Managing the endodontic patient with disabling anxiety or phobia

Disabling anxiety and phobia are commonly encountered in dental practice. Successful management of these patients is especially important in endodontic practice, where patients are often compelled to seek treatment because of acute or threatened pain. This article reviews the recognition and management of these common disorders. Mild anxiety can be managed with oral sedatives and/or nitrous oxide; however, moderate to severe anxiety and phobia is best treated with deep sedation or general anesthesia.     

Pediatric breast deformity

Congenital breast anomalies represent a relatively common set of disorders encountered by pediatric plastic surgeons with a spectrum of severity that ranges widely from the relatively benign polythelia to the very complex disorders such as Poland's syndrome and tuberous breast deformities. While the former can be treated in a single surgical setting with minimal morbidity, the more complicated disorders often require a staged reconstructive algorithm. Some disorders also require a multidisciplinary management for both workup and management. Although rarely a source of functional morbidity, these physical deformities are often a significant source of psychological stress for the adolescent male or female who feels alienated from their peers. The purpose of this article is to review the most common congenital breast disorders including the diagnosis, workup, and management especially the timing of surgical intervention as guided by normal developmental milestones.     

Chronic tendo Achilles injuries: a management rationale

Chronic tendo Achilles ruptures are relatively uncommon. The exact definition of a chronic rupture is subject to debate but generally held to be a rupture that has not been treated for 6 weeks prior to diagnosis. Beyond the diagnosis which is a clinical one it is important to assess the length of the now lengthened tendo Achilles as well as the general health and the functional expectations of the patient. The tendo Achilles change in length or tendon gap is ascertained both clinically and radiologically. As a general rule non-surgical treatment is poorly tolerated and most patients will consider surgery. The type of surgery is governed by the amount of increased length or gap of the tendon with minor increases in length (up to 2 cm) being treated by end-to-end repair, intermediate gaps (up to 5 cm) by VY advancement and defects greater than 5 cm being managed by tendon transfer. The outcome of surgical intervention for this condition is generally reported as being satisfactory with restoration of function although recovery may require a prolonged period of rehabilitation.     

Comprehensive care for children with bleeding disorders. A physician's perspective.

As a result of recent advances in the understanding of hemostatic mechanisms--and the availability of more accurate diagnostic tests, effective replacement therapy and medications--most of the common bleeding disorders in children can be diagnosed and managed. Children with bleeding disorders often present with dental problems. Their comprehensive care requires specialized preventive and acute dental treatment. With improvements in dental care protocols and surgical procedures, the risk of excessive bleeding in these children as a result of dental procedures should be minimal, particularly if they are well prepared and treated beforehand. It is important for dentists to be familiar with these specialized dental care protocols and procedures, and knowledgeable about the medical treatment provided to children with bleeding disorders. This allows dentists to coordinate the care of a hemophiliac with his or her physician in a comprehensive manner.     

Anterior knee pain

Anterior knee pain is a common symptom in orthopaedic practice. Various conditions can affect the anterior knee, and treatment outcome depends on adequate diagnosis, but this is sometimes very difficult to establish. Nowadays, modern diagnostic and imaging procedures (CT, MRI, scintigraphy, arthroscopy) can make diagnosis more accurate and precise. Furthermore, improved surgical techniques and technologies in the treatment of cartilage, tendon, internal knee derangements, make outcomes in some diagnostic categories more favorable than previously. In this article, we describe our experience of the diagnosis and treatment of patellofemoral disorders, extensor tendon overuse, synovial plicae, bursal, bone and meniscal pathology - the predominant causes of anterior knee pain.     

Pigmented villo-nodular synovitis of joints and tendon sheaths

Pigmented villo-nodular synovitis (PVNS) is a rare, benign and aggressive disorder of synovial joints and tendon sheaths which is capable of eroding articular structures and bone. It represents a spectrum of pathological disorders ranging from the most common giant-cell tumour of tendon sheath to localized or diffuse intra-articular PVNS lesions and may be associated with joint erosions. It is best treated surgically but recurs if inadequately excised. Adjunctive therapies include injection of intra-articular radio-isotopic materials and external beam radiotherapy.     

Headaches and their relationship to sleep.

Despite the complex influences of normal sleep physiology and sleep disorders on the development or presentation of headache, it is important to recognize and understand these relationships. Successful outcomes depend on the provision of treatment interventions specifically directed toward each condition. Nocturnal or early morning headaches that are associated with OSA are often eradicated after the sleep disorder is successfully managed with CPAP, oral appliances, or surgery. Substantial improvement in headache can also result from the successful management of other sleep disorders that may incite headaches such as heavy snoring, PLMS, or the various forms of insomnia. To improve headache patterns associated with bruxism and TMD, it is often necessary to formulate a multidisciplinary treatment approach that combines oral appliance therapy, stress management, biofeedback, oromandibular physical therapy, and, at times, pharmacologic treatment (i.e., tricyclic antidepressant, intramuscular botulinum toxin injections). There are still many gaps in the understanding of the interrelationships of sleep physiology and headache pathophysiology. More well-designed clinical trials are needed so that enough data can be amassed for the formulation of evidence-based guidelines or consensus statements that can better delineate the identification, diagnostic evaluation, and treatment of sleep-related headache disorders and headaches that develop as a consequence of disordered sleep.     

(v) Biceps and triceps tendon pathology at the elbow

Rupture of the distal biceps and triceps tendons are amongst the rarest of all tendon injuries. Rupture is often the result of forceful, eccentric contraction on a background of pre-existing tendon degeneration. The diagnosis of rupture is usually made on clinical grounds, with imaging assisting in the diagnosis of partial tendon ruptures. Left untreated, considerable functional deficit may ensue. Surgical repair offers good to excellent results regardless of the fixation technique used, though the risk of complications must be taken into account: the ultimate goal being anatomical reconstruction of the tendon attachment. The choice of approach to the distal biceps tendon remains controversial, with most choosing between a single anterior or double-incision technique. This article provides an overview of the anatomy, biomechanics and management of biceps and triceps tendon pathology.     

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.     

Common factors in the presentation and management of chronic temporomandibular disorders and chronic overlapping pain disorders

The International Association for the Study of Pain has released a new classification scheme for chronic pain. This classification scheme describes chronic pain as either a symptom of a disease (chronic secondary pain) or the disease itself (chronic primary pain). Chronic temporomandibular disorders have many similarities to other proposed chronic overlapping pain disorders, but are classified and managed by dental practitioners as a localized pain condition of the orofacial region. We review the literature to describe the similarities between chronic temporomandibular disorders and chronic overlapping pain disorders, and discuss how this evolving concept may affect the way that dentists approach the diagnosis and management of chronic temporomandibular disorders.     

Nasopharyngeal carcinoma mimicking a temporomandibular disorder: a case report

Patients referred from an otorhinolaryngologist with a chief complaint of earache or other ear symptoms are common in a temporomandibular disorders (TMD) clinic. These patients often complain of other symptoms, such as headache, facial pain, and limited mouth opening, all of which can be present in a patient suffering from a nasopharyngeal carcinoma (NPC). The aim of this case report was to describe the signs and symptoms of NPC and discuss possible causes for the misdiagnosis of NPC as TMD. The characteristics of 8 NPC patients reported in the literature whose cancer was initially misdiagnosed as TMD and those of an NPC patient with TMD-like symptoms treated at the clinic of 1 of the authors are described, and the reasons for misdiagnosis are discussed. A revision of Trotter's syndrome for the differential diagnosis of TMD is proposed. There is a need for detailed exclusion criteria to be applied prior to the assignment of a clinical diagnosis based on the Research Diagnostic Criteria for TMD.     

Tendon physiology and repair

Tendon disorders are common and account for a significant proportion of musculoskeletal pain presentations. Tendon pathology can occur in all ages leading to pain and disability that can substantially impact daily function, recreational activities, occupation and quality of life. An understanding of the complex tendon macro- and microscopic structure, along with its physiology and biomechanics provides the basic rationale for its medical or surgical treatments following injury. There are numerous described techniques for surgical repair of ruptured flexor tendons, and therefore it is important to understand the core principles for a successful repair which will be summarized in this article.     

Diagnosis and management of oral lichen planus

Oral lichen planus is a complex and poorly understood clinical condition which cannot be cured. A definitive diagnosis and careful, conscientious follow-up are imperative. Symptoms and complications are common and challenging but may be managed with a variety of therapies including orally administered and systemic medications as well as lifestyle alterations and reduction of precipitating factors.     

Posterior heel pain

Heel pain at or around the insertion of the Achilles tendon is a common presenting complaint affecting both young, active patients and those who are older and more sedentary. So-called posterior heel pain is often presumed to run a self-limiting course over a few months, resolving with rest, weight loss and stretching exercises. However, a small number of patients suffer with increasingly disabling symptoms that are refractory to this regimen. Posterior heel pain is classically split into insertional and non-insertional types, and in order to select an appropriate management plan the diagnosis must be precise. Further management without a clear understanding of the pathology is potentially detrimental to the patient. This review aims to provide a structured approach to careful clinical and radiological assessment and treatment of this condition.     

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.     

Oral medicine and the elderly

A focus often exists in dental practice on the maintenance and management of the dentition and the periodontium, however, conditions of the oral mucosa and orofacial pain can cause significant problems for older patients. Oral mucosal conditions are more prevalent in older patients and many orofacial pain disorders, such as burning mouth syndrome and trigeminal neuralgia, are more common in patients over the age of 50 years. Although these conditions may not be routinely managed in general practice, identification of these patients in primary care and appropriate referral will lead to more prompt and effective treatment. CLINICAL RELEVANCE: Dental practitioners need to be able to identify what is considered to be within the normal physiological limits of the ageing oral tissue and hence what is abnormal and requires further investigation to facilitate appropriate referral.     

(iii) Extensor tendon injuries

Extensor tendon injuries are more common in presentation than flexor injuries. They are often viewed as the poorer cousins on whom the more junior doctor can practice the art of tendon repair without significant risk of morbidity and poor functional outcome. Unfortunately this is not the reality. Understanding of the extensor anatomy helps predict associated injuries and guide subsequent management resulting in decreased morbidity and improved functionality.     

Teamwork in orthodontics: limiting the risks of root resorption

Orthodontic treatment is not without risk. The risks may be due to patient factors (which may not always be evident before treatment) or may come about because of the treatment itself. While the common types of risk are well documented, less information is available as to how some of the more unusual problems can best be managed when they arise; often the need for teamwork between the patient, orthodontist and general dental practitioner (GDP) are underestimated. This paper presents three patients in whom various root-related problems existed either before orthodontic treatment or which arose during orthodontic treatment; demonstrates how they were managed; and highlights the need for teamwork to ensure a 'least harmful' outcome. All patients were followed up for over a year.     

Orofacial movement disorders

This article reviews three poorly recognized yet relatively common presentations of hyperactive orofacial movement disorders: oromandibular dystonia, orofacial dyskinesia, and drug-induced extrapyramidal syndrome reactions. Orofacial movement disorders are often misdiagnosed as temporomandibular disorders, hence understanding these conditions is pertinent for the practitioner treating orofacial pain. Aspects of epidemiology, etiology, pathophysiology, clinical presentation, and diagnosis are discussed along with treatment considerations for these orofacial movement disorders.     

Use of TMJ arthrotomography in the diagnosis and treatment of anterior disk dislocation

Treatment of TMJ pain and dysfunction should primarily be directed at correction of a specific abnormality and the patient's chief complaint. The specific approach to treatment of TMJ abnormalities is based on an accurate diagnosis. Although sound clinical judgment often suggests a tentative diagnosis, the specific diagnosis can often be confirmed radiographically. Fluoroscopic arthrotomography can effectively aid in the diagnosis and treatment needed for effective and efficient TMJ care. It is especially beneficial in the diagnosis and treatment of anterior disk dislocation. The authors conclude that (1) anterior disk dislocation is a common occurrence in TMJ intra-articular disorders; (2) standard radiographs are not diagnostic for ADD; (3) arthrotomography is an effective aid in the diagnosis and treatment of TMJ soft tissue derangements, especially ADD; (4) use of arthrotomography should be based on sound clinical judgment; (5) the causes and significance of and the optimal treatment for ADD are controversial at this time; and (6) knowledge gained from arthrotomography may clarify these controversies.