Michael T. Montgomery

Changes in signs and symptoms following temporomandibular joint disc repositioning surgery

Fifty-one subjects with documented intra-articular pathology refractory to non-surgical therapy underwent temporomandibular joint (TMJ) disc repositioning surgery. Following surgery, subjects were evaluated for 6 months to 6 years by clinical examinations and questionnaires at designated times, and by postsurgical joint imaging. Significant decreases were noted in pain (headache, TMJ pain, ear pain, and neck/shoulder pain), the incidence of joint sounds and locking, and the presence of dietary restrictions. However, 35% of the subjects continued to have residual TMJ pain, and a similar percentage continued to need periodic nonsteroidal anti-inflammatory drugs for analgesia. Some degree of dietary restriction remained in approximately 50% of the subjects, and joint sounds persisted in a similar percentage following surgery. Mean mouth opening was improved by 8 mm, although lateral movements were increased by less than 0.5 mm. Surgery did not decrease the occurrence of jaw deviation, and disc position was unchanged in 86% of the joints imaged at an average of 2 years following surgery. Although TMJ disc repositioning surgery significantly improved pain and dysfunction in TMJ surgery patients, the improvement in disc position was not maintained in most subjects following surgery.

Arthroscopic TMJ surgery: effects on signs, symptoms, and disc position.

Nineteen subjects with documented intra-articular pathology refractory to nonsurgical therapies underwent temporomandibular joint (TMJ) arthroscopy involving lysis and lavage in the superior joint space. Following surgery, subjects were evaluated for 6 to 12 months by clinical examinations and questionnaires at designated time periods and by postsurgical joint imaging. Significant improvement was noted in pain, mandibular movement, and diet. No improvement was noted in the incidence of joint sounds, and disc position was unchanged in 80% of the joints. The findings suggest that disc repositioning may not be needed to achieve clinical success.

Morbidity and mortality from pharmacosedation and general anesthesia in the dental office

Morbidity and mortality (M&M) statistics have been used to determine the safety of pharmacosedation and general anesthesia for dental procedures. Although relevant, these data often do not describe what actually caused the problems. Descriptive data are needed to understand etiologic factors and to accurately set malpractice insurance rates, establish legislative regulations, and determine means of prevention. The purpose of this study was to characterize the factors involved in causing M&M in a national data base of dental patients who received either pharmacosedation or general anesthesia. Letters were sent to all state dental boards requesting detailed information on cases associated with M&M during the last 15 years. Follow-up letters and telephone contacts were made with noncompliant boards. Forty-three cases were reported from nine states, with mortality comprising 81.4% of the cases. The mean patient age was 18 years, with a range from 2 to 42 years. Seventy-five percent of the cases were classified as American Society of Anesthesiologists (ASA) class I, 21% as ASA II, and 4% as ASA III. The mean number of pharmacological agents used was three, with a range from one to seven. In 32% of the cases heart rate was monitored, in 23% respiration was monitored, in 23% blood pressure was monitored, in 8% tissue oxygen saturation was monitored, and in 4% heart rhythm was monitored. Fifty-nine percent of the practitioners performed basic life support as a part of resuscitative efforts, 21% performed some measure of advanced cardiac life support, and in 45% of the cases narcotic reversal was attempted.(ABSTRACT TRUNCATED AT 250 WORDS)

Success of temporomandibular joint arthroscopy in disk displacement with and without reduction

Forty-three subjects with disk displacement without reduction (DNR) or disk displacement with reduction (DWR) underwent arthroscopic lysis and lavage of the temporomandibular joints. Both groups of subjects were assessed by clinical examination, a questionnaire, and joint imaging, to determine the impact of internal derangement type (DWR vs DNR) on postsurgical outcome. There were no significant differences in postsurgical outcomes between the two groups of meniscal disorders with respect to clinical and questionnaire data. However, the DNR group generally exhibited a smoother, less erratic recovery. After surgery dramatic improvements were in range of motion, pain, and function in both groups, although some level of residual pain and dietary limitation remained in approximately half the subjects. The incidence of joint sounds and deviation were not improved by surgery. Significant differences were found between the two groups with respect to imaging results. Arthroscopy had little effect on the disk positions of DNR subjects: 84% were unchanged after surgery, and the remaining 16% were improved. The disk position of DWR subjects appeared more labile, with 31% unchanged, 38% worsened, and 31% improved.

Acyclovir prophylaxis for oral herpes simplex virus infection in patients with bone marrow transplants.

Reactivation of herpes simplex virus (HSV) appears to play a significant role in oral mucositis resulting from bone marrow transplantation. The acyclic guanosine derivative acyclovir has been shown to be effective in treating and protecting against HSV infection in this group. The purpose of this study was to determine the role of HSV reactivation in oral mucositis in patients undergoing bone marrow transplantation who were seronegative for HSV or who received acyclovir prophylaxis. The results suggest that HSV plays an insignificant role in oral mucositis in these patients.

Systemic lupus erythematosus: a consideration for antimicrobial prophylaxis.

Endothelial damage to heart valves, similar to that seen with rheumatic heart disease, occurs in 50% of all patients with systemic lupus erythematosus. Bacterial endocarditis is a consequence in 1% to 4% of these patients. This rate is greater than the incidence of endocarditis after rheumatic heart disease and compares favorably with the incidence of endocarditis in patients with prosthetic heart valves. At present, it is not possible to accurately delineate the subpopulation of patients with SLE that is at risk for this disease; hence, it is recommended that antibiotic prophylaxis (standard regimen suggested by the American Heart Association) be considered for all patients with systemic lupus erythematosus undergoing dental procedures associated with transient bacteremias.

The prevalence of cardiac valvular pathosis in patients with systemic lupus erythematosus

The purpose of this study was to determine the prevalence of valvular pathosis in a population of patients with SLE, to assess the candidacy of such patients for antibiotic prophylaxis before dental treatment. The hospital records of 112 patients with SLE were reviewed and screened for endocarditis, heart murmurs, and other valvular pathosis. Two of the 112 patients had confirmed cases of bacterial endocarditis. This prevalence is comparable to endocarditis prevalence rates in patients with prosthetic valves and is also three times that in patients with rheumatic heart disease. The high prevalence of endocarditis in this population of patients with SLE suggests that according to present perspectives on patient management, patients with SLE should be considered for antibiotic prophylaxis before dental therapies associated with formation of a bacteremia.

Ewing's sarcoma metastatic to the gingiva

Although involvement of the jaws by Ewings sarcoma is uncommon, when it occurs the clinical and radiographic presentation may mimic an inflammatory process, specifically pericoronitis. A case that illustrates this dilemma is presented.

The prevention and treatment of aspiration of vomitus during pharmacosedation and general anesthesia

The aspiration of gastric contents can occur in patients with a depressed level of consciousness. Pulmonary aspiration is a serious potential complication of pharmacosedation and general anesthesia. Sequelae associated with aspiration include pulmonary obstruction, chemical pneumonitis, secondary infection, and possibly death. Morbidity following aspiration is enhanced with an increased volume of aspirate, a more acidic pH, a high particle content, and bacterial contamination. Treatment of aspiration is dependent on the nature of the aspirate. Identifying aspiration-susceptible patients, employing preventive measures, and using careful anesthetic technique can effectively reduce the risk of aspiration.

Orofacial metastasis of pulmonary giant cell carcinoma

A patient was admitted to the hospital with multiple skin nodules of recent origin and signs and symptoms suggestive of acute pulmonary infection. Because one of the skin masses was located overlying the left mandibular body region, the patient was referred to the hospital dentistry clinic for evaluation. Historical, clinical, and radiographic assessments were consistent with reactive lymphadenopathy, and an intraoral excisional biopsy was performed. The biopsy results were indicative of giant cell carcinoma, which was confirmed by biopsy results from a similar skin lesion on the shoulder and by malignant cells recovered in the sputum and pleural fluids. Although this carcinoma has been shown to rarely metastasize to the skin and lymphatics of the neck, this is the first case report of metastasis to facial lymphatics.