own- recall that the maxillary ostium, which drains the sinus, is half way up the sinus

wall. We have gravity working against us, and a FLAP CLOSURE will likely be necessary.

(reminder: if you are going to attempt a flap, this should be the subject of an Informed Consent discussion. Your patient initially was expecting to “just” have a tooth removed).

   For a flap, a broad base with adequate tissue to have a so-called tension-free closure is needed. You should have a good knowledge of the relevant anatomy in the area (example- infraorbital nerve).

   Whenever I can, I mobilize a buccal fat flap from the infratemporal fossa- just postior and a bit lateral to the third molar. This permits a thick cushion of tissue to

fill the defect, rather than a thin layer of gingival and mucosa only. Thin flaps frequently break-down, or re-open. Of course, you do not want to do ANY surgery

which you’re not intimately familiar with- the maxillary artery and nerves run through the area described.

 

   ANTIBIOTICS: whether you choose to repair yourself or refer, this is very important. Recall that a normal sinus is close to sterile. Taking drug allergies into

consideration, the antimicrobial spectrum of 10 days of amoxicillin, or Augmentin ( amoxicillin with clavulanic acid), or clindamycin /Cleocin is generally suitable.

As with any drug which you prescribe, discussion of side effects is important. {ex: both Augmentin and Cleocin may cause diarrhea. Fairly well-known is that

Cleocin may cause pseudomembraneous enterocolitis. Cleocin in particular, although being a very good antibiotic for coverage of OAC, should be discontinued

and you should be notified immediately, if this side-effect occurs.}.

 

If you encounter an OAC, and don’t wish to repair it yourself, please let me know of your patient early-on. The sinus is quite finicky- pre-existing sinus disease

is readily worsened by the direct introduction of oral flora.

 

An Oroantral Communication associated with a posterior extraction is statistically a fairly frequent event. Please be able to identify that a communication of any reasonable size has occurred.  [Tiny covert cracks in the sinus floor may not respond to these tests- these usually heal uneventfully unless significant pre-existing sinus disease is present]. Routine post-extraction tests, as above should be part of each of your upper extractions-and the results of your testing should be in your charting of the procedure. Informing the patient, keeping them comfortable with a suitable analgesic, and a suitable spectrum antibiotic, and directly arranging for a transfer of care will help your patient, as well as your own blood pressure, in the face of an unexpected surgical event.

 

       Questions, comments? : info @drlevyoralsurgery.com           Speak with you next week!   

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22  March., 2008

 

  WISDOM TEETH AND YOUR OLDER PATIENTS:

 The AAOMS Parameters of Care are a reflection of the greatly increased difficulty frequently found in treating these patients. Studies have almost universally

 found a higher degree of difficulty, and complications, compared to the standard 17 to 20 year old age for assessment and treatment.               

                      

 

            CASE REPORT

 

  An otherwise healthy woman, approx. 60 y.o. has had continual pain in the right retromolar area despite repeated denture adjustments.  You might agree that the

film presents the diagnosis

  I counseled the patient on her quite high risk of jaw fracture and/or numbness. After an appropriate pre-op workup, I was able to provide the deep IV sedation

which she desired.

  Happily: no complications. Mandible intact by both introp exam and postop film.  NO nerve dysesthesias- normal sensation in her jaw, lip, tongue and chin as well

as normal taste discrimination ( -hypoglossal nerve).

  Pathology: an intensely inflamed dentigerous cyst. Marked fibrotic changes were noted- the body’s attempt to “wall-off” the inflammation with collagenous scar.

 

  This was one happy woman, as I had prepared her for mandibular fracture, and the possible need for nerve repair.

 

Commentary: When you refer your “average” teenage patient, she and her parent should know that scores of Peer-Reviewed studies support early removal,

  when it is clear that the thirds will not be erupting appropriately. Pathologic formations, ease of recovery, treatment when the patient is quite healthy, and minimal

   impact (or future preservation of the periodontium of the second molar) are some of the findings which support your referral.

     Education is a major part of my professional duty, and I am happy to explain such issues with patient and parent. It will reflect well upon you and your training

if you can spare a few moments to explain a few core indications for removal. Patients do sometimes come in stating that they were told that “it’s time you got your

wisdom teeth out”.

  I will deal with the detailed pros and cons. I’d suggest that a few good reasons why the patient doesn’t want to wait until things are very difficult reflects well

on YOU, as their caring family dentist.

 

  See you next week! ?s or comments-  info@drlevyoralsurgery.com

      PAUL

 

 

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