Samuel Y.P. Quek

A model for the pathogenesis of bisphosphonate-associated osteonecrosis of the jaw and teriparatide's potential role in its resolution

OBJECTIVE The objective of this study was to present a comprehensive model for the pathogenesis of bisphosphonate-associated osteonecrosis of the jaw (BON). STUDY DESIGN Review of PubMed literature relevant to BON, bisphosphonates (BPs), and bone remodeling. RESULTS Six case reports of spontaneous resolution of BON lesions following administration of teriparatide (Forteo; Eli Lilly and Co., Indianapolis, IN) were identified. These reports suggest that osteoanabolic therapies may hold promise in BON management. Here we propose that BON pathogenesis is multifactorial and is the combined result of attenuated osteoblastic activity (owing to the patients underlying disease, e.g., osteoporosis or multiple myeloma), BP-mediated osteoclast toxicity, and the resultant compromised osteoblast-osteoclast interactions during bone remodeling. Consequently, a vicious cycle of ineffective local remodeling results in the persistence of defective bone, compromised tissue perfusion, and if unresolved, ultimately leads to necrosis. CONCLUSIONS Our model for BON pathogenesis advocates for earlier therapeutic intervention in BON. The biological rationale for teriparatides efficacy in BON justifies further investigation.

Use of Masseteric and Deep Temporal Nerve Blocks for Reduction of Mandibular Dislocation

A patient presented with a unilateral dislocated condyle that was resistant to reduction by simple manual manipulation because of elevator muscle spasm and severe muscle and temporomandibular joint pain. A technique involving a masseteric nerve block and a temporal nerve block was used, allowing a quick, safe, and minimally painful reduction. The method used for delivering these nerve blocks is described here.

Atypical dental implant failure with long-term bisphosphonate treatment—akin to atypical fractures?

Concern that long-term bisphosphonate therapy may significantly undermine bone quality in osteoporotic patients has been heightened by rare instances of low-impact atypical femoral fractures that are often bilateral. Reduced fracture toughness is believed to result from reduced bone remodeling, leading to increased homogeneity in bone microarchitecture, narrowed bone mineral density distribution, and increased bone tissue microdamage burden. We postulate that these long-term alterations in bone quality may undermine the ongoing remodeling surrounding osteointegrated endosseous dental implants as well. To illustrate our hypothesis, we report the catastrophic failure of multiple, successfully osteointegrated dental implants in an osteopenic patient following long-term bisphosphonate treatment. This clinical presentation may reflect underlying adverse changes in bone quality, in a manner analogous to atypical fractures in a small percentage of patients on bisphosphonates. This report highlights the need for multidisciplinary care of patients who have dental implants and begin or are receiving long-term bisphosphonate therapy.

The twin block: a simple technique to block both the masseteric and the anterior deep temporal nerves with one anesthetic injection

The objective of this article is to describe a new technique to anesthetize the masseter muscle and the temporalis muscle using a single extraoral approach. The block targets both the masseteric and the deep temporal nerves as they leave the infratemporal fossa to innervate the deep surfaces of their respective muscles.

Efficacy of regional nerve block in management of myofascial pain of masseteric origin

Objective: To compare the efficacy of a regional masseteric nerve block (MNB) in the management of myofascial pain of masseteric origin, relative to trigger point injection (TrP-Inj) and intra-oral stabilization appliance (IOA). Study design: A retrospective chart review of 200 patients treated for myofascial pain of masseteric origin was performed. Sixty patients met the eligibility criteria and were grouped based on their treatment regimen; IOA, TrP-Inj or MNB. Pain scores recorded at pre-treatment (baseline), 30 minutes post-treatment, and 2 weeks post-treatment were analyzed. Results: Treatment with MNB resulted in significant reduction in pain at 30 minutes and two weeks post-treatment compared to TrP-Inj and IOA. Conclusion: MNB provided an immediate and sustained therapeutic effect for the management of myofascial pain for at least up to two weeks. MNB is a simple and valuable tool in the management of myogenous pain, especially for the non-orofacial pain practitioner.

The impact of patient centered communication in managing Gardner's syndrome

Effective patient communication and comprehension are fundamental toward empowering the patient to make optimal health decisions. Barriers in patient health literacy extend beyond cultural and language differences and can significantly impede this process. This case report illustrates a major communication gap that resulted in contradictory perceptions between a treating oncologist and a patient. The patient′s dentist was able to resolve this miscommunication and facilitate the patient′s acceptance of the recommended intravenous chemotherapy for management of malignant desmoid tumors occurring secondary to Gardner′s syndrome (GS). This report also documents classic craniofacial manifestations of GS including multiple unerupted supernumerary teeth, compound odontomas associated with a dentigerous cyst, as well as multiple osteomas in both arches and in the ethmoid and irregularly shaped radioopacities in both arches. In summary, effective patient-centered communication is a prerequisite for the optimal delivery of healthcare. Both interdisciplinary care and one-on-one patient-provider relationship center on coherent bidirectional communication.