Intravenous cannula used for continuous intraoral mandibular nerve block in trigeminal neuralgia

Trigeminal neuralgia is a chronic pain condition affecting one or more distributions of the trigeminal nerve. Patients with this condition experience short, sharp, shooting pain attacks, which can progress to longer, more frequent durations. The pain is often difficult to control. We report of a man who was admitted with severe neuralgia of the third division of the trigeminal nerve. Talking and any oral intake triggered a severe agonising pain. The latter made the regular oral intake of analgesia challenging. The pain was temporarily controlled with frequent local anaesthesia (LA). Dental core trainees were performing regular inferior alveolar nerve blocks which significantly improved patients' condition allowing him to communicate and have oral intake. Subsequently, a catheter was placed allowing for a continuous anaesthesia. The connecting tube of the cannula was then used by nursing staff to administer LA providing pain relief without the need of repeated intraoral injections.

Management of necrotic immature permanent maxillary incisors using a modified technique of revascularisation

The management of necrotic immature permanent teeth has always been a challenge to endodontists. Various treatment modalities have been tried and tested for achieving a successful outcome. Revascularisation is one among these treatment options, which is gaining widespread attention among endodontists. The growing body of evidence demonstrating the success of revascularisation has led to different variations of this treatment option. Clinicians have over time used different scaffolds such as blood clot, collagen, platelet-rich fibrin (PRF) and platelet-rich plasma for revascularisation. This case report outlines the management of immature maxillary central incisors with pulp necrosis and large periapical lesions in a 19-year-old female patient with a modified technique of revascularisation by combining PRF and blood clot. At the end of 12 months, the patient was completely asymptomatic along with regression of the periapical lesions.

Bilateral isolated mylohyoid groove fracture progressing as submandibular abscess: an usual fracture pattern of mandible

The mylohyoid ridges or lines are pairs of anatomical bony structures located on the internal or lingual surface of mandible. They are the origin for the mylohyoid muscle. These bony structures are distinct in the mandibular molar region, well protected and gradually become undiscernible towards anterior mandible. Bilateral, isolated fracture of the mylohyoid ridges without concomitant mandibular fracture is rare and, to the best of the authors knowledge, was never previously described. This case report describes an isolated bilateral mylohyoid groove fracture, where one side of a necrotic bone fragment at the fracture site progress to became a nidus of infection, which later caused submandibular space abscess requiring emergency surgical intervention. Diagnosis, possible theory to explain the occurrence of isolated mylohyoid groove fracture and management of these condition are explained in this report.

Palatal flap in bilateral inferior partial maxillectomy

Maxillectomy is done for a variety of disease conditions. Reconstruction following maxillectomy is done to restore the form and function. One of the important goals that are to be achieved in reconstruction is the separation of the oral and nasal cavities. In this article, we report the use of palatal flap by preserving the descending palatine artery during bilateral inferior partial maxillectomy, for separating the nasal cavity from the oral cavity. This technique eliminates the need for an obturator or another free or local flap for this purpose.

Surgical management of an odontogenic cutaneous fistula

A patient presented to our unit with a long history of a discharging skin infection on his left cheek, which came and went. He had been seen by numerous healthcare practitioners including his general practitioner, general dental practitioner and dermatologist, with no resolution. He was eventually diagnosed with an odontogenic cutaneous fistula (OCF), for which he underwent surgical management. The purpose of the study is to describe the diagnosis and surgical management of an OCF, from initial assessment through to postoperative review and discharge. Following surgical management of the OCF and treatment of the source of infection by dental extraction, the patient is no longer experiencing purulent discharge through his left cheek. The extraoral skin site of drainage at his left cheek has resolved completely, with minimal residual scarring. OCF can be managed by a number of different treatment modalities. The treatment of an OCF by surgical excision is presented.

Lemierre's syndrome with cavernous sinus thrombosis caused by dental infection

Lemierre's syndrome is a rare multisystemic infection beginning in oropharynx commonly caused by oral anaerobic organisms and leading to internal jugular vein thrombosis with septic emboli. Here, we describe a 45-year-old woman with hypertension and unrecognised type 2 diabetes who presented to a community hospital with fever, double vision and septic shock. Examination showed neck pain aggravated by neck flexion, limited ocular movement of right lateral rectus, left medial rectus and left superior oblique and incomplete ptosis of the left eye. These symptoms were suggestive of bilateral cavernous sinus syndrome. CT of the brain showed bilateral proximal internal jugular vein and cavernous sinus thrombosis. CT angiography revealed septic emboli at both upper lungs. The patient had good improvement of neurological symptoms after dental extraction, intravenous antibiotic and anticoagulant.

Cowden syndrome: new clinical features in a large family; joint hyperextensibility, dental abnormalities and gingival enlargement

A 4-year-old boy presented with his mother to genetics in the 1980s, with a family history (FH) of macrocephaly and intellectual disability (ID). He remained undiagnosed until his mother developed multiple cancers and was diagnosed with Cowden syndrome (CS) in 2017, a rare, multisystem cancer predisposition syndrome. CS was then confirmed in multiple family members. Clinical examination revealed potentially novel features; gingival enlargement, dental abnormalities and joint hyperextensibility. These features could contribute to revised PTEN hamartoma tumour syndrome, National Comprehensive Cancer Network, minor diagnostic criteria. The paediatric CS phenotype is still emerging and features expressed in this family during childhood could potentially aid paediatric diagnosis. This case reminds clinicians to seek genetic input for PTEN testing when macrocephaly is identified alongside, a personal or FH of ID, early-onset tumours (especially breast, bowel or thyroid) or multiple tumours. Thus detailed FH is pivotal to earlier CS diagnosis and improved patient outcomes.

Management of severe traumatic intrusion in the permanent dentition

Traumatic intrusion is considered one of the most severe luxation injuries to the permanent dentition. There are limited studies based on minimal evidence supporting suggested management protocols, owing to the rare occurrence of intrusion. The following case report details the multidisciplinary management and 18-month follow-up, in line with current UK guidelines, of a 23-year old adult male who sustained severe intrusion injuries to both permanent maxillary central incisor teeth. Timely, accurate diagnosis and subsequent appropriate management correlates with improved outcomes for traumatic injuries and it is therefore imperative those involved with the acute and long-term management of dentoalveolar trauma are aware of current guidelines.

Rothia dentocariosa causing intracranial mycotic aneurysm and ischaemic stroke

We describe a case of subacute bacterial endocarditis and mycotic brain aneurysm caused by Rothia dentocariosa due to untreated dental caries. R. dentocariosa is a rare cause of endocarditis that has a high incidence of aneurysmal and haemorrhagic complications. All patients with intracranial aneurysms who have signs of systemic infection should be considered to have mycotic aneurysms until proven otherwise. Dental habits should be included in regular medical assessment and dental care should be considered for patients presenting with infectious symptoms.

Osteonecrosis of the jaw secondary to haematopoietic stem cell transplantation

Osteonecrosis of the jaw (ONJ) is necrosis of mandibular or maxillary bone, which sometimes leads to bone exposure and sequestration. There is evidence that the microenvironment of the marrow stromal system is severely and irreversibly damaged after haematopoietic stem cell transplantation (HSCT) leading to a deficit in the quantity and quality of osteoblastic progenitors, compromising the ability to regenerate a normal osteogenic cell population and abnormality in bone remodelling/turnover. While osteonecrosis of the appendicular skeleton is a common complication after HSCT, there have been no reports of an association with ONJ. This is a report of the first case of ONJ secondary to HSCT in a 69-year-old woman who developed a unique pattern of osteonecrosis involving all four quadrants of the jaw 2 months after allogeneic stem cell transplantation.

Pharyngeal haematoma and partial airway obstruction caused by interaction between warfarin and topical miconazole gel

A man in his 70s on warfarin attended the emergency department three times over a 24-hour period, complaining of a sore throat, neck swelling and difficulty swallowing. He was initially diagnosed with pharyngitis, given antibiotics and discharged home, which was reconfirmed on the second attendance after an episode of haemoptysis. On the third, he was diagnosed with a pharyngeal haematoma causing partial airway obstruction and admitted to critical care. His international normalised ratio (INR) was reported initially as unreadable by the laboratory, then eventually came back as >20. After a thorough medication history, he said that he had recently been prescribed topical miconazole oromucosal gel by his dentist for oral candidiasis, which had interacted with the warfarin to cause this life-threatening haematoma.

Solitary median maxillary central incisor with congenital strabismus and autoimmune thyroiditis in a young child

Single median maxillary central incisor (SMMCI) syndrome is rare. It is commonly associated with other midline defects. About 50% of children with SMMCI have short stature, associated with isolated growth hormone deficiency or panhypopituitarism.A 6-year-old girl presented to us with worsening convergent squint, slowing linear growth and a suspected pituitary macroadenoma on neuroimaging. The key findings on examination included a disproportionate short stature, SMMCI, congenital abduction defect and pseudohypertrophy of calf muscles with myopathy. The evaluation showed autoimmune thyroiditis with pituitary hyperplasia. Bone age corresponded to 3 years.Three months after initiation of thyroxine, her myopathy resolved, and the hormone profile and neuroimaging were normal. Autoimmune thyroiditis in association with SMMCI is not reported previously. This case study emphasises the importance of growth monitoring and the exclusion of common treatable conditions.

Endoscopic removal of ectopic dentition in ethmoid sinus

A 66-year-old woman presented with a 6-month history of unilateral right nasal obstruction and rhinorrhoea not responding to medical therapy. She had a history of dental implantation for an unerupted tooth on the right side 3 years ago. Physical examination including flexible nasendoscopy demonstrated yellow debris in the right middle meatus. CT paranasal sinuses demonstrated a radiopaque lesion in the right anterior ethmoid sinus and resembled the unerupted tooth. The tooth was removed endoscopically from the right nasal cavity without complications. This case highlights the importance of eliciting an accurate dental history and considering ectopic dentition as a differential diagnosis in a patient with unilateral symptoms of sinusitis.

Secrets to a successful awake fibreoptic intubation (AFOI) on a patient with odentogenous abscess

Awake fibreoptic intubation (AFOI) is an established modality in patients with anticipated difficulty with tracheal intubation. This case demonstrates that with careful and meticulous preparations, AFOI can lead to improved airway management and excellent patient outcomes. A 38-year-old woman presented with severe trismus secondary to odentogenous abscess was identified preoperatively as having a potential difficult airway. AFOI was performed successfully using combined Spray-As-You-Go and dexmedetomidine technique.

Floor of mouth schwannoma mimicking a salivary gland neoplasm: a report of the case and review of the literature

Schwannomas or neurilemmomas are slow-growing, benign and often firm lumps that are typically painless. They are extremely rare in the oral cavity, with the tongue and the palate being the most common intraoral sites. This is a case report of this pathology in the floor of the mouth. We present a case of a 28-year-old female patient with a 2-month history of a floor of mouth swelling. On clinical examination this was non-tender and appeared firm. An ultrasound of the lesion was performed which revealed a well-defined, rounded and low reflective soft tissue mass. Following an MRI scan and surgical excision of the lesion, a definitive diagnosis of a schwannoma was made. The presence of schwannoma in the oral cavity is unusual. Based on the literature and the presented case, it should be considered as a differential diagnosis until the final histopathological confirmation.

MRSA infection of masticatory spaces in a paediatric patient

Diagnosis of source of maxillofacial infection in paediatric patients can be challenging due to difficulty in eliciting a proper history and multiple potential sources of infection. Identification and removal of the nidus of infection with decompression and institution of antibiotic therapy as per the culture-sensitivity report form the mainstay treatment of the infection. Deviation from it may result in persistence or even progression of infection, resulting in significant morbidity and mortality. In the past decade, the incidence of community-acquired methicillin-resistant Staphylococcus aureus infection in the oral cavity has seen an upward trend. This has further led to an increase in complexity in the diagnosis of maxillofacial infections. In this case, the authors want to bring to light the challenges faced in managing a paediatric patient with persistent fascial space infection even after removal of the offending tooth, which signifies the importance of managing the infection by the time-tested protocol.

Endoscopic management of a giant dentigerous cyst

Dentigerous cyst is one of the most common developmental cyst of the jaw which accounts for approximately 20%-30% of bone cyst in the head and neck region. Most common site is the third molar of the mandible. However, maxillary involvement is not uncommon. The clinical presentation of this depends mainly on the size and anatomical compromise that occur due to compression. This case highlights the role of endoscopic approach in the management of large expansible cyst of maxilla involving the palate, thus preserving the anatomy and reducing the morbidity associated with an open procedure.

Unique case of glandular odontogenic cyst showing mucoepidermoid carcinoma-like islands in cystic wall

Glandular odontogenic cyst (GOC) is a very rare jaw cyst accounting for 0.2% of all odontogenic cysts. It presents usually in adults with a slight male predominance. It shows radiological, histopathological and even immunohistochemical overlap with low grade intraosseous mucoepidermoid carcinoma (MEC) but their distinction is crucial. A 57-year-old woman with bilocular radiolucency in the anterior mandible crossing the midline is described here. Microscopy features were consistent with glandular odontogenic cyst but multiple MEC-like islands were seen in the capsule, creating a diagnostic head trip with low grade intraosseous MEC. However, the absence of cellular atypia and epidermoid and intermediate cells led to a final diagnosis of GOC, with close follow-up of the patient recommended. This rare finding shows the relation between GOC and MEC or the origin of MEC from GOC.

Pilomatrixoma: a common tumour of head and neck, but rarely reported

Pilomatrixoma is a benign subcutaneous tumour arising from the sebaceous glands. Mutation in the CTNNB1 gene is seen, suggesting beta-catenin misregulation may be the cause of pilomatrixoma. The preoperative diagnosis may be improved by the awareness of the fact that pilomatrixoma is a common and benign skin tumour of the head and neck region. It presents as a well-defined mass, which may be firm to hard in consistency, usually attached to the skin, but not to the underlying tissue. The colour of overlying skin appears a reddish-brown tinge, indicating that it could be a case of pilomatrixoma. Here, we report a case of pilomatrixoma of the cheek in a woman along with the CT findings and histopathological appearances. Dental surgeons should consider it as one of the differential diagnosis in superficial head and neck swelling with calcification.

Pulmonary Aggregatibacter actinomycetemcomitans infection masquerades as malignancy in a patient with periodontitis

A 49-year-old man with a 37.5 pack-year smoking history presented with a suspected neoplasm of the right lung following the discovery of a metabolically active mass on positron emission tomography-CT imaging. The patient, who demonstrated poor oral hygiene, had a history of irregular problem-oriented dental visitation. Having excluded malignancy through histologic investigations, Aggregatibacter actinomycetemcomitans-a well-established periodontal pathogen-was subsequently cultured from his pulmonary aspirate. The patient was therefore managed with systemic antimicrobials and adjunctive dental extractions to eliminate the likely source of infection, whereafter the mass resolved without complication. This case corroborates previous reports of extraoral isolation of A. actinomycetemcomitans, which may mimic cancer clinically and radiographically. While a definitive causative link between untreated periodontitis and systemic infection remains to be elucidated, such cases present a compelling argument in favour of promoting oral health to prevent systemic disease.

The retrieval of a surgical blade broken within the alveolar bone during minimally traumatic tooth extraction

Minimally traumatic tooth removal is the norm for removing teeth when a dental implant is planned at that site. The quantity of available bone is the primary requisite to place an implant. The initial use of a scalpel blade to widen the periodontal space followed by the use of luxators is one of the techniques that is being followed for atraumatic extraction. A case of accidental breakage of a number 11 scalpel blade while attempting tooth removal and the method adopted in removing this portion of the blade without further bone destruction is reported here. The authors have not found any previously published cases, reporting the breakage of a scalpel blade during the bone expansion procedure and its management.

Fusobacterium nucleatum causing a pyogenic liver abscess: a rare complication of periodontal disease that occurred during the COVID-19 pandemic

Fusobacterium nucleatum is a periodontal commensal and pathogen. In rare cases, these anaerobic gram-negative bacilli have been reported to cause pyogenic liver abscesses (PLAs). We describe a patient who developed a periodontal abscess during the COVID-19 pandemic and was unable to access the restricted General Dental Services at this time. She subsequently developed a F. nucleatum bacteraemia and liver abscess. The non-specific signs and symptoms experienced meant the patient self-isolated due to suspected COVID-19 infection and presentation to hospital was delayed. We also include the results of a literature search of other cases of PLAs attributed to F. nucleatum PLAs often develop insidiously. They require percutaneous drainage and prolonged antimicrobial therapy. Clinicians should be aware of this rare complication of a dentoalveolar infection in a patient who is systemically unwell.

Management of unilateral idiopathic masseter muscle hypertrophy with botulinum toxin type A

Masseter hypertrophy (MH) is an uncommon disorder which can cause both aesthetic and functional problems. The most common aetiological factors associated with MH are habit of chewing gum, clenching and/or bruxism. The treatment of MH includes conservative management as well as surgical resection of the enlarged muscle and/or bone. Injection of botulinum toxin type A is a relatively new and minimally invasive method for management of masseter muscle hypertrophy, which offers many advantages over conventional surgical management. This paper reports a case of unilateral MH of unknown origin which was treated with injection of botulinum toxin type A, resulting in satisfactory reduction in the volume of muscle and improvement of facial aesthetics.