The management of craniofacial pain in a pain relief unit

Craniofacial pain can be one of the more intractable problems that presents to the GDP. One management route can be referral to a specialist pain relief unit, where the facilities and expertise will be available for diagnosis, counselling, drug management and invasive therapy. In this article the authors describe the results achieved at one such unit, over a one-year period, for a group of 34 craniofacial pain sufferers. At the end of the year 30 patients reported total or partial relief from their pain.     

Dislodged lower right third molar tooth into the parapharyngeal space

Lower third molar teeth can be dislodged into fascial tissue spaces when they are extracted or elevated out of their sockets. Thankfully, this rarely occurs. We present a case report on a lower right wisdom tooth dislodged into the right parapharyngeal space on its removal from the socket and the subsequent management of this rare complication. CLINICAL RELEVANCE: Though a rare complication, clinicians have to be aware that lower third molars can be dislodged into tissue spaces and the importance of prompt appropriate management.     

Management of adverse drug reactions in conscious-sedation

To thoroughly detail adverse reactions that may take place following the administration of agents used to modify behavior or to control fear and anxiety is beyond the scope of this presentation. Nevertheless, an attempt has been made to examine the mechanism of action, preventative measures, and management techniques for a few of the most common adverse reactions involving the more popular agents. Emphasis has been placed on the prevention of pharmacologic misadventures rather than on their management. The taking of an adequate pretreatment history and physical examination (including blood pressure determination) is invaluable in this respect. On occasion, however, despite all precautions and preventative measures, problems can arise. I have emphasized the mechanical, or nonpharmacologic approach, to the management of adverse reactions. Because untoward events occur so infrequently, the nonpharmalogic approach is the safest, most effective way for the clinician to cope with the majority of problems that can arise. The need for all practitioners to be competent in the management of the unconscious patient cannot be overemphasized. Production of unconsciousness is the most serious reaction with which the dentist is likely to be confronted on a routine basis. Mismanagement of this relatively benign state can, and on occasion does, result in deterioration to a catastrophic conclusion. It must also be emphasized that in the face of serious adversity the first few moments are usually the most critical in determining the final outcome. Although the summoning of assistance may be necessary and appropriate, one must not rely on the arrival of "emergency teams" to resolve the problem. If serious sequelae are to be avoided, proper management procedures must be instituted immediately and continued until medical assistance arrives and definitive care can be instituted. Thorough understanding of the pharmacology of all agents employed during the course of dental care is the key to the prevention and management of adverse drug reactions.     

Differential diagnosis for orofacial pain, including sinusitis, TMD, trigeminal neuralgia

Correct diagnosis is the key to managing facial pain of non-dental origin. Acute and chronic facial pain must be differentiated and it is widely accepted that chronic pain refers to pain of 3 months or greater duration. Differentiating the many causes of facial pain can be difficult for busy practitioners, but a logical approach can be beneficial and lead to more rapid diagnoses with effective management. Confirming a diagnosis involves a process of history-taking, clinical examination, appropriate investigations and, at times, response to various therapies. CLINICAL RELEVANCE: Although primary care clinicians would not be expected to diagnose rare pain conditions, such as trigeminal autonomic cephalalgias, they should be able to assess the presenting pain complaint to such an extent that, if required, an appropriate referral to secondary or tertiary care can be expedited. The underlying causes of pain of non-dental origin can be complex and management of pain often requires a multidisciplinary approach.     

(ii) Management of acute fractures of the hand

Fractures of the metacarpals and phalanges are the commonest fractures of the upper limb. They can be incapacitating if not treated appropriately. Hand fractures can be complicated by deformity as a result of inadequate treatment, or stiffness from overzealous treatment, leading to poor results. It is important for the treating surgeon to diagnose and understand the management of these fractures. Immediate mobilization after adequate stabilization is the key to treating hand fractures. A comprehensive review of hand fracture management is outlined in this paper.     

Prosthetic Rehabilitation of Orofacial Donor Site Fistula Following Surgical Reconstruction: A Clinical Report

Orofacial defects can be either congenital or acquired. Rehabilitation of these patients can be done using a surgical and/or a prosthetic approach. In situations where surgical reconstruction is not possible, prosthetic management becomes the only option. This clinical report describes a simple, economical, and effective technique for the prosthetic rehabilitation of a patient with oro-cutaneous fistula due to donor site dehiscence following tumor defect reconstruction.     

Effective and safe pediatric oral conscious sedation: philosophy and practical considerations

Because dental treatment can represent a threatening event for some children, need exists to include sedation within our management arsenal. By definition, pre-cooperative children and those lacking in cooperative ability have immature cognitive skills, a highly restricted range of coping abilities, brief or negligible attention spans, and virtually no experience coping with stress. As result, they can be especially prone to maladaptive responses to anxiety provoking situations. For many of these, traditional non-pharmacologic behavior management strategies may often prove inadequate or inappropriate to overcome resistive or uncooperative behaviors. The importance of intervention with non-aversive techniques that provide a safe, child-oriented environment and timely opportunity in which to encounter and cope with fear-producing situations cannot be dismissed. The use of sedation techniques can frequently serve to obtund interfering and potentially harmful behaviors to safely permit quality care, minimize or eliminate the need for aversive measures, and help bridge the transition for a child lacking cooperative ability to the time when cooperation potential develops.     

Stress management in the difficult patient encounter

Patient care and management can present a significant source of stress for the practicing dentist. This article presents the various facets and underpinnings of stress, followed by an overview of the physiologic phenomena attending the classic stress response, with an examination of the interplay between the psychologic components of stress and its influences on the development or exacerbation of somatic disorders. In addition, the characteristics that can be attributed to the patient and the practitioner that give rise to difficult encounters are explored, with an eye toward proper professional management. Further, the motivations of select patient personae are examined, including discussions regarding the angry patient, the anxious or demanding patient, and the noncompliant and addicted patient. The article offers suggestions for management of such patients, with short- and long-term stress management techniques.     

Advanced trauma life support (ATLS) and facial trauma: can one size fit all? Part 2: ATLS, maxillofacial injuries and airway management dilemmas

Maxillofacial trauma poses an obvious threat to the patient's airway, which may not be immediately evident. In the multiply injured patient, the co-existence of actual or potential injuries elsewhere may complicate airway management, notably in the presence of full spinal immobilization. Following high-velocity trauma, injuries to the cervical spine must be assumed to be present. They also need to be ruled out in an appropriate and timely manner, as patients may wish to sit up. Assessment and management of the airway in maxillofacial trauma can be difficult, requiring a senior anaesthetist or other individual appropriately trained in emergency airway care. A number of management options may exist to protect the airway, each with advantages and drawbacks. Agitation and vomiting can occur unexpectedly and need to be managed safely with due consideration to the spine. Oral and maxillofacial surgeons need to be aware of these dilemmas and their early warning signs, and be skilled in emergency surgical airway procedures, especially if involved as part of the trauma team. Prolonged immobilization is associated with significant morbidity and mortality. A number of protocols currently exist for 'clearing' the spine. Imaging now plays a greater role, especially in the obtunded, unconscious or intubated patient, and this is discussed.     

The Fixed/Detachable Implant Provisional Prosthesis

Interim modification and management of a complete denture following surgical uncovering of dental implants can be time-intensive and may fail to provide adequate patient benefit until the definitive prosthesis can be completed. Inadequate interim management can result in functional and tissue difficulties. Modification of the conventional complete denture to a fixed/detachable provisional prosthesis in a one-stage procedure provides the patient an opportunity to experience a fixed prosthesis. The incorporation of fixed, provisional cylinders to the existing denture base using autopolymerizing acrylic resin with a closed-mouth technique is described. The peripheral regions are reduced and the distal extension shortened to resemble a fixed/detachable prosthesis. This conversion technique can provide patient satisfaction and comfort until delivery of the definitive prosthesis. Esthetic concerns, home care problems, or patient difficulties with the provisional prosthesis can be rectified in the final prosthesis.     

The prosthetic management of gingival aesthetics

Periodontal disease, trauma, and congenital defects can result in both soft tissue and hard tissue defects that can present with aesthetic problems. The management of these problems may be limited to prevention or surgical management which can result in significant morbidity especially if a second surgical site for grafting is utilised. This article describes the various prosthodontic techniques to improve gingival aesthetics using contemporary materials such as gingivally coloured composite and gingivally coloured porcelain in addition to more traditional materials such as standard prosthetic acrylic.     

Management of tooth resorption

A correct diagnosis and an understanding of the aetiology and dynamics of the processes involved in tooth resorption is critical to effective management. Tooth resorptions can be classified as: (1) trauma induced; (2) infection induced; or (3) hyperplastic invasive. Some transient trauma induced resorptions require no treatment but must be carefully monitored to check that there are no complicating issues such as infection. In cases of trauma induced replacement resorption, a multidisciplinary approach is usually necessary to ensure an optimal long-term solution. Infection induced tooth resorptions require the removal of the invading micro-organisms by endodontic therapy including intra-canal medication which can also facilitate repair of the resorbed tooth structure. The hyperplastic invasive tooth resorptions pose considerable challenges in management due to the complexity and aggressive nature of the resorptive process. With careful case selection and complete inactivation of resorptive tissue successful management can be achieved.     

Tracheobronchiale Perforationen – eine Komplikation nach mund-, kiefer- und gesichtschirurgischen Eingriffen

After difficult endotracheal intubation in oral and maxillofacial surgery, esophageal or tracheal injuries can cause mediastinal, pericardial or cervicofacial soft tissue emphysema. If a patient has of thoracic pain after general anesthesia, mediastinal emphysema should be taken into consideration because of the possibility of subsequent life-threatening complications. Diagnosis can be established with computed tomography and fiberendoscopy.We present the diagnostic and therapeutic management of two patients.     

(i) The management of irreparable rotator cuff tears

The management of massive irreparable rotator cuff tears can be challenging. There are, however, a number of operative and non-operative options available to the shoulder surgeon.Non-operative management with simple analgesics, steroid injections and a deltoid re-education programme may be appropriate for patients with few symptoms, particularly elderly, lower demand patients with lower expectations. In more symptomatic patients, especially younger patients with higher demands, surgical intervention may be considered. Arthroscopic debridement and/or, sub-acromial decompression (with or without biceps tenotomy) may suffice, but partial or augmented rotator cuff repair or tendon transfer surgery is available. In the presence of arthrosis, cuff tear arthroplasty or reverse geometry arthroplasty are valid options.Treatment should be individualized depending on the patient's symptoms, age, expectations, needs and the presence or absence of associated glenohumeral joint arthrosis.     

Hamular Bursitis and its possible craniofacial referred symptomatology: two case reports

The diagnosis of craniofacial pain is conditioned by the interdisciplinary management of its presentation especially in the absence of unique and objective signs. Bursitis is a pathological entity recently found in the hamular area and should be included in the diagnosis for exclusion of temporomandibular disorders (TMD), ear-nose-throat pathologies, due to the similar symptomatology to other head and neck conditions. The hamular process bursitis is a painful condition that can easily be confused with glosopharinge or trigeminal neuralgia that generates an uncomfortable feeling in the oropharinge with ipsilateral referred--heteretopic-symptomatology to the head. This pathology, in chronic states, can be responsible for the amplification of the pain perceived by the central excitation effect. In this report are presented two clinical cases of hamular bursitis and its conservative therapeutic management. The recognition of the inflammation of the bursa of the tensor veli palati muscle supplies the specialist with another tool in the management of craniofacial pain.     

Life cycles of traumatized teeth: long‐term observations from a cohort of dental trauma victims – series 2

In this the second of a series of life cycles of dental trauma victims, the short and particularly long‐term responses of four survivors of either multiple luxation injuries or avulsions have been documented over periods varying up to 41 years. The development of ankylosis, either in the short or longer term post trauma, proved a common feature in the series and management strategies have been outlined. External invasive resorption was also identified as a complicating response for which the topical application of trichloracetic acid, intracanal dressing and root canal obturation proved effective in resorption management. Long‐term observations indicate that some compromised teeth can be functionally and aesthetically retained for extended periods, but follow‐up examinations are important so that treatment interventions can be implemented if adverse responses are diagnosed.     

Monteggia injuries and radial neck fractures in children

This paper reviews the means to evaluate these injuries and reviews the evidence for different management strategies. Monteggia injuries and radial neck fractures are not amongst the most common fractures in children. However, the morbidity associated with a missed or underappreciated injury can be significant. Monteggia injuries are classically associated with a fracture of the ulna but radio-capitellar dislocation can also occur with plastic deformation of the ulna alone. Closed reduction of the ulna is the primary method of management. The reduction is stabilized by application of cast or fixation of the ulna; though uncertainty remains about how aggressive surgeons should be with ulnar fixation. Should a patient present late ulnar osteotomy is often required to allow reduction of the radio-capitellar joint. Radial neck fractures are often associated with other injuries around the elbow. The fracture can result in both angulation and translation. Angulation can be better tolerated and has a higher potential for remodelling. If translation of more than 2–3 mm is present this can result in the fracture healing with a significant cam lesion which impinges on rotation of the forearm. There are several means to try and achieve a closed reduction which are described.     

A cutaneous horn – benign or malignant?

This is a case report of a cutaneous horn, which was difficult to diagnose as benign or malignant. It demonstrates how these lesions can be approached in terms of diagnosis and management.     

Avascular necrosis of the foot and ankle: aetiology,investigation and management

Avascular necrosis (AVN) of the foot and ankle can pose both a diagnostic challenge, and a management dilemma. This paper seeks to describe the various types of AVN in the foot and ankle and clarify the expected presentation, examination findings, investigations and management strategies available. In addition, discussion of the relevant basic sciences, and the process of bone healing will facilitate a broader understanding of the condition, and the risk factors for its development. AVN can be secondary to trauma, as in most cases of talar AVN, or secondary to factors such as steroid use, alcohol excess, metabolic diseases, repetitive microtrauma, and abnormal biomechanics. Usually, a combination of the above is thought to be responsible. Many of the conditions described are established in childhood, either presenting at the time, or in the third or fourth decade. Management ranges from exercise limitation and offloading footwear, to surgical decompression, osteotomy, fusion or excision. AVN has a high morbidity and affects a young demographic, causing a substantial burden on healthcare. Early recognition of symptoms, and appropriate investigation and management could reduce the number of patients progressing to advanced disease, avoiding the frequently unsatisfactory surgical outcomes associated with options such as fusion and excision.     

Management of epistaxis in the oral and maxillofacial surgery setting: An update on current practice

Epistaxis is a common and, in most cases, benign event. Although most nosebleeds resolve spontaneously, some may be profuse and life-threatening. Severe or recurrent epistaxis can be a challenging management problem. In otolaryngologic practice, it is the most commonly seen emergency. Oral and maxillofacial surgeons will also encounter this clinical problem in varied settings. It is our aim to present an update on the contemporary management of epistaxis in maxillofacial practice. The etiology and relevant surgical anatomy are discussed. This is followed by an update on current treatment regimens in different scenarios. A stepwise algorithm for the management of epistaxis is presented.