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
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
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
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
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
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
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-
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 (
*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.
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
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
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-
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
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
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 –
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
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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