Acute periodontal lesions

This review provides updates on acute conditions affecting the periodontal tissues, including abscesses in the periodontium, necrotizing periodontal diseases and other acute conditions that cause gingival lesions with acute presentation, such as infectious processes not associated with oral bacterial biofilms, mucocutaneous disorders and traumatic and allergic lesions. A periodontal abscess is clinically important because it is a relatively frequent dental emergency, it can compromise the periodontal prognosis of the affected tooth and bacteria within the abscess can spread and cause infections in other body sites. Different types of abscesses have been identified, mainly classified by their etiology, and there are clear differences between those affecting a pre‐existing periodontal pocket and those affecting healthy sites. Therapy for this acute condition consists of drainage and tissue debridement, while an evaluation of the need for systemic antimicrobial therapy will be made for each case, based on local and systemic factors. The definitive treatment of the pre‐existing condition should be accomplished after the acute phase is controlled. Necrotizing periodontal diseases present three typical clinical features: papilla necrosis, gingival bleeding and pain. Although the prevalence of these diseases is not high, their importance is clear because they represent the most severe conditions associated with the dental biofilm, with very rapid tissue destruction. In addition to bacteria, the etiology of necrotizing periodontal disease includes numerous factors that alter the host response and predispose to these diseases, namely HIV infection, malnutrition, stress or tobacco smoking. The treatment consists of superficial debridement, careful mechanical oral hygiene, rinsing with chlorhexidine and daily re‐evaluation. Systemic antimicrobials may be used adjunctively in severe cases or in nonresponding conditions, being the first option metronidazole. Once the acute disease is under control, definitive treatment should be provided, including appropriate therapy for the pre‐existing gingivitis or periodontitis. Among other acute conditions affecting the periodontal tissues, but not caused by the microorganisms present in oral biofilms, infectious diseases, mucocutaneous diseases and traumatic or allergic lesions can be listed. In most cases, the gingival involvement is not severe; however, these conditions are common and may prompt an emergency dental visit. These conditions may have the appearance of an erythematous lesion, which is sometimes erosive. Erosive lesions may be the direct result of trauma or a consequence of the breaking of vesicles and bullae. A proper differential diagnosis is important for adequate management of the case.     

Assessing the anxious patient

Dental anxiety is a problem for many adults and children and for many patients anxiety acts as a barrier to treatment: avoidance of treatment, irregular attendance or attendance for emergency treatment only being typical ways of dealing with the problem. For the dental team a patient's anxiety poses major management problems, as an anxious patient may require more time for treatment, is very likely to miss appointments and may have raised pain thresholds. A major cause of stress for clinicians is the management of anxiety in their patients.     

Treatment of temporomandibular joint ganglion cyst

Ganglion cysts of the temporomandibular joint are very rare and always misdiagnosed as synovial cyst, parotid gland tumor, or other cystic lesions. They present with pain, swelling, or dysfunction. Image studies could facilitate to identify the tumor mass from the adjacent soft tissue, but a definitive diagnosis could be made from the pathologic report.A 59-year-old woman presented to the clinics with a chief complaint of a painless swelling mass in the right preauricular region of 3-month duration. Computed tomography was performed, which showed a small radiolucent lesion adjacent to the right condyle. Local excision was performed, and the specimen was sent for histologic examination.Microscopic examination showed a cystic space walled by dense fibrous connective tissue without epithelial or endothelial lining. Immunohistochemical staining of these lining cells showed positivity for vimentin and negativity for cytokeratin. These findings were consistent with the diagnosis of ganglion cyst.Ganglion cysts present as unilobulate or multilobulate cysts that arise from the collagenous tissue and is filled with highly viscous fluid. It does not communicate with the joint cavity. In contrast, synovial cyst is a true cyst lined by cuboidal or flattened cells from the synoviocytes and is filled with gelatinous fluid. It may or may not communicate with the joint cavity. Excision is the treatment of choice of symptomatic cystic lesions. Incomplete excision of these lesions may cause further recurrence or infection. Thus, injection of hydrocortisone or aspiration may be considered as an alternative management.     

Idiopathic bone cavity (traumatic bone cyst) with the radiographic appearance of a fibro-osseous lesion.

This article presents an unusual case of idiopathic bone cavity that originally was either not observed or diagnosed as a fibro-osseous condition. When a differential diagnosis was established, it included fibro-osseous conditions, odontogenic cysts and neoplasms, and central giant cell granuloma but not the definitive diagnosis. The patient's demographic data, history, symptoms, and clinical and radiographic appearance all conspired to obscure the true nature of the condition, which was not revealed until a biopsy was attempted. A more thorough initial radiographic examination might have led to an earlier diagnosis.     

Brainstem auditory evoked potentials in atypical facial neuralgia

Atypical facial neuralgia is an ill-defined syndrome of obscure etiology characterized by chronic facial pain. The diagnosis is one of exclusion, made only after carefully ruling out a variety of conditions that may cause orofacial pain. The present study detected brainstem abnormalities on the side of the facial pain through examination of brainstem auditory evoked potentials in two out of 12 patients who were clinically diagnosed as having atypical facial neuralgia. The recording of brainstem auditory evoked potentials provides a simple, well-standardized, noninvasive test that may be of value in the investigation of patients who have chronic facial pain.     

The use of a soft denture liner for chronic residual ridge soreness

Chronic residual ridge soreness in patients with complete dentures can be caused by various factors. A differential diagnosis between physiologic or anatomic problems (or both) and functional deficiencies in the patient's present dentures must be made. The functional deficiencies can often be eliminated easily, whereas physiologic and anatomic problems may be more difficult to correct, especially in the geriatric patient. If the functional deficiencies in the patient's dentures have been corrected and surgical procedures are not a viable alternative, placement of a long-term resilient liner can often resolve the chronic residual ridge soreness that is present in denture patients. Properly placed and properly cared for silicone or silicone rubber resilient denture liners can provide comfort for over 70% of patients with chronic residual ridge soreness for 3 to 5 years and often longer.     

The use of bone imaging to detect a periapical lesion of endodontic origin

This article reports the detection of a lesion of dental origin in the mandible of a 41-yr-old male patient during a routine bone scan used as a follow-up to cancer therapy. Unfortunately, more than 1 yr passed before the patient's signs and symptoms became severe enough for a definitive diagnosis to be made. A comprehensive dental examination is indicated for patients with positive bone scans in the area of the oral cavity. The use of bone imaging can be recommended to complement the dental examination of high risk patients with suspected metastasis or when all routine dental diagnostic measures are inconclusive.     

Temporomandibular disorders: associated features

Temporomandibular disorder (TMD) encompasses a number of clinical problems involving the masticatory muscles or the temporomandibular joints. These disorders are a major cause of nondental pain in the orofacial region, and are considered to be a subclassification of musculoskeletal disorders. Orofacial pain and TMD can be associated with pathologic conditions or disorders related to somatic and neurologic structures. When patients present to the dental office with a chief complaint of pain or headaches, it is vital for the practitioner to understand the cause of the complaint and to perform a thorough examination that will lead to the correct diagnosis and appropriate treatment. A complete understanding of the associated medical conditions with symptomology common to TMD and orofacial pain is necessary for a proper diagnosis.     

Role of oral medicine in the teaching of temporomandibular disorders and orofacial pain

This paper discusses the role of oral medicine in the teaching of temporomandibular disorders (TMD) and orofacial pain. Education in orofacial pain and TMD has traditionally been managed in academic dental settings as 2 distinct processes separate from the teaching of diagnosis and management as applied to systemic diseases and oral conditions. The rationale for such a segmented approach appears to have been driven by the concept that orofacial pain usually reflects a localized disease rather than arising as a component of more generalized systemic disease or modulated in intensity or morbidity by systemic pathology, generalized neurobiological, or behavioral contributors. Conversely, oral disease and head and neck manifestations of systemic disease often provoke pain as a major symptom. Management of such conditions should include acute and long-term pain management strategies when the underlying condition has no definitive cure and the pain is disabling. An argument is made for integrating the teaching of oral medicine and orofacial pain to enhance a broad-based approach to the assessment and management of primary pain disorders and to assure appropriate management of pain that is associated with mucosal disease and other forms of regional or systemic pathology including behavioral disorders that present as somatic and painful complaints.     

Bursitis: a factor in the differential diagnosis of orofacial neuralgias and myofascial pain dysfunction syndrome

A woman had pain on swallowing and talking when initially seen. Previous diagnoses of glossopharyngeal, neuralgia and myofascial pain dysfunction syndrome had been made. Appropriate treatment for these conditions failed to produce any improvement. Palpation revealed two tender areas bilaterally, overlying the hamulus. Treatment with an injection of 1 ml of dexamethasone (Decadron) 4 mg/ml into each area of tenderness resulted in a dramatic improvement. An anatomic review disclosed the presence of a bursa on the hamulus to protect the tendon of tensor veli palatini. A diagnosis of bursitis was made because of the dramatic improvement in the patient's condition as the result of corticosteroid therapy. Bursitis should therefore be considered in the differential diagnoses of orofacial neuralgias, temporomandibular joint dysfunction, and myofascial pain dysfunction syndrome.     

Pulpalgia contributing to temporomandibular disorder-like pain: a literature review and case report

BACKGROUND: Dentists need to be cognizant that temporomandibular disorder (TMD) -like pain can be caused by a tooth pulpalgia. The author provides suggestive symptom characteristics and definitive diagnostic techniques. CASE DESCRIPTION: A patient had severe bilateral TMD-like pain, which increased when something cold touched a premolar and when the patient lay down, and which awakened her several times every night. The author identified the offending tooth and administered a ligamentary injection along the tooth, which eliminated her bilateral TMD-like pain. Occlusal adjustment of her tooth reduced her pain, and subsequent endodontic therapy eliminated her pain. To the author's knowledge, this is the first report of a pulpalgia in a posterior tooth causing bilateral TMD-like pain. CLINICAL IMPLICATIONS: Pulpalgia may cause symptoms that mimic TMD or may contribute to TMD signs and symptoms. When patients with TMD-like pain report feeling increased pain due to a cold stimulus' coming into contact with a tooth, practitioners should ensure that a pulpalgia is not contributing to their pain.     

The KBG syndrome, characteristic dental findings: a case report

Short stature and developmental delay may be observed in many genetic conditions and well-defined syndromes. A 7-year-old girl presented with the non-specific findings of subtle dysmorphism, short stature and developmental delay. Although a genetic syndrome was suspected, a definitive diagnosis was not made until the dental findings of KBG syndrome were recognised, namely grossly enlarged maxillary permanent central incisors and hypodontia.     

Recognition and management of headache

Pain of all types continues to cause substantial burdens to society because of high health care costs and decreased productivity. Dental patients may present with facial pain (often subjectively defined as pain below the ala-tragus line) associated with headache (subjectively defined as pain above the ala-tragus line), both of which are often poorly diagnosed and treated. People with ongoing pain lasting for more than 3-6 months (chronic pain) may experience multiple types of pains in the head and neck region, including headache, facial pain or even global head pain (pain throughout the head, from the neck up). Some pain problems do not follow strict anatomic boundaries, and the pain may spread into adjacent regions, which complicates diagnosis. A better understanding and appreciation of headaches and facial pain can lead to improved outcomes and better overall management. This article reviews frequently occurring headache disorders that should be considered in the differential diagnosis of pain seen in the dental office.     

Odontogenic signs and symptoms as predictors of odontogenic infection: a clinical trial

BACKGROUND: The authors conducted a study to determine if odontogenic signs and symptoms in the emergency department predicted the development of overt odontogenic infection at a follow-up dental visit. METHODS: One hundred ninety-five patients with odontalgia, but without overt signs of infection, were enrolled in a prospective, double-blind, randomized clinical trial. Data included dental diagnosis, pain characteristics, presence of caries and restorations, presence and size of periapical radiolucencies and other diagnostic test results. RESULTS: Thirteen of 134 subjects for whom data were available had signs of infection at the follow-up visit. Subjects in the follow-up infected (FU-I) group had larger baseline radiolucencies than did subjects in the follow-up noninfected (FU-NI) group, and restorations were more prevalent for involved teeth in the FU-I group than in the FU-NI group. CONCLUSIONS: A relationship exists between radiolucency size and the presence of amalgam restorations in patients who develop clinical signs of infection. Penicillin did not appear to influence this progression. CLINICAL IMPLICATIONS: Antibiotics are not effective in preventing the development of odontogenic infection when definitive dental therapy cannot be provided for acute pain in the absence of clinical signs of infection. Although the overall risk of developing infection is low, early treatment is indicated for teeth with larger periapical radiolucencies, amalgam restorations or both.     

A prospective survey of hospital ambulatory dental emergencies Part 1: Patient and emergency characteristics

Part 1 of this study describes the dental disorders and patient characteristics of 253 patients who presented as dental emergencies to the University Hospital dental clinic, Vancouver, BC, during a three-month period. Most patients had a true perception of what constitutes a dental emergency. Dental pain was the predominant reason for seeking help, and the pain existed for more than seven days prior to contact in more than 50% of patients. Patients were not always able to identify the number and location of painful teeth, and a perceived low cost for treatment was a major reason for contacting the hospital. Reliability of emergency patients in keeping scheduled appointments was very high. Almost 69% of patients did not see a dentist regularly. Referrals to the hospital dental service were most numerous in the summer months. Diagnosis of the complaints revealed infection to be the cause of pain in 76.7% of patients.     

Dental perspectives on neuropathic origin

The most common cause of intraoral pain is odontogenic and rarely presents a diagnostic challenge. Pain in a tooth site area that is not dental or periodontal in origin may be difficult to diagnose and treat. Successful management of non-odontogenic pain complaints is inherently dependent on taking a detailed 'pain history'. Treatments that are irreversible and potentially harmful to the underlying dentoalveolar structures must be avoided when the diagnosis is uncertain. Information gleaned from the pain history usually provides a provisional or working diagnosis, and this diagnosis must later be confirmed by specific testing (based on response to medication trials, imaging, laboratory tests, etc.). Patients who suffer from chronic pain conditions are likely to show comorbidity with other pain problems (e.g., neuropathic pain with background muscle discomfort or temporomandibular disorders and headache problems). Thus, in more complex patients, the various elements that comprise the chronic pain condition must be identified and managed, for adequate resolution of the symptoms.