A microbiological study of pre- and postoperative apicectomy sites

There is little information on the microbiology of periapical lesions, and no data on the residual microbial flora in the periapex, if any, after apicectomy procedures. Hence, 64 patients treated by apicectomy procedures were prospectively studied to assess the bacterial flora in the periapex and to evaluate the residual bacteria in postoperative apicectomy sites. Of the 64 lesions studied, 14 (22%) were sterile and 50 (78%) yielded bacteria preoperatively. Bacteria could be recovered from 28 (56%) of the latter lesions after apicectomy and curettage. A total of 105 bacterial strains was isolated from 50 lesions, yielding a range of 1–4 (mean 2.1) species per sample. The isolates comprised 84 (80%) facultative anaerobes and 21 (20%) strict anaerobes. A polymicrobial growth was obtained from 39 lesions whilst 11 lesions yielded pure cultures. On detailed microbiological analyses of 29 lesions, 40% of the isolates were identified as alpha-haemolytic streptococci, half of which were Streptococcus sanguis; anaerobic streptococci were the predominant anaerobes. None of the organisms or group(s) of organisms emerged as recalcitrant colonisers which were difficult to dislodge after surgical debridement. These data indicate that the majority of periapical lesions harbour a variety of flora which cannot be eradicated despite thorough apicectomy procedures.     

An investigation into post-operative pain after third molar surgery under local analgesia

The pain experienced after third molar surgery was investigated over a 7 day post-operative period in 80 patients. The results from the study suggest that post-operative pain is of short duration and reaches its maximum intensity in the early post-operative period. Nearly all patients required an analgesic at some time during the 7 days. The sex of the patient and whether there is a previous history of pericoronitis are important determinants of post-operative pain. However, the magnitude of post-operative pain does not appear to be dependent upon the operator or related to the extent of surgical trauma as assessed by operating time and radiographic score.     

Treatment of injuries to the inferior alveolar nerve after endodontic procedures

Overextension of filling material into the mandibular canal after root treatment in the lower jaw is a rare but serious complication. Mechanical compression, chemical neurotoxicity and local infection may cause irreversible nerve damage. A report on 11 patients with neurological complaints of the inferior alveolar nerve after endodontic treatment is summarised. The neurological findings are dominated by hypaesthesia and dysaesthesia. Half of the patients reported pain. Hyperaesthesia is found much more rarely. Nearly all the patients had a combination of one or more symptoms. Initial X-rays showed root filling material in the area of the mandibular canal. Nine cases were treated with apicectomy and decompression of the nerve; in two cases, extraction of the tooth was necessary. Only one patient reported persistent pain after surgery. If neurological complaints appear after root filling in the lower jaw, a nerve injury due to root filling material should be ruled out. In cases of overfilling, immediate apicectomy and decompression of the nerve with conservation of the tooth is often the treatment of choice; the tooth may be preserved and the best chance of avoiding permanent nerve damage is provided.     

颌骨大型囊性病变相关牙的保存治疗

目的:研究保存颌骨大型囊性病变相关牙的临床效果。方法:对22例颌骨囊性病变患者的102颗相关受累牙术前行根管治疗。手术彻底刮除颌骨病变组织后,用电钻将暴露于骨腔中的根尖磨除2～3mm。术后随访7～28个月,检查经治牙的松动、咬合、牙根吸收以及骨质修复情况。结果:22例患者颌骨囊性病变均无复发。102颗经治牙中,98颗成功保留,均能正常行使咀嚼功能;4颗因松动加剧于术后3个月拔除。结论:颌骨大型囊性病变相关牙,经术前根管治疗联合术中根尖切除可予有效保存,不增加囊性病变的复发率。     

Post-operative dental pain and analgesic efficacy. Part I

Two groups, each of 100 adult patients who had undergone either a periodontal or oral surgical procedure were asked to record their pain experience over a three day investigation period. The results show that post-operative dental pain is variable in its nature and intensity, but reaches its maximum intensity in the first 12 hours post-operatively. Women appear to be more sensitive to post-operative pain than men. Significant differences in the pain experience after different operative procedures were noted. Removal of impacted lower third molars and retained roots result in more post-operative pain than the various other operative procedures. The incidence and severity of post-operative pain showed no clear relationship to the duration of the surgical procedure.     

Pain management following dental trauma and surgical procedures

Surgical procedures and post-traumatic management of dental patients require effective pain management during treatment, but being considerably more invasive than conservative treatments, pain management is required into the postoperative period. Clinical trials on pain intensity following dental surgical procedures (e.g., 3rd molar extraction, implant placement, periodontal, and endodontic surgery) have shown that pain is most intense approximately 5–6 h after completion of the procedure, reaching its peak levels during the first postoperative day. Greatest consumption of analgesics occurs during the first 48–72 h after 3rd molar extraction. For the management of perioperative pain associated with either conservative or surgical dental treatment, the local anesthetics articaine, lidocaine, mepivacaine, and prilocaine are preferred. These drugs, with a vasoconstrictor, provide a rapid onset and a duration of pulpal anesthesia adequate to complete most dental and surgical procedures painlessly. For management of post-traumatic and postsurgical pain, bupivacaine—administered by an appropriate nerve block—near the conclusion of a surgical procedure, can provide the patient with a pain-free period of up to 12 h. Nonsteroidal anti-inflammatory drugs represent the most effective drugs for the management of dental postsurgical pain. NSAIDs, as a group in therapeutic doses, have numbers needed to treat (NNTs) ranging from 2 to 3, while opioid analgesics do not approach those for NSAIDs. A protocol for management of pain following surgical procedures and traumatic injuries is discussed in this paper and includes preemptive NSAID; perioperative pain management; postoperative pain management—local anesthesia; postoperative pain management—analgesics; postoperative telephone call.     

Incidence of pain after biomechanical preparation: a review of 302 cases treated by dental students

Records of 302 root-filled teeth treated by dental undergraduates were reviewed by four lecturers in the Department of Conservative Dentistry, University of Malaya. Preoperative and operative factors were evaluated for their association with postoperative pain experience of patients during the visit immediately after completion of biomechanical preparation. Eighty four percent of patients did not experience any pain after biomechanical preparation whilst the remaining 16 percent only complained of slight or moderate pain. The incidence of pain after biomechanical preparation is not high even when performed by inexperienced undergraduates. Teeth with a pre-existing painful condition had a higher chances of postoperative of pain. The incidence of postoperative pain was halved when teeth were associated with a sinus tract.     

Evaluation of etidocaine hydrochloride for local anesthesia and postoperative pain control in oral surgery

Etidocaine hydrochloride, an amide-type local anesthetic with prolonged duration of action, was evaluated and compared with a standard local anesthetic, lidocaine, to determine its efficacy as a local anesthetic and its effect on postoperative pain following removal of impacted third molars. The findings indicate that 1.5% etidocaine hydrochloride with 1:200,000 epinephrine, in comparison with 2% lidocaine hydrochloride with 1:100,000 epinephrine, suppresses the magnitude of postoperative pain, and results in anesthesia comparable with that obtained by lidocaine, but results in greater blood loss during surgery.     

Extradural subtemporal transzygomatic approach to the clival and paraclival region with endoscopic assist

ABSTRACT: The authors describe the extradural subtemporal transzygomatic (ESTZ) approach and its variants to expose the clival and paraclival areas. A microanatomical study was conducted to quantify the clival and paraclival exposure and the maneuverability areas obtained by microscope and endoscope using the ESTZ approach. Section versus preservation of the third trigeminal branch (V3) and petrous apicectomy to obtain a wider clival exposure and a better internal carotid artery control are discussed.Eight cadaveric specimens were dissected to obtain morphometric measurements after performing the ESTZ approach and its variants. Anatomic areas exposed by the approaches were calculated using the ImageJ 1.37a software.The ESTZ approach performed with sectioning of V3 and petrous apicectomy allowed for a mean incremental exposed area of 1.8 cm (range, 1.24-2.43 cm). The mean amount of additional anatomic areas visualized after the ESTZ approach with petrous apicectomy if compared with the ESTZ approach without petrous apicectomy was 24% (range, 14.4%-37.5%). The mean percentage increase of maneuverability area after petrous apicectomy was 69.9% (range, 43.8%-96.6%).The ESTZ approach is suitable when dealing with extradural tumors of the middle-upper clivus extending into the ipsilateral paraclival area. V3 section and petrous apicectomy increase the operability, the surgical exposure, and the maneuverability area and improve vascular control on the internal carotid artery. Application of endoscopy does not impact on the maneuverability area but enhances the visualization of blind corners; endoscopic surgical view without drilling the petrous apex is comparable to that obtained by the microscope after petrous apicectomy.     

Postoperative pain experience after gingivectomies using different combinations of local anaesthetic agents and periodontal dressings

The present study examines postoperative pain experience following 243 gingivectomies in Norwegian patients using possible combinations of 3 local anaesthetics (lidocaine-adrenalin, prilocaine-felypressin or mepivacaine) and 3 periodontal dressings (Coe-pak, Wondrpak or Nobetec). When Coe-pak was used, the mean pain score was higher (P less than 0.05) in the group treated with lidocaine-adrenalin 4 to 6 h after gingivectomy than the groups treated with prilocaine-felypressin or mepivacaine. There was no significant difference between the groups treated with prilocaine-felypressin or mepivacaine. When Wondrpak or Nobetec were used, there was no significant difference between any of the local anaesthetics used. The present finding shows that the local anaesthetic combination of lidocaine-adrenalin (1:80,000) gives rise to a higher mean postoperative pain experience after gingivectomy than prilocaine-felypressin or mepivacaine. However, the relative difference in pain experience seen after gingivectomy when using the present local anaesthetic agents is masked when using an eugenol-containing periodontal dressing. Thus, the higher pain experience reported after lidocaine-adrenalin may only be clinically important when using periodontal dressings without local anaesthetic components such as eugenol.     

A comparison of postoperative pain experience following periodontal surgery using two local anesthetic agents

This controlled, double-blind, split-mouth study was designed to evaluate postoperative pain experience following periodontal surgery on 20 patients. Two commercially available local anesthetic agents, bupivacaine HCl and lidocaine HCl, were used. Periodontal surgeries were standardized to minimize differences in difficulty, extent and time. A patient questionnaire was used to collect data for the 24-hour observation period following periodontal surgery. During this period, pain perception was assessed by visual analogue scales. The results indicated that when bupivacaine was used, there was less postoperative pain, fewer postoperative analgesics taken and a longer period of "numbness" (anesthesia) as compared to lidocaine. The patients expressed a strong preference for bupivacaine over lidocaine.     

碧兰糊剂和碘仿糊剂根管充填后疼痛的比较

目的比较碧兰糊剂和碘仿糊剂根管充填后疼痛的发生率与持续时间。方法将根管预备后行根管充填的260颗患牙随机分成2组,碧兰糊剂组130颗患牙,用碧兰糊剂加牙胶尖充填,碘仿糊剂组130颗患牙,用碘仿糊剂加牙胶尖充填,观察术后疼痛的发生率及持续时间。结果碧兰糊剂组的根充后疼痛发生率为10.8%(14/130),碘仿糊剂组为32.3%(42/130),两组间差异具有统计学意义(χ2=4.90,P<0.05)。碧兰糊剂组根充后疼痛持续1～2 d 10颗,3～4 d 3颗,5～6 d 1颗;而碘仿糊剂组根充后疼痛持续1～2 d 6颗,3～4 d 20颗,5～6 d 14颗,7 d以上2颗。两组疼痛持续时间差异具有统计学意义(χ2=73.11,P<0.01)。结论碧兰糊剂根充后疼痛的发生率明显低于碘仿糊剂,且疼痛持续的时间较短。     

Learning by doing virtually

Selective reduction of bone without collateral damage (nerves, teeth) is essential in apicectomy. To test whether skills acquired on a virtual apicectomy simulator (VOXEL-MAN system with integrated force-feedback) are transferable from virtual to physical reality, two groups of trainees were compared. Group 1 received computer-based virtual surgical training before performing an apicectomy in a pig cadaver model. The probability of preserving vital neighboring structures was improved significantly, i.e. six-fold, after virtual surgical training (P<0.001). The average volume of the bony defects created by the trainees of Group 2 (mean: 0.47 ml) was significantly (P<0.001) larger than by the trainees of Group 1 (mean: 0.25 ml). Most importantly, the ability to objectively self-assess performance was significantly improved after virtual training. Training with a virtual apicectomy simulator appears to be effective, and the skills acquired are transferable to physical reality.     

Bio-oss填塞根切术后骨腔疗效观察

目的:探讨Bio-oss填塞骨腔对提高根尖切除术疗效的意义。方法:选择根尖切除术病例43例,采用单盲法随机分为2组,实验组17例根切术后植Bio-oss骨粉,对照组26例根切术后不植入任何材料,分别于术后3月、6月、1年、2年复诊摄片及对照检查,随访时间最长者为5年。结果:除对照组中有2例术后半年复发外,其余均取得良好的疗效。实验组治愈达100%,较对照组92%有显著差异。结论:采用Bio-oss骨粉填塞根切术的骨腔,是促进术后骨腔愈合的有效方法。     

Reducing postoperative pain by changing the process

Untreated postoperative pain is an important ethical and financial issue that can lead to unnecessary suffering and prolonged stays in hospital. Despite the availability of effective analgesics and a growing body of published material that supports their use, postoperative pain remains a problem worldwide. To reduce acute postoperative pain, we introduced an intervention combining evidence-based analgesic protocols with the education of staff and patients on a surgical ward. The experiences of 68 patients before and 80 patients after the intervention were compared (worst pain scores, duration of pain, and satisfaction). Inadequately controlled pain was significantly reduced after the intervention, which suggests that the introduction of analgesic protocols supported by the education of staff and patients can be beneficial. Despite this, severe pain remained relatively common, indicating room for improvement. Duration of pain and patient satisfaction were not affected by the intervention, and patient satisfaction remained high throughout the study.     

Reduction of mandibular residual ridge after vestibuloplasty. A two-year follow-up study comparing the Edlan flap, mucosal and skin graft operations

Mandibular residual ridge reduction (RRR) after Edlan flap vestibuloplasty, buccal mucosal graft, and split skin graft vestibuloplasty was measured on lateral cephalometric radiographs obtained 1, 3, 6, 12 and 24 months postsurgery in 50 patients. The ridge reduction was most severe during the immediate postoperative period. The different operation methods did not give rise to significant variations in the reduction pattern, neither did the sex of the patient appear to be an important factor. The temporary increase of mandibular resorption after vestibuloplasty surgery is of a magnitude comparable to the average RRR during 1 year in full denture wearers with a long denture experience.     

3D evaluation of postoperative swelling using two different cooling methods following orthognathic surgery: a randomised observer blind prospective pilot study

Orthognathic surgery is associated with side effects including severe postoperative swelling, pain, neurological dysfunction and trismus. The beneficial effects of localised cold treatment on postoperative swelling have been described. Topographical considerations make it difficult to quantify facial swelling. A new and promising method to measure facial swelling seems to be optical face scanning. This study aimed to evaluate the 3D optical scanner to measure soft tissue swelling following orthognathic surgery. Postoperative swelling was treated either with conventional cooling by cold packs or with the water-circulating cooling device Hilotherm Clinic. Secondary endpoints in each group included postoperative pain, neurological complaints, duration of hospital stay, trismus and patient satisfaction. The use of the cooling device by Hilotherm significantly reduced postoperative swelling, pain and hospital duration compared with conventional cooling. Postoperative trismus and satisfaction with the cooling method was significantly higher in the Hilotherm group compared with conventional cooling. No differences were observed concerning neurological score and outcome. In conclusion, 3D optical scanning is a simple and precise method of quantifying face swelling after orthognathic surgery. Hilotherm significantly reduces swelling and duration of hospital stay compared with conventional cooling.     

Atypical odontalgia: a review

Since persistent and chronic pain is more common in the head and neck region than in any other part of the body, dentists are more likely to encounter these rather complex cases in their practices. This article is a review and update on atypical odontalgia (AO). AO is a persistent neuropathic pain which may be initiated after deafferentiation of trigeminal nerve fibers following root canal treatment, apicectomy, or tooth extraction, or it may be of idiopathic origin. Details concerning its characteristics, pathophysiology, diagnostic criteria, differential diagnosis, and treatment are made. The aim of this article is to help the clinician with the diagnosis and management of AO. The prognosis for AO is most often only fair, and the administration of tricyclic antidepressants often resolves symptoms. Invasive and irreversible treatment attempts are not recommended.