Infection following treatment of mandibular fractures in human immunodeficiency virus seropositive patients

Wound Healing Problems in the Mouth

Wound healing is a primary survival mechanism that is largely taken for granted. The literature includes relatively little information about disturbed wound healing, and there is no acceptable classification describing wound healing process in the oral region. Wound healing comprises a sequence of complex biological processes. All tissues follow an essentially identical pattern to complete the healing process with minimal scar formation. The oral cavity is a remarkable environment in which wound healing occurs in warm oral fluid containing millions of microorganisms. The present review provides a basic overview of the wound healing process and with a discussion of the local and general factors that play roles in achieving efficient would healing. Results of oral cavity wound healing can vary from a clinically healed wound without scar formation and with histologically normal connective tissue under epithelial cells to extreme forms of trismus caused by fibrosis. Many local and general factors affect oral wound healing, and an improved understanding of these factors will help to address issues that lead to poor oral wound healing.

Outcomes research: Mandibular fractures in the diabetic population

OBJECTIVE

The study aimed to examine the management and outcomes of mandibular fractures in patients with diabetes mellitus by examining the injury modalities, treatment methods, and complications.

METHODS

The study conducted was a retrospective case review of patients admitted to Memorial Hermann Hospital from 2007 to 2011 with diagnoses of diabetes mellitus and mandibular fracture. The electronic medical records were reviewed for patient demographics, injury data, surgery methodology, treatment variables, and complications.

RESULTS

Out of the 34 diabetic patients, the average age was 52 with the majority of the fractures being the result of falls, 12 (35.3%). Of the 63 total fractures, 24 (38.1%) fractures were repaired through closed reduction and 39 (61.9%) fractures required open reduction with internal fixation. 17 (50.0%) patients had at least one complication following mandibular fracture repair. The most common complications in this sample population included nerve injury, 7 (20.6%), infection, 7 (20.6%), wound dehiscence with or without hardware exposure, 6 (17.7%), and malocclusion, 5 (14.7%).

CONCLUSION

When compared to the limited published data our findings imply that diabetic patients with mandibular fractures present as an older population than commonly seen with mandibular fractures and suggest a higher overall rate of complications.

Long-term outcome assessment of closed treatment of mandibular fractures

Mandibular fractures are among the most common trauma injuries of the craniomaxillofacial region. This study evaluated the late results of mandibles fractures treated with arch bar. Forty-nine patients were examined clinically and by questionnaires for late results of arch bar treatment. Demographic data (age, sex, etc), trigeminal nerve sensation (Weber test), temporomandibular joint evaluation, masticatory muscle function, and occlusion were recorded. The data were analyzed by χ test using Sigma Stat 2.0 software. Fifty-one percent of the patients with angular fractures complained of sensory disturbances. Condylar and angular fractures demonstrated higher levels of pain. According to Pearson χ test, a statistically significant relation between angular fracture and tenderness of the internal pterygoid muscles (P = 0.047), angular fracture and cross-bite (P = 0.021), parasymphysial fracture and pain upon wind blowing (P = 0.026), and body fracture and mastication discomfort (P = 0.038) was found. In closed reduction therapy, fracture location of the mandible seems to be more likely correlated in producing particular long-term complications. Regular follow-ups for functional treatments and physiotherapy of chewing muscles and temporomandibular joint, along with removal of occlusal abnormalities, should be considered following arch bar reduction of mandibular fractures.

Risk factors for surgical wound infection in HIV-positive patients undergoing surgery for orthopaedic trauma

PURPOSE

To identify risk factors associated with surgical wound infection in patients infected with human immunodeficiency virus (HIV) undergoing surgery for orthopaedic trauma.

METHODS

Records of 29 male and 7 female HIV-positive patients aged 18 to 47 years who underwent surgery for orthopaedic trauma were reviewed. Data on HIV-specific variables (HIV clinical classification, CD4+ lymphocyte count) and highly active antiretroviral therapy were retrieved, as were data on wound class, fracture type, surgery type, surgical wound infections, and outcomes. Possible risk factors associated with surgical wound infection were analysed.

RESULTS

The median follow-up period was 27 (range, 19-41) months. Of the 36 patients, 14 (39%) developed surgical wound infections (4 were deep and 10 superficial). 89% and 67% of them were in HIV clinical category B and in CD4+ T-lymphocyte category 3, respectively. 12 of these infections resolved after debridement and prolonged antibiotic treatment, and 2 developed chronic osteomyelitis. Four of the patients had non-union. Surgical wound infections were associated with HIV clinical category B (p<0.001), CD4+ T-lymphocyte category of more than or equal to 2 (p=0.041), and contaminated wounds (p=0.003).

CONCLUSION

Identification of risk factors may help minimise morbidity in HIV-positive patients.

Risk factors for development of infection in patients with mandibular fractures located in the tooth-bearing area

PURPOSE

The aim was to identify the main risk factors for infection in patients with mandibular fractures located in the tooth-bearing area.

MATERIAL AND METHODS

Seven hundred and eighty-nine case histories were retrospectively reviewed regarding treatment results and nature of complications developed. The data concerning possible risks were analysed statistically to find out those factors that seemed to have a significant influence on the development of infection.

RESULTS

The incidence of infection in patients with mandibular fractures located in the tooth-bearing area was determined by the following risk factors: social and organizational conditions of medical care, trauma pattern, preexisting medical status and treatment tactics. The main contributory factors were delayed medical care, accompanying pathological disorders, angular location, multiple and comminuted fractures and the type of antibiotic used.

Infection following treatment of mandible fractures: the role of immunosuppression and polysubstance abuse

OBJECTIVE

There is little data available on the relationship between immunosuppression and polysubstance abuse and postoperative infection in patients with mandibular fractures. In this study we aimed to assess these parameters.

STUDY DESIGN

This study sample consisted of 120 patients who were admitted to the Department of Oral and Maxillofacial Surgery at the Washington Hospital Center between January of 1999 and February of 2002. Patient charts were reviewed and data regarding fracture location, mode of treatment, type of antibiotic therapy, and outcome of treatment including postoperative complications were also recorded. Patient's medical and social histories were also reviewed for a history of diabetes mellitus (DM), human immunodeficiency virus (HIV) status, alcohol abuse, and intravenous drug abuse (IVDA).

RESULTS

Of the 120 patients in this study, 17 (14.1%) patients were identified as having a postoperative infection. Among those with postoperative infections, 8 (6.7%) had history of immunosuppression or polysubstance abuse. The strongest association found in this review is the relationship between alcohol (P = 0.50) and IVDA (P = 0.68), and the development of post-operative infections. There was also an increased rate of postoperative infection in HIV-positive patients (P = 0.71) and DM patients (P = 0.77).

CONCLUSION

In our study, we observed an increased risk for post-operative infection in HIV-positive individuals and diabetics. This finding lends support to other studies, which have shown a higher incidence of infection in HIV-positive individuals. We also observed an increased risk for postoperative infection among patients with history of alcohol and drug abuse. Therefore, in treatment planning for the correction of mandible fractures in patients with histories of substance abuse, it seems appropriate to make efforts to decrease the postoperative risk.

HIV-assoziiertes Lymphom ? ungew�hnliche Ursache einer pathologischen Unterkieferfraktur

Despite the introduction of highly active antiretroviral therapy (HAART), diffuse large B-cell lymphoma (DLBCL) remains a common malignancy in human immunodeficiency virus (HIV)-infected patients, especially the plasmablastic variant. About 50% of lymphomas in HIV patients are extranodal and half of them occur in the head and neck area. The main oral symptoms are pain, swelling, numbness and tooth mobility. We report the case of a 52-year-old patient with a known HIV infection and fracture of the angular region of the mandible. The fracture did not unite following open reduction and osteosynthesis. A biopsy performed at the time of revision revealed the diagnosis of a primary lymphoma in the mandible. After chemotherapy had induced complete remission of the lymphoma and autogenous iliac crest bone grafting had been performed the fracture united. Primary lymphoma in the mandible is a disease that presents with a nonspecific radiological appearance which may mimic osteomyelitis or periodontal pathology. A rapid and accurate diagnosis is critical for the appropriate treatment. In our experience HIV-positive patients with mandibular fracture should be treated according to the guidelines established for HIV-negative patients. However, risky compromises such as intraoral approach or hazardous fracture fixation should be avoided.

Hospital course of HIV-positive patients with odontogenic infections

OBJECTIVE

The study purpose was to compare and contrast the hospital course of patients who are human immunodeficiency virus-positive (HIV+) and human immunodeficiency virus-negative (HIV-) who were admitted to manage their odontogenic infection.

STUDY DESIGN

We used a retrospective case-control study design and a sample derived from patients admitted for management of their odontogenic infections. Cases and controls were defined as patients who were HIV+ or HIV-, respectively. HIV status was determined by patient self-report. Outcome variables included admission temperature (degrees Celsius) and white blood cell count, number of fascial spaces infected, days with temperature >38 degrees C, need for intensive care, and length of hospital stay.

RESULTS

The study sample consisted of 60 patients (10 HIV+ cases and 50 HIV- controls matched for age and sex) with a mean age of 32.8 +/- 6.6 years and was predominantly male (78%). Significant differences existed between patients who were HIV+ and those who were HIV- for the following variables: admission white blood cell count, number of days with maximum temperature >38.0 degrees C, and use of the intensive care unit.

CONCLUSIONS

The study results suggest that patients who are HIV+ who are admitted for management of odontogenic infection have a significantly more intense hospital course than those who are HIV-. However, the overall length of hospital stay is not significantly different.

A financial analysis of maxillomandibular fixation versus rigid internal fixation for treatment of mandibular fractures

PURPOSE

The aim of this study was to compare the cost-effectiveness of mandibular fracture treatment by closed reduction with maxillomandibular fixation (CRF) with open reduction and rigid internal fixation (ORIF).

PATIENTS AND METHODS

This was a retrospective study of 85 patients admitted to the Oral and Maxillofacial Surgery Service at San Francisco General Hospital and treated for mandibular fractures from January 1 to December 31, 1993. The patients were divided into 2 groups: 1) those treated with CRF and 2) those treated with ORIF. The outcome variables were length of hospital stay, duration of anesthesia, and time in operating room. The charge for primary fracture treatment included the fees for the operation and hospitalization without any complications. Within the group of 85 patients treated for mandibular fractures in 1993, 10 patients treated with CRF and 10 patients treated with ORIF were randomly selected, and hospital billing statements were used to estimate the average charge of primary treatment. The average charge to manage a major postoperative infection also was estimated based on the billing statements of 10 randomly selected patients treated in 1992 (5 treated with CRF, 5 with ORIF) who required hospital admission for the management of a complication. The average total charge was computed by using the average charge for primary treatment plus the incidence of postoperative infection multiplied by the average charge for management of that complication.

RESULTS

Eighty-five patients were included in the study. The average charge for primary treatment was $10,100 for the CRF group and $28,362 for the ORIF group. The average charge for the inpatient management of a major postoperative infection was $26,671 for the CRF group and $39,213 for the ORIF group. The average total charge for management of a mandible fracture with CRF was $10,927; the total charge for the ORIF group was $34,636.

CONCLUSION

The results of this retrospective study suggest that the use of CRF in the management of mandibular fractures at our institution provides considerable savings over treatment by using ORIF. The use of ORIF should be reserved for patients and fracture types with specific indications.

The risk of serious odontogenic infections in HIV-positive patients: a pilot study

OBJECTIVE

The purpose of this study was to perform a preliminary test of the hypothesis that patients infected with the human immunodeficiency virus (HIV) have an increased risk for serious odontogenic infections in comparison with HIV-negative patients.

STUDY DESIGN

To address the research purpose, we used a case-control study design. A case was a serious odontogenic infection requiring inpatient management. A control was a nonserious odontogenic infection that could be managed on an outpatient basis. The ratio of controls to cases was 2:1. HIV status was determined by record review.

RESULTS

The sample was composed of 300 patients. Sixteen patients (5%) were HIV-positive. Overall, 37.5% of the HIV-positive patients had serious infections; this compared with 33% of the HIV-negative patients (odds ratio = 1.21; 95% confidence interval = 0.43-3.44; P = .79).

CONCLUSIONS

The results of this pilot study suggest that HIV-positive patients do not have an increased risk for developing serious odontogenic infections.

Predictors of postextraction complications in HIV-positive patients

OBJECTIVE

The purpose of this study was to identify factors associated with an increased risk for post-tooth-extraction complications in a sample of HIV-positive patients.

STUDY DESIGN

A cohort of HIV-positive patients who required the extraction of one or more teeth was enrolled. The predictor variables were grouped into the following sets: demographics; medical and social history; preoperative clinical findings; preoperative laboratory measures (hematologic, immunologic, and nutritional); and treatment. The outcome variable was defined as the presence or absence of a complication following tooth extraction. Logistic regression techniques were used to identify variables associated with an increased risk for complications following tooth extraction.

RESULTS

During the enrollment period, 76 HIV-positive patients were enrolled into the study cohort. Seventeen patients (22.4%) had postoperative complications. Based on the bivariate statistical analyses, variables associated with the presence of postoperative complications were red blood cell count, CD8 count, total number of positive sites tested using cell-mediated immunity skin tests, and extraction technique (p < or = 0.05). Using a stepwise logistic regression technique, the variable identified as being predictive of postoperative complications was the CD8 count (p = 0.02). The post-tooth-extraction complication rate of the HIV-positive patients in this study sample was greater than the rate reported in most other studies (22% vs. 3%-5%). The complications, however, were minor and easily treated. The variable consistently identified with an increased risk for complications was the CD8 count: the lower the CD8 count, the higher the risk for complications. The CD8 count, however, had poor predictive value.

CONCLUSION

In acute clinical situations--for example, in cases of patients with significant dental pain--the results suggest that delaying treatment to obtain laboratory studies may be of little clinical value. It may be appropriate to proceed with suitable, definitive procedure(s) to alleviate symptoms.

HIV status and the risk of post-extraction complications

Tooth extraction is commonly performed for patients infected with the human immunodeficiency virus (HIV). We undertook a prospective study to determine if HIV-positive patients had an increased risk for complications following tooth extraction. The study sample was composed of patients who presented for tooth extraction to the outpatient oral/maxillofacial surgery clinic at Grady Memorial Hospital, Atlanta, GA. The predictor variable was HIV status (positive or negative). The outcome variable was the presence or absence of a post-extraction complication. Other study variables were grouped into the following sets: (1) demographic, (2) past medical and social history, (3) clinical, (4) laboratory values, and (5) treatment. Between 11/93 and 4/96, 166 patients were enrolled. The study sample was composed of the 151 patients who completed the study protocol and consisted of 76 HIV-positive and 75 HIV-negative patients. The post-extraction complication rates were 22.3 and 13.3% for the HIV-positive and -negative groups, respectively (relative risk = 1.68, 95% confidence interval = 0.82 to 3.42, p = 0.15). The types of complications that occurred were similar in both groups. While the data suggest an increased rate of post-extraction complications in the HIV-positive group, the difference in complication rates between the two groups was not statistically significant. In addition, the complications were minor, self-limiting, and readily treated. Based on these findings, we believe that tooth extraction is a low-risk procedure in HIV-positive patients. Treatment may be rendered routinely to patients who present on an outpatient basis without the need for an extensive pre-operative work-up, unless otherwise indicated by relevant history.

Chronic osteomyelitis of the mandible following tooth extraction in HIV infection

A case is presented of refractory chronic osteomyelitis of the left mandible arising after a tooth extraction in HIV infection. The challenges of prompt diagnosis and the dilemma of satisfactory management are highlighted. It is imperative that dental and oral health providers have a particularly high index of suspicion of conditions that occur in HIV infection so that early identification and appropriate management may be instituted.