Salvaging a Periodontally Compromised and Endodontically Involved Three-Rooted Mandibular First Molar With Cervical Enamel Projection

This case report describes the management of a mandibular first molar with an additional distolingual root (radix entomolaris) and grade III cervical enamel projection through a multidisciplinary approach. Diagnosis for the case was endodontic-periodontal lesion due to non-vitality and associated advanced periodontal destruction. The patient was treated with drainage of the periodontal abscess with adjunct antibiotics, phase I periodontal therapy, endodontic therapy, radiculoplasty, regenerative periodontal therapy, replacement of the missing right mandibular second molar, and long-term maintenance. Follow-up of the patient up to 9 months has been uneventful. Cases of advanced periodontal destruction typically show some degree of tooth mobility, which was absent in this case. The article discusses the tripod effect as well as the increased surface area for periodontal attachment provided by the additional root contributing to the non-mobility of the involved tooth.

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.

Antibiotics in the treatment of periodontal disease: a guide for the general dental practitioner

The objective of the present paper is to discuss the appropriate use of systemic and local adjunctive antibiotics/antimicrobials in the management of periodontal diseases using a number of case studies to illustrate an evidence-based approach to treatment.

The protective effect of recombinant FomA-expressing Lactobacillus acidophilus against periodontal infection

A number of studies have shown that the outer membrane protein FomA found in Fusobacterium nucleatum demonstrates great potential as an immune target for combating periodontitis. Lactobacillus acidophilus is a useful antigen delivery vehicle for mucosal immunisation, and previous studies by our group have shown that L. acidophilus acts as a protective factor in periodontal health. In this study, making use of the immunogenicity of FomA and the probiotic properties of L. acidophilus, we constructed a recombinant form of L. acidophilus expressing the FomA protein and detected the FomA-specific IgG in the serum and sIgA in the saliva of mice through oral administration with the recombinant strains. When serum containing FomA-specific antibodies was incubated with the F. nucleatum in vitro, the number of Porphyromonas gingivalis cells that coaggregated with the F. nucleatum cells was significantly reduced. Furthermore, a mouse gum abscess model was successfully generated, and the range of gingival abscesses in the immune mice was relatively limited compared with the control group. The level of IL-1β in the serum and local gum tissues of the immune mice was consistently lower than in the control group. Our findings indicated that oral administration of the recombinant L. acidophilus reduced the risk of periodontal infection with P. gingivalis and F. nucleatum.

Pulpal involvement-roots-sepsis index: a new method for describing the clinical consequences of untreated dental caries

OBJECTIVES

To describe a modification of the index of clinical consequences of untreated dental caries [pulpal involvement, ulceration, fistula and abscess (PUFA/pufa) index] to pulpal involvement-roots-sepsis (PRS/prs) and to compare the two indices using the example of caries in primary molar teeth in children aged 6-8 years.

SUBJECTS AND METHODS

The study sample included 542 children aged 6-8 years, from five randomly selected schools in the Bialystok District, Poland. The occurrence of clinical consequences of untreated caries in deciduous molars using the pufa and prs indices was evaluated. Data were analysed to express the prevalence, the experience and the distribution of particular pufa and prs codes in the sample population. The differences in layout of the pufa and prs components were expressed.

RESULTS

The response rate was 77.6%. The prevalence of the clinical consequences of untreated caries was 40.77%, mean pufa and prs were the same (0.85 ± 1.33). According to the pufa index, the following mean values were obtained: p = 0.79, u = 0.01, f = 0.04 and a = 0.01. For the prs index, the mean values were as follows: p = 0.45, r = 0.35 and s = 0.05.

CONCLUSION

The proposed prs index was a useful epidemiological instrument for the evaluation of the clinical consequences of untreated caries in the surveyed population. The PRS instrument could be a good alternative to the PUFA index.

Streptococcal lung abscesses from a dental focus following tocilizumab: a case report

Patients suffering from dental infections and concurrently using immunosuppressive medication are at increased risk of developing systemic streptococcal infections. Tocilizumab is a novel therapeutic agent targeting interleukin-6. We describe a case of streptococcal lung abscesses from a dental focus after use of tocilizumab for treatment of Takayasu arteritis.

Regional odontodysplasia: management of an acute case with a scanning electron microscope

Regional odontodysplasia (RO) is an uncommon, nonhereditary, odontogenic developmental disturbance characterized by hypoplasia and hypocalcification of the dental tissues that produce so-called "ghost teeth." This report describes a case of a 2.5-year-old girl who came to the clinic with RO affecting her right maxillary arch. The distinguishing characteristics of this case were the involvement of both the primary and permanent dentitions and the early occurrence of odontogenic abscesses that required the patient's hospitalization. Ultrastructural analysis revealed dental tissue failures that compromised the integrity of the involved teeth, justifying the high susceptibility to caries that was clinically observed. Follow-up was characterized by periodic prosthetic adjustments to maintain the patient's ability to masticate and for social interaction, beyond allowing normal development of her maxillofacial complex. Patients with RO require individualized treatment planning and close follow-up with a multidisciplinary approach.

[Tooth abscess: management in the field]

Tooth abscess can be diagnosed based solely on clinical findings. No additional studies are required. Abscess can be treated using a few basic instruments.

[Clinical and therapeutical considerations regarding odontogenic acute mediastinitis]

Odontogenic acute mediastinitis is an polymicrobial infections caused in most cases by gram negative and anaerobic germs. The odontogenic origin of the cases in this study was based on anamnestic inquiry of the patients, which reveales a dental treatment 7-15 days before the diagnosis of acute mediastinitis was established. Clinical features are often nonspecific at the debut of this affection; septic shock could appear suddenly associated with multiple systems and organs failure. This is the explication why, some of these patients presented septic shock when are diagnosed. In this situations, when acute mediastinitis is suspected, based on clinical and imaging findings, it must be confirmed by surgical exploration and perioperative bacteriological evaluations. Positive diagnosis is based on clinical features associated with labs and imaging studies. Surgery plays an important role in therapy of acute mediastinitis: debridement and drainage of mediastinum with subsequently lavage of it, using antiseptic solutions. Broad spectrum antibiotherapy should be administrated immediately, before antibiogram is ready.

Periodontal abscess during supportive periodontal therapy: a review of the literature

AIM

The aim of this review is to present the current status of the occurrence and management of a periodontal abscess during supportive periodontal therapy (SPT).

BACKGROUND

A periodontal abscess depicts typical features and has been described in patients under SPT in clinical trials. Common periodontal pathogens have been observed in this lesion and some etiologic factors may be responsible for its recurrence. This condition can be isolated or associated with factors that can change the prognosis of affected teeth.

REVIEW RESULTS

Although it has been frequently noticed in untreated periodontitis, the periodontal abscess can also occur in patients under SPT and has been regarded as one of the possible complications of SPT. Patients with a high susceptibility to periodontal disease lost more teeth than those with a healthy periodontium.

CONCLUSION

Early diagnosis and appropriate intervention for periodontal abscesses in patients under SPT are extremely important for the management of the periodontal abscess since this condition can lead to loss of the involved tooth. A single case of a tooth diagnosed with periodontal abscess that responds favorably to adequate treatment does not seem to affect its longevity.

CLINICAL SIGNIFICANCE

An accurate diagnosis and adequate treatment can preserve the longevity of affected teeth.

Endodontic-periodontic bifurcation lesions: a novel treatment option

AIM

The purpose of this preliminary clinical report is to suggest a novel treatment modality for periodontal bifurcation lesions of endodontic origin.

METHODS AND MATERIALS

The study consisted of 11 consecutive patients who presented with periodontal bifurcation lesions of endodontic origin (endo-perio lesions). All patients were followed-up for at least 12 months. Treatment included calcium hydroxide with iodine-potassium iodide placed in the root canals for 90 days followed by canal sealing with gutta-percha and cement during a second stage. Dentin bonding was used to seal the furcation floor to prevent the ingress of bacteria and their by-products to the furcation root area through the accessory canals.

RESULTS

A radiographic examination showed complete healing of the periradicular lesion in all patients. Probing periodontal pocket depths decreased to 2 to 4 mm (mean 3.5 mm), and resolution of the furcation involvement was observed in post-operative clinical evaluations.

CONCLUSIONS

The suggested treatment of endo-perio lesions may result in complete healing. Further studies are warranted.

CLINICAL SIGNIFICANCE

This treatment method improves both the disinfection of the bifurcation area and the healing process in endodontically treated teeth considered to be hopeless.

Multidisciplinary approach to the rehabilitation of a crown fracture with glass-fibre-reinforced composite: a case report

Traumatic tooth injuries are common in children. When permanent teeth are involved, it can be a challenge to save these teeth. This clinical case study describes the multidisciplinary treatment of a complex crown fracture and luxation of a right maxillary incisor along with esthetic management. After periodontal surgery including guided bone regeneration and endodontic treatment, we used a glass-fibre-reinforced composite post to increase retention and distribute stress along the root. The restoration was completed using composite in an incremental technique. During follow-up appointments, clinical and radiographic examinations revealed no root canal or periodontal problems, suggesting the efficacy of the treatment in retaining the fractured tooth. Periodontal surgery with endodontic treatment is an alternative treatment for severe trauma in permanent teeth.

Severe osteomyelitis following immediate placement of a dental implant

Risk factors and complications in immediate implant placement are widely discussed. The present report describes a case of severe osteomyelitis as a serious complication after the immediate placement of a dental implant into an extraction socket of a 61-year-old woman. The course leads from initial treatment of recurrent perimandibular abscesses with surgical drainage and high-dose intravenous antibiotics to a refractory osteomyelitis. Hemimandibulectomy and partial mandibular reconstruction with a free fibular flap followed.

Necrotizing fasciitis of the maxillofacial region caused by dental infection. A case report and review

Necrotizing fasciitis (NF) is a destructive and potentially fatal soft tissue infection characterized by extensive necrosis and gas formation in subcutaneous tissues and fascia, with serious involvement of muscles, vessels, nerves, and fat. In the maxillofacial region, NF is less common. The process can represent the evolution of a dental infection supported by aerobic and anaerobic bacteria that are resistant to antibiotic therapy (multidrug resistance) in immunocompromised patients or the natural evolution of untreated infection. Because of the rarity of the disease, diagnosis and treatment are often delayed, which may result in a fatal outcome due to respiratory problems or systemic complications. The success of the treatment is surgical debridement and high doses of antibiotic therapy. The AA described a case of NF in a female, 59 years old, who developed NF in the maxillofacial and neck region following dental infection and after consulting our Institute for remarkable swelling of the right cheek, palpebral and parotid regions, submaxillary region, and neck; this swelling is associated with hyperpyrexia, trismus, poor systemic conditions, and serious respiratory difficulty. Through prompt clinical diagnosis, early surgical treatment, appropriate antibiotic therapy (culture analysis revealed sensitivity to Imipenem and Levofloxacina), and local control of the lesion through surgical medications twice daily, we were able to not only avoid serious and fatal evolution of the process, but also to limit tissue involvement, preventing further extension of the necrosis to other anatomical structures of the region. A satisfactory clinical result was thus obtained.

Benefits of additional courses of systemic azithromycin in periodontal disease case report

The strong association of subgingival anaerobic bacteria, such as Porphyromonas gingivalis, Treponema denticola and Tannerella forsythia, with destructive periodontal disease has been well documented in the literature. Several double-blind studies have also shown the beneficial use of systemic antimicrobials that are active against these microorganisms in conjunction with conventional periodontal treatment, especially when periodontal abscesses and/or suppuration upon probing are present. Four cases with periodontal abscesses were treated with scaling/root planing in conjunction with systemic azithromycin. Partial improvement led to retreatment with two additional courses of azithromycin. Bone formation was noted on periapical radiographs after the patients took additional courses of azithromycin. In view of the benefits of using additional courses of azithromycin in the treatment of destructive periodontal disease, we conclude that the single course of systemic antimicrobials currently used in periodontal therapy may be insufficient to reach necessary therapeutic levels in infected sites.

Management of odontogenic infection of pulpal and periodontal origin

The dental biofilm is a complex bacterial ecosystem that undergoes evolution, maturing and development, and thus leads to odontogenic infection. The infection is normally located in the tissues of the dental organ itself, and follows a chronic course of evolution. However, bacterial pathogens express virulence factors in the biofilm, and this together with changes in host immunity, may cause clinical exacerbations and spread of infection to other areas of the body. Odontogenic infection management should take into consideration the fact that therapeutic success lies in the control of the infectious aetiologic agent, using mechanical-surgical debridement and/or antimicrobial therapy. Debridement techniques have a fundamentally quantitative effect (by reducing the size of the inoculum) and therefore if these techniques are used alone to control infection, despite an initial clinical improvement that is sometimes prematurely considered as therapeutic success, odontopathogens may persist and the process may recur or become chronic. Microbiological examination may be helpful in defining therapeutic success in a more reliable way, it could define the prognosis of recurrence more precisely, and could enable the most appropriate antibiotic to be selected, thus increasing therapeutic efficacy. Antimicrobial therapy brings about a quantitative and qualitative change in the bacterial composition of the biofilm, in addition to being able to act on sites that are inaccessible through mechanical debridement. However, incorrect antimicrobial use can lead to a selection of resistant bacterial species in the biofilm, in addition to side effects and ecological alterations in the host. In order to minimise this risk, and obtain maximum antimicrobial effect, we need to know in which clinical situations their use is indicated, and the efficacy of different antibiotics with regard to bacteria isolated in odontogenic infection.

Mandibular fracture caused by periodontal abscess: Radiological, US, CT and MRI findings

Mandibular fracture is a rare but possible outcome of a periodontal abscess. A case of complete fracture of the mandible with abscess infiltrating the surrounding soft tissues is described. The patient reported nor trauma, nor locoregional surgery. Ultrasonography and orthopantomography revealed the fracture of the mandible and the abscess at the masseter muscle. Further preoperative diagnostic examinations included CT and MRI. CT revealed the complete fracture line more clearly; MR the extension of the abscess.

Clinical application of povidone-iodine oral antiseptic 1% (Betadine mouthwash) and povidone-iodine skin antiseptic 10% (Betadine solution) for the management of odontogenic and deep fascial space infection

Treatment of infections largely encompasses the field of dental medicine. Prevention and management of infection in the oral and maxillofacial region involve every facet of dental care that may be necessary due to caries, periodontal disease, pulpal pathology, trauma, reconstructive and surgical implants. One of the first surgical procedures in the treatment of localized infection commenced with the opening of bulbous abscesses with sharp stones and pointed sticks. The principles for the management of infection basically remain the same although the surgical technique has remarkably improved. It takes a qualitative and quantitative amount of bacterial insult to produce a certain degree of infection that may eventually lead to facial swelling, asymmetry, discomfort and loss of function. In the oral cavity and its surrounding structures, the predominant organisms such as the staphylococci and streptococci release enzymes responsible for the breakdown of fibrin (connective tissue ground substances) and lyse cellular debris, which facilitates a rapid spread of infection. At the University of the Philippines, Philippine General Hospital Medical Center, where I have served for 18 years, 90% of dental consultations from the outpatient department and emergency room complex concern infection, and 85% of facial swelling is dental in origin. A typical odontogenic infection is a dentoalveolar abscess that spreads deeply into the soft tissue rather than exiting superficially through the oral and cutaneous route, consequently involving the fascial spaces. Following the path of least resistance through connective tissue and along fascial planes, infection may diffuse quite distantly from its dental source, causing damage to the surrounding structures. Appreciation not only of the anatomy of the face and neck is necessary to predict sufficiently the pathway of spread of these infections, but also knowledge of how to drain these spaces adequately.

[Periodontal abscess: etiology, diagnosis and treatment]

The periodontal abscess is an acute destructive process in the periodontium resulting in localized collections of pus communicating with the oral cavity through the gingival sulcus or other periodontal sites and not arising from the tooth pulp. The prevalence of periodontal abscess is relatively high and it affects the prognosis of the tooth. Periodontal abscesses can develop on the base of persisting periodontitis but can also occur in the absence of periodontitis. The cause of the development of periodontal abscess originating from chronic periodontitis is the marginal closure of a periodontal pocket, or the pocket lumen might be too tight to drain the increased suppuration due to changes in the composition of subgingival microflora, alteration of bacterial virulence or host defenses. Diagnosis of a periodontal abscess is based on medical and dental history as well as oral examination (pocket depth, swelling, suppuration, mobility, sensibility of the tooth). The most prevalent group of bacteria: P. gingivalis, P. intermedia, B. forsythus, F. nucleatum and P. micros. Previous studies have suggested that the complete therapy of the periodontitis patients with acute periodontal abscess has to do in two stages: the first stage is the management of acute lesions, then the second stage is the appropriate comprehensive treatment of the original and/or residual lesions. The management of acute lesions includes establishing drainage via pocket lumen, subgingival scaling and root planing, curettage of the lining pocket epithelia and seriously inflamed connective tissue, compressing pocket wall to underlying tooth and periodontal support, and maintaining tissue contact. Some authors recommend the incision or to establish drainage and irrigation, or a flap surgery, or even extraction of hopeless teeth. We recommend the use of systemic antibiotics as a preventive measure of systemic disease or in case of systemic symptoms.

Human cytomegalovirus and Epstein-Barr virus type 1 in periodontal abscesses

OBJECTIVES

Recent studies have linked herpesviruses to severe types of periodontal disease, but no information exists on their relationship to periodontal abscesses. The present study determined the presence of human cytomegalovirus (HCMV) and Epstein-Barr virus type 1 (EBV-1) in periodontal abscesses and the effect of treatment on the subgingival occurrence of these viruses.

MATERIAL AND METHODS

Eighteen adults with periodontal abscesses participated in the study. Subgingival samples were collected from each patient with sterile curettes from an abscess-affected site and a healthy control site. HCMV and EBV-1 were identified by polymerase chain reaction at the time of the abscess and at 4 months after surgical and systemic doxycycline therapy.

RESULTS

HCMV was detected in 66.7% of periodontal abscess sites and in 5.6% of healthy sites (P=0.002). EBV-1 occurred in 72.2% of abscess sites but not in any healthy site (P<0.001). HCMV and EBV-1 co-infection was identified in 55.6% of the abscess sites. Posttreatment, HCMV and EBV-1 were not found in any study site.

CONCLUSIONS

HCMV and EBV-1 genomes are commonly found in periodontal abscesses. These data favor a model in which a herpesvirus infection of the periodontium impairs the host defense and serves as a platform for the entrance of bacterial pathogens into gingival tissue with subsequent risk of abscess development.

[The adverse effect of gas formation on prognosis in a patient with deep neck infection]

A seventy-one-year-old woman was hospitalized with a suspicion of deep neck infection and poor general health. She had been receiving treatment for hepatitis, diabetes mellitus, and cardiac failure and had a history of tooth ache and severe neck pain lasting for the past 10 days. She had been admitted to another center where she had received antibiotic treatment for five days for widespread swelling in the neck and lower extremities, fatigue, and difficulty in breathing and swallowing. Upon admission, computed tomography showed gas formation in the neck and facial regions. Prompt abscess drainage was performed and intense treatment with antibiotics was continued. Despite all efforts, the patient died on the second day of hospitalization from cardiopulmonary arrest. This case emphasizes how urgent drainage is when gas formation is detected in deep neck infections, with inevitable poor prognosis with antibiotic treatment alone.

Diabetic ketoacidosis secondary to dento-alveolar infection

Diabetic ketoacidosis (DKA) is a medical emergency with a potentially fatal outcome if not recognized and treated appropriately. Infective processes are a common precipitant of DKA. We report two cases of dentoalveolar infections in patients with type I diabetes mellitus who presented with DKA. The management of such cases requires both specialist surgical and medical intervention.

Increasing frequency of dental patients in the urban ED

This study examined the spectrum and frequency of dental disorders presenting to an urban ED. Data were retrospectively collected on all patients presenting with dental complaints between January 1, 1987 and December 31, 1995. Data included age, date and time of presentation, diagnosis, triage acuity and disposition. Of the 3,943 charts reviewed, 1,892 (48%) patients required emergent oral surgery management and 2,051 (52%) emergency physician management only. The frequency of dental patients increased from 4.4/1,000 total ED patients in 1987 to 11.5/1,000 in 1995 (P < .05). The rate of emergent dental trauma, emergent nontraumatic dental care, and nonemergent nontraumatic dental care increased similarly during the study period. There was no significant difference by day of week, but a significantly greater number of nonemergent patients presented between 7:00 a.m. and 3:00 p.m. (72%). The incidence of dental patients presenting to the ED increased significantly between 1987 and 1995. Approximately one-half did not require specialist consultation and could potentially have been managed by a primary care dental practitioner.

The swollen face. Severe odontogenic infections

Owing to the widespread availability of preventive dental care and the development of effective antibiotics for the treatment of orofacial infection, the incidence of serious odontogenic infections has decreased dramatically over the past 50 years. Serious dental infections still occur, however, and their occasionally severe complications or even mortality warrant serious study of the clinical presentation, anatomy, and pathophysiology of orofacial infections. The goal of this review is to provide the emergency practitioner with a concise description of the clinical presentation, relevant anatomy, and treatment principles of odontogenic infection in the patient who presents to the ED with a swollen face or difficulty in opening the mouth widely. Prompt institution of surgical therapy for the infection, aided by appropriate antibiotic therapy enables the healthcare professions to continue their remarkable progress in treating these once-dreaded infections.

The periodontal abscess: a review

BACKGROUND/AIMS

The periodontal abscess is a frequent periodontal condition in which periodontal tissues may be rapidly destroyed. Its importance is based on the possible need of urgent care, the affectation of tooth prognosis, and the possibility of infection spreading. There is scant information in the scientific literature regarding this condition and most of it has been published as case reports and text books, where conclusions are not evidence-based, but rather empirical observations made by recognised clinicians. The aim of this review was to critically analyse all available information on this subject in the dental and medical literature, including information on its prevalence, proposed etiologies and pathogenesis, diagnosis, microbiology and treatment alternatives.

SUMMARY

The periodontal abscess is the 3rd most frequent dental emergency, and it is specially prevalent among untreated periodontal patients and periodontal patients during maintenance. Different etiologies have been proposed, and 2 main groups can be distinguished, depending on its relation with periodontal pockets. In the case of a periodontitis-related abscess, the condition may appear as an exacerbation of a non-treated periodontitis or during the course of periodontal therapy. In non-periodontitis related abscesses, impaction of foreign objects, and radicular abnormalities are the 2 main causes. The abscess microflora seems to be similar to that of adult periodontitis, and it is dominated by gram-negative anaerobic rods, including well-known periodontal pathogens. Complications and consequences include tooth loss and the spread of the infection to other body sites. Diagnosis and treatment is mainly based on empiricism, since evidence-based data are not available. The role of systemic antibiotics, in the treatment of periodontal abscesses, is especially controversial.

Parameter on acute periodontal diseases. American Academy of Periodontology

The American Academy of Periodontology has developed the following parameter on the treatment of acute periodontal diseases. Patients should be informed about the disease process, therapeutic alternatives, potential complications, expected results, and their responsibility in treatment. Consequences of no treatment should be explained. Failure to treat acute periodontal diseases appropriately can result in progressive loss of periodontal supporting tissues, an adverse change in prognosis, and could result in tooth loss. Given this information, patients should then be able to make informed decisions regarding their periodontal therapy.

[The time characteristics of the exacerbation of chronic periodontitis and of odontogenic perimaxillary abscesses]

Time course of some laboratory values and clinical manifestations of inflammatory process is studied in 52 patients with exacerbations of chronic periodontitis and 284 patients with odontogenic perimaxillary abscesses. Routine laboratory studies (clinical and biochemical analyses of the blood and urine) were carried out. Acute odontogenic inflammations are characterized by an intermittent course with periodicity of about a week. The end of the first week from the disease onset coincided with recovery in exacerbation of chronic periodontitis and with the beginning of stabilization of inflammatory process in abscess. Recovery after abscess was observed 2 weeks after disease onset. These regularities may be useful for specifying the pathogenesis, terms of check-ups, and duration of treatment.

Descending necrotizing mediastinitis: a retrospective surgical experience

OBJECTIVE

Descending necrotizing mediastinitis (DNM) is a primary complication of cervical or odontogenical infections that can spread to the mediastinum through the anatomic cervical spaces. We reviewed the last 10 years of our surgical experience in DNM and commented on early diagnosis and aggressive surgical treatment in these patients.

METHODS

Five males (71%) and two females (29%), mean age 34 years, with DNM, were surgically treated. Primary oropharyngeal infection occurred in three (43%) and odontogenic abscess in four (57%) patients. All had serious cervical and mediastinal infections with severe respiratory and hemodynamic repercussions, i.e. bacteremia, systemic arterial hypotension and obnubilation. Diagnosis was confirmed by computerized chest tomography.

RESULTS

All patients underwent surgical drainage of the cervical region by bilateral transverse cervicotomy with debridement of the necrotic and infected tissues, associating ample mediastinal drainage with or without thoracotomy. Six patients (86%) evolved well and were discharged after a mean of 35 days. Two patients (29%) required reoperation due to local surgical complications: empyema and dehiscence of the sternum. One patient (14%) died on the second postoperative (p.o.) day due to renal and respiratory insufficiency. Cultures of DNM showed the development of associated aerobic and anaerobic flora in 71% of the operated patients and only aerobic in 29%.

CONCLUSION

Early diagnosis by CAT scan of the neck and thorax aids in rapid indication of a surgical approach of DNM. Performing ample cervicotomy with mediastinal drainage generally associated with thoracotomy can significantly reduce the mortality rate for this condition to 14%.

Heart transplants--assessment of dental procedures

The object of this study was to evaluate the effects of dental foci on survival rates and rejection episodes in heart transplant recipients. Therefore, in a retrospective longitudinal study we studied 74 heart transplant recipients at the Department of Maxillofacial Surgery and Department of Thoracic and Cardiovascular Surgery, University of Münster. Study patients were divided into groups: those in which dental foci had been verified (n = 31) and those without dental foci (n = 43). Statistical analysis was performed using the chi-square test, Kaplan-Meier life table analysis, and the log-rank test. Before heart transplantation, patients were screened clinically and radiographically to determine the extent of dental foci. Postoperatively, patients were evaluated dentally and medically to identify the impact of dental foci on the incidence of systemic and oral infections, frequency and severity of rejection episodes, mortality, and complications arising during dental treatment. By comparing the mortality, infection and rejection rates in the various groups no statistically significant differences (P > 0.05) were found between patients. Despite immunosuppression, extended inflammatory processes such as abscess formation or viral stomatitis were not found in the oral cavity. We therefore suggest that patients suffering from the symptoms of severe heart failure need not be subjected to rigorous preoperative dental treatment.

Median mental sinus in twins

Sinus on the chin can be the result of a chronic apical abscess due to pulp necrosis of a mandibular anterior tooth. The tooth is usually asymptomatic, and a dental cause is therefore not apparent to the patient or the unsuspecting clinician. Not infrequently, the patient may seek treatment from a dermatologist or general surgeon instead of a dentist. Excision and repair of the fistula may be carried out with subsequent breakdown because the dental pathology is not removed. This paper reports the presence of median mental sinus of dental origin in twins. One case healed following root canal therapy while the other required both root canal therapy and surgery to eliminate the infection.