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Reliability of Panoramic Radiography in Evaluating the Topographic Relationship Between the Mandibular Canal and Impacted Third Molars JADA The Journal of the American Dental Association March 2004, vol. 135, no. 3, pp. 312-318(7) Monaco G.1; Montevecchi M.2; Alessandri Bonetti G.1; Gatto M.R.A.1; Checchi L.3Conclusion: Increased radiolucency, narrowing and interruption of the radiopaque border, as well as the concomitant presence of two or more radiographic markers, on the PR were highly predictive of contact between the third molar and the mandibular canal. An axial CT scan probably is indicated in such cases.,According to various surveys, the rate of neurological complications has varied from 0.5 to 1 percent for cases involving permanent damage and 5 to 7 percent for cases involving temporary damage. The risk increases dramatically when there is contact between an impacted molar and the mandibular canal (defined as the absence of cortical bone around the alveolar nerve, the point at which the root touches the nerve). In these cases, the incidence of temporary damage to the inferior alveolar nerve rises to about 30 percent of extractions.,“Horizontal inclination is the most dangerous in terms of contact between tooth and canal.”,Microneurosurgery,Nerves damaged from trauma or from an iatrogenic injury may be helped by microsurgeryIdeally performed 6-12 months following the traumaEarly (3 months) referral to specialist indicated if nerve shows no signs of improving,FDA obtained evidence that Canfield manufactured and distributed adulterated (i.e., not manufactured according to good manufacturing practice) and unapproved drugs, including D.S. Dressing (20% Eugenol), D.S. Mini-Dressing (20% Eugenol), D.S. Syringe (20% Eugenol), and D.S. Ointment (20% Eugenol). Canfield promoted these products for the treatment of dry socket, a condition in which the socket does not heal properly following the extraction of a tooth. The products were available nationwide through dental practices for use by dentists and consumers.,FOR IMMEDIATE RELEASEOctober 6, 2006,Permanent Injunction of Dental Products Manufacturer Furthers FDA Efforts Against Marketed Unapproved Drugs,AlvogylDry Socket Alveolar DressingAlvogyl is a one-step, self-eliminating treatment which rapidly alleviates pain and provides a soothing effect throughout the healing process. Its fibrous consistency allows for easy filling of the socket and good adherence during the entire healing process. The active ingredients of Alvogyl include eugenol for analgesic action, butamben* for anesthetic action, and iodoform for anti-microbial action.,*Butamben, a lipophilic local anesthetic of the ester class, produces a differential nerve block of long duration,Odontogenic Infections Dr. J. Bruce Bavitz,From Diagnosis and Treatment of Odontogenic Infections, Hooley, JR, Whitacre, RJ editors Stoma Press 1983,Odontogenic Infxts.-Prevention(My heart, artificial joint or jaw are not infected now, and I dont want them infected after the procedure),Local Site Infxt:Post-op InfxtsSubperiosteal InfxtsDry Sockets?,Distant Site Infxt:Heart (endocarditis)Prosthetic JointsShunts,“Prevention is better than cure.” Desiderius Erasmus 1466-1536,Prevention-Antiseptic Rinse,ChlorhexidineAlcoholIodophorsCetylpyridinium Chloride,Infect Control Hosp Epidemiol. 2007 May;28(5):577-82. Effect of a chlorhexidine mouthwash on the risk of postextraction bacteremia.Toms I, Alvarez M, Limeres J, Toms M, Medina J, Otero JL, Diz P.The chlorhexidine group had 0.2% chlorhexidine mouthwash administered for 30 seconds before any dental manipulation. Blood samples were collected at baseline, 30 seconds, 15 minutes, and 1 hour after the dental extractions. Subculture and further identification of the isolated bacteria were performed by conventional microbiological techniques. RESULTS: The prevalence of bacteremia after dental extraction in the control and chlorhexidine groups were 96% and 79%, respectively, at 30 seconds (P=.008), 64% and 30% at 15 minutes (P.001), and 20% and 2% at 1 hour (P=.005). The most frequently identified bacteria were Streptococcus species in both the control and chlorhexidine groups (64% and 68%, respectively), particularly viridans group streptococci. CONCLUSION: We recommend the routine use of a 0.2% chlorhexidine mouthwash before dental extractions to reduce the risk of postextraction bacteremia.,Prevention-Prophylactic Antibiotics,2007 AHA Recommendations for Heart2003 ADA Recommendations for Ortho ? results at reducing incidence dry socketsDo give to immunocompromised patients prior to surgeryDont give in a cavalier fashion,Prophylactic Antibiotics-When?,Immunocompromised: Type one diabetes, high dose steroids, immunosuppressive agents, prior infection history, poor protoplasm“Long” surgical visitMetastatic/distant site infection risk: (heart valves, orthopedic implants, shunts),Evidence Base for Duration of Antimicrobial Prophylaxis,“The goal of antimicrobial prophylaxis is to achieve serum and tissue levels of the antibiotic, at the time of incision and for the duration of the operation, that are in excess of the minimum inhibitory concentration needed for the organisms that may be encountered during the operation. The National Surgical Infection Prevention Project recommends the antibiotics not be extended beyond 24 hours of the end of the operation.”,Updated August 2003,Proof Nailed Down that Antibiotics Use Leads to Resistance,ANTWERP, Belgium, Feb. 9, 2007 - For the first time, the unassailable proof that physicians can do harm by indiscriminate use of antibiotics has emerged from a randomized controlled trial.Physicians should take into account the striking ecological side-effects of antibiotics when prescribing such drugs to their patients, the researchers concluded. Malhotra-Kumar S et al. Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers: a randomized, double-blind, placebo-controlled study. Lancet 2007; 369: 482-490,2007 AHA,The AHAs latest guidelines were published in its scientific journal, Circulation, in April 2007 and there is good news: the AHA recommends that most of these patients no longer need short-term antibiotics as a preventive measure before their dental treatment.,Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE,2007 AHA,Preventive antibiotics prior to a dental procedure are advised for patients with:1. artificial heart valves 2. a history of infective endocarditis 3. certain specific, serious congenital (present from birth) heart conditions, including unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits 4. a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure 5. any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device 6. a cardiac transplant that develops a problem in a heart valve.,Prophylactic Antibiotics-Specifics,According to the 2007 AHA guidelines, which patient should receive antibiotics before an extraction?A. Mitral valve prolapse with echocardiogram confirmed murmurB. Recent (less than 6 months) bypass surgeryC. History of rheumatic heart diseaseD. Surgical repair of a heart valveE. Heart transplant recipients,None of the above,J Am Dent Assoc. 2003 Jul;134(7):895-9.Antibiotic prophylaxis for dental patients with total joint replacements.American Dental Association; American Academy of Orthopedic Surgeons.The statement concludes that antibiotic prophylaxis is not indicated for dental patients with pins, plates or screws, nor is it routinely indicated for most dental patients with total joint replacements. However, it is advisable to consider premedication in a small number of patients who may be at potential increased risk of experiencing hematogenous total joint infection.,Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known risks of antibiotic toxicity; allergy; and development, selection and transmission of microbial resistance,Prevention-Good Surgical Care,Remove infected granulation tissueRemove bone of questionable vitalityCopious saline irrigationRubber dam for endoNo high speed when large flaps reflectedChange needles often,Treatment(My teeth, gums, jaw are infected.cure me Doctor),Determine etiologyDetermine how sick patient isDetermine if you want to treatGive antibiotics (therapeutic, not prophylactic)Remove etiologyConsider I+D with C+SClose follow up,Determine Etiology,Usually non-vital toothRare perio-abscess or pericoronitisDont forget salivary glands/maxillary sinusPost-op infection? Make sure there isnt another tooth,How Sick Is Patient?,Airway most importantMental statusSwallowing/ SecretionsTrismusVital SignsPMHSpeed of onset,Treat?,Your officeOral surgeons office (document referral)Hospital,Antibiotics,Choose narrowest spectrumGive in proper doseMore expensive not usually better for odontogenic infectionsNot effective for intrapulpal pathology or for walled off abscesses.need surgery,Antibiotics,Give ASAP- in office before surgeryPEN Vk 500mg q6h $5-10.00Clindamycin 450mg q8h $65.00PEN Vk 500mg + Flagyl 500mg q6h $65.00Big Dog Infection? Then IV antibioticsBugs are usually overgrowth of normal flora - both aerobes and anaerobes,Remove Etiology (More important than antibiotics),Anesthesia challenge?-Akinosi/ V2 blockTrismus challenge- consider sedationEndo, ExtractNever faulted for performing I+DNever faulted for obtaining C+S, but expensive (about $350.00),Incision and Drainage 101,Intraoral more esthetic but not always indicated as most dependent area bestMust contact bone Obtain cultures without contaminationSuture in drain after copious irrigationAnesthesia usually challengingRecall fascial space anatomy,I+D with C+S,Anaerobic Culture Tube,Cellulitis vs. Abscess,CellulitisDiffuseInduratedAcute“Body l