- Email: [email protected]
Authors’ response
COMMENTARIES
MELANOMA AND TMD
I felt I had to write a letter after reading Dr. Samir Singh and colleagues’ October JADA article, “Metastatic Melanoma Misdiagnosed as a Temporomandibular Disorder: A Case Report and Review of the Literature” (Singh S, Desai B, Laskin D. JADA. 2014;145[10]:1052-1057). As the referring general dentist in this case, I felt some of the facts regarding our patient’s care were misrepresented. On reading the title, one may assume that the general dentist in this case “misdiagnosed” our patient with temporomandibular disorder (TMD) when, in fact, my referral to the oral medicine department was made after I realized her symptoms of orofacial pain were not related to temporomandibular joint disorder/clenching/bruxism issues. The patient’s primary care physician had thought she might be suffering with TMD, as did the otolaryngologist to whom she was referred. I did make her an appliance (nonrepositioning hard acrylic) to satisfy her thoughts that the pain may be from “clenching” or from the recently placed temporary crown (which is visible on the panoramic view in the article). However, after further examination, I noted her limited range of tongue motion and felt some neurologic pathology and/or sublingual tumor could be potential etiology. The ear, nose, and throat referral was also at my request and, sadly, on her return to our office, our patient said he did not “look at my tongue.” Had a more thorough examination been performed, this physician would have recommended magnetic resonance imaging (MRI) to be taken. Fortunately, she was able to be seen at Medical College of Virginia/Virginia Commonwealth University (MCV/VCU) Department of Oral Medicine but, as the article stated, still returned to my office with the tentative misdiagnosis of TMD. As the authors of the article may remember, but failed to mention, it
was not until I called them to insist that MRI be taken that it was done. Again, unfortunately, the neoplasm found under the tongue was secondary metastasis from the previously asymptomatic malignant melanoma in her abdomen. After this diagnosis, she received excellent care at MCV/VCU but, due to the extremely poor long-term prognosis, she and her family elected to spend her remaining days with loved ones on the West Coast. She was a remarkably strong and caring woman and has since passed away. My effort in writing this letter is not to criticize but to re-emphasize our role as clinicians and caregivers, as patients rely on and trust us to help them. This patient knew “something was wrong” and sought help. Her cancer was too advanced by the time it was caught, but maybe the next patient with atypical symptoms won’t have such advanced problems and could be helped sooner. My regards to the excellent people at MCV/VCU School of Dental Medicine and to Drs. Singh, Desai, and Laskin. Thank you for an informative article. Thank you to JADA for allowing my commentary. Ted M. Blaney, DMD Williamsburg, VA
http://dx.doi.org/10.1016/j.adaj.2015.01.006 Copyright ª 2015 American Dental Association. All rights reserved.
Authors’ response: Our thanks to JADA for the opportunity to respond to Dr. Blaney’s letter in which he takes issue with the term “misdiagnosed” to describe what occurred with this patient. A review of the specific chronology in this case, which is not possible to ascertain from Dr. Blaney’s letter, will indicate why we believe this term was justified. According to our records, and as indicated in the published report, this patient was originally treated by Dr. Blaney with a bite appliance. He indicates that this was done “to
satisfy her thoughts that the pain may be from ‘clenching’ or the recently placed temporary crown.” Occlusal bite appliances are typically not standard of care after placement of a crown, and one does not ordinarily treat a patient based solely on a self-diagnosis. Hence, it can be assumed that, at that time, Dr. Blaney did feel the patient had a TMD. As he also notes, the patient’s primary care physician and the otolaryngologist to whom she was subsequently referred also believed this was the correct diagnosis. As described in the case report, we entertained a tentative diagnosis of a TMD ourselves based on the clinical examination alone. The exact diagnosis was made only after obtaining magnetic resonance imaging, which was ordered and preauthorized by our office after the first visit. Subsequently, the imaging findings were explained to the patient, and the appropriate referrals mentioned in the report were facilitated. As clinicians managing chronic facial pain, we often have to revise our diagnosis because chronic facial pain from other sources and a TMD can be confused and may be erroneously treated with multiple failed procedures.1 As our report suggests, neoplasms of the head and neck region may be difficult to diagnose and, therefore, may initially have an empirical diagnosis of a TMD, trigeminal neuralgia, or atypical facial pain. Dr. Blaney is to be complimented on his persistence that this patient’s problem be solved and for his emphasis on the reliance and trust that patients put on us as treating doctors. An accurate diagnosis of the patient’s symptoms would not have been possible without his diligent referral. Samir Singh, DMD Resident Oral and Maxillofacial Surgery Bhavik Desai, DMD, PhD Assistant Professor Oral Medicine
JADA 146(3) http://jada.ada.org
March 2015 145
COMMENTARIES
Daniel M. Laskin, DDS, MS Professor and Chairman Emeritus Department of Oral and Maxillofacial Surgery School of Dentistry Virginia Commonwealth University Richmond, VA
http://dx.doi.org/10.1016/j.adaj.2015.01.007 Copyright ª 2015 American Dental Association. All rights reserved.
1. Israel HA, Ward JD, Horrell B, Scrivani SJ. Oral and maxillofacial surgery in patients with chronic orofacial pain. J Oral Maxillofacial Surg. 2003;61(6):662-667.
ANTIBIOTICS AND IMPLANTS
Dr. Ben Balevi’s October JADA Critical Summaries article, “Patients Who Received Preoperative Antibiotics Showed Fewer Early Implant Failures” (JADA. 2014;145[10]:10681070), eloquently summarized the results of an updated Cochrane review,1 which after evaluating 6 trials with a total of 1,162 participants and a follow-up period of 3 to 5 months, suggested that 2 grams of amoxicillin administered 1 hour before implant placement may reduce the patient’s risk of experiencing implant failure by 66%, without risk to the patient. Dr. Balevi, however, in defining the clinical implications of the Cochrane review, claimed that “the sample size of all the trials together is far too small to allow for the identification of rare—and even lifethreatening—adverse events such as anaphylactic shock.” In reality, the American Heart Association (AHA) has monitored adverse events among even greater numbers of patients associated with the prophylactic use of penicillintype agents—in this instance for prevention of endocarditis (IE) for more than 50 years,2 as has the National Institute for Health and Clinic Excellence (NICE).3 Specifically, the AHA report unequivocally states just the opposite. The AHA statement found on pages 1743-1744 specifically notes, “For 50 years, the AHA has recommended [a form of] penicillin as the preferred choice for dental prophylaxis for IE.
146 JADA 146(3) http://jada.ada.org
During these 50 years, the Committee is unaware of any cases reported to the AHA of fatal anaphylaxis resulting from the administration of [a form of] penicillin recommended in the AHA guidelines for IE prophylaxis. The Committee believes that a single dose of amoxicillin or ampicillin is safe and is the preferred prophylactic agent for people who do not have a history of type I hypersensitivity reaction to a penicillin, such as anaphylaxis, urticaria or angioedema.”2 Furthermore, the NICE clinical guidelines report specifically notes on page 76 that, “the studies included in this review that considered antibiotic prophylaxis against IE did not . identify any episodes of anaphylaxis.”3 Arthur H. Friedlander, DMD Associate Chief of Staff Director, Graduate Medical Education VA Greater Los Angeles Healthcare System Los Angeles, CA and Professor-in-Residence Oral & Maxillofacial Surgery and Director Quality Assurance Hospital Dental Service UCLA Dental School and Medical Center Los Angeles, CA Renna C. Hazboun, DMD Oral & Maxillofacial Surgery Research Fellow VA Greater Los Angeles Healthcare System Los Angeles, CA
http://dx.doi.org/10.1016/j.adaj.2015.01.008 Copyright ª 2015 American Dental Association. All rights reserved.
1. Esposito M, Grusovin MG, Worthington HV. Interventions for replacing missing teeth: antibiotics at dental implant placement to prevent complications. Cochrane Database Syst Rev. 2013; 7:CD004152. 2. Wilson W, Taubert KA, Gewitz M, et al; American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research
March 2015
Interdisciplinary Working Group. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group [published correction appears in Circulation. 2007;116(5):e376-377]. Circulation. 2007; 116(15):1736-1754. 3. Centre for Clinical Practice at NICE (UK). Prophylaxis against infective endocarditis: Antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures. London, United Kingdom: National Institute for Health and Clinical Excellence (UK); 2008. Available at: www.nice.org.uk/guidance/cg64. Accessed October 20, 2014.
Author’s response: I welcome the opportunity to respond to Dr. Friedlander and Dr. Hazboun regarding my article. The systematic review reported that implant success rate can improve by approximately a 4% arithmetic difference in the first 5 months after placement with the administration of antibiotic prophylaxis at the time of placement.1 In their letter, Drs. Friedlander and Hazboun cite reports by the American Heart Association (AHA)2 and the National Institute for Health and Clinic Excellence (NICE),3 which state that, after many years of administering antibiotic prophylaxis to patients undergoing surgery, including dental and oral surgery, no cases of fatal anaphylaxis have been reported. Subsequently, Drs. Friedlander and Hazboun take exception to my claim that “the sample size of all the trials together is far too small to allow for the identification of rare—and even life-threatening— adverse events such as anaphylactic shock.” It is my opinion that Drs. Friedlander and Hazboun have taken the AHA report out of context and, furthermore, have misquoted the NICE report. I would like to address these issues now. First, the AHA report also states on pages 1743-1744, “Nonfatal adverse reactions, such as rash,
MELANOMA AND TMD
I felt I had to write a letter after reading Dr. Samir Singh and colleagues’ October JADA article, “Metastatic Melanoma Misdiagnosed as a Temporomandibular Disorder: A Case Report and Review of the Literature” (Singh S, Desai B, Laskin D. JADA. 2014;145[10]:1052-1057). As the referring general dentist in this case, I felt some of the facts regarding our patient’s care were misrepresented. On reading the title, one may assume that the general dentist in this case “misdiagnosed” our patient with temporomandibular disorder (TMD) when, in fact, my referral to the oral medicine department was made after I realized her symptoms of orofacial pain were not related to temporomandibular joint disorder/clenching/bruxism issues. The patient’s primary care physician had thought she might be suffering with TMD, as did the otolaryngologist to whom she was referred. I did make her an appliance (nonrepositioning hard acrylic) to satisfy her thoughts that the pain may be from “clenching” or from the recently placed temporary crown (which is visible on the panoramic view in the article). However, after further examination, I noted her limited range of tongue motion and felt some neurologic pathology and/or sublingual tumor could be potential etiology. The ear, nose, and throat referral was also at my request and, sadly, on her return to our office, our patient said he did not “look at my tongue.” Had a more thorough examination been performed, this physician would have recommended magnetic resonance imaging (MRI) to be taken. Fortunately, she was able to be seen at Medical College of Virginia/Virginia Commonwealth University (MCV/VCU) Department of Oral Medicine but, as the article stated, still returned to my office with the tentative misdiagnosis of TMD. As the authors of the article may remember, but failed to mention, it
was not until I called them to insist that MRI be taken that it was done. Again, unfortunately, the neoplasm found under the tongue was secondary metastasis from the previously asymptomatic malignant melanoma in her abdomen. After this diagnosis, she received excellent care at MCV/VCU but, due to the extremely poor long-term prognosis, she and her family elected to spend her remaining days with loved ones on the West Coast. She was a remarkably strong and caring woman and has since passed away. My effort in writing this letter is not to criticize but to re-emphasize our role as clinicians and caregivers, as patients rely on and trust us to help them. This patient knew “something was wrong” and sought help. Her cancer was too advanced by the time it was caught, but maybe the next patient with atypical symptoms won’t have such advanced problems and could be helped sooner. My regards to the excellent people at MCV/VCU School of Dental Medicine and to Drs. Singh, Desai, and Laskin. Thank you for an informative article. Thank you to JADA for allowing my commentary. Ted M. Blaney, DMD Williamsburg, VA
http://dx.doi.org/10.1016/j.adaj.2015.01.006 Copyright ª 2015 American Dental Association. All rights reserved.
Authors’ response: Our thanks to JADA for the opportunity to respond to Dr. Blaney’s letter in which he takes issue with the term “misdiagnosed” to describe what occurred with this patient. A review of the specific chronology in this case, which is not possible to ascertain from Dr. Blaney’s letter, will indicate why we believe this term was justified. According to our records, and as indicated in the published report, this patient was originally treated by Dr. Blaney with a bite appliance. He indicates that this was done “to
satisfy her thoughts that the pain may be from ‘clenching’ or the recently placed temporary crown.” Occlusal bite appliances are typically not standard of care after placement of a crown, and one does not ordinarily treat a patient based solely on a self-diagnosis. Hence, it can be assumed that, at that time, Dr. Blaney did feel the patient had a TMD. As he also notes, the patient’s primary care physician and the otolaryngologist to whom she was subsequently referred also believed this was the correct diagnosis. As described in the case report, we entertained a tentative diagnosis of a TMD ourselves based on the clinical examination alone. The exact diagnosis was made only after obtaining magnetic resonance imaging, which was ordered and preauthorized by our office after the first visit. Subsequently, the imaging findings were explained to the patient, and the appropriate referrals mentioned in the report were facilitated. As clinicians managing chronic facial pain, we often have to revise our diagnosis because chronic facial pain from other sources and a TMD can be confused and may be erroneously treated with multiple failed procedures.1 As our report suggests, neoplasms of the head and neck region may be difficult to diagnose and, therefore, may initially have an empirical diagnosis of a TMD, trigeminal neuralgia, or atypical facial pain. Dr. Blaney is to be complimented on his persistence that this patient’s problem be solved and for his emphasis on the reliance and trust that patients put on us as treating doctors. An accurate diagnosis of the patient’s symptoms would not have been possible without his diligent referral. Samir Singh, DMD Resident Oral and Maxillofacial Surgery Bhavik Desai, DMD, PhD Assistant Professor Oral Medicine
JADA 146(3) http://jada.ada.org
March 2015 145
COMMENTARIES
Daniel M. Laskin, DDS, MS Professor and Chairman Emeritus Department of Oral and Maxillofacial Surgery School of Dentistry Virginia Commonwealth University Richmond, VA
http://dx.doi.org/10.1016/j.adaj.2015.01.007 Copyright ª 2015 American Dental Association. All rights reserved.
1. Israel HA, Ward JD, Horrell B, Scrivani SJ. Oral and maxillofacial surgery in patients with chronic orofacial pain. J Oral Maxillofacial Surg. 2003;61(6):662-667.
ANTIBIOTICS AND IMPLANTS
Dr. Ben Balevi’s October JADA Critical Summaries article, “Patients Who Received Preoperative Antibiotics Showed Fewer Early Implant Failures” (JADA. 2014;145[10]:10681070), eloquently summarized the results of an updated Cochrane review,1 which after evaluating 6 trials with a total of 1,162 participants and a follow-up period of 3 to 5 months, suggested that 2 grams of amoxicillin administered 1 hour before implant placement may reduce the patient’s risk of experiencing implant failure by 66%, without risk to the patient. Dr. Balevi, however, in defining the clinical implications of the Cochrane review, claimed that “the sample size of all the trials together is far too small to allow for the identification of rare—and even lifethreatening—adverse events such as anaphylactic shock.” In reality, the American Heart Association (AHA) has monitored adverse events among even greater numbers of patients associated with the prophylactic use of penicillintype agents—in this instance for prevention of endocarditis (IE) for more than 50 years,2 as has the National Institute for Health and Clinic Excellence (NICE).3 Specifically, the AHA report unequivocally states just the opposite. The AHA statement found on pages 1743-1744 specifically notes, “For 50 years, the AHA has recommended [a form of] penicillin as the preferred choice for dental prophylaxis for IE.
146 JADA 146(3) http://jada.ada.org
During these 50 years, the Committee is unaware of any cases reported to the AHA of fatal anaphylaxis resulting from the administration of [a form of] penicillin recommended in the AHA guidelines for IE prophylaxis. The Committee believes that a single dose of amoxicillin or ampicillin is safe and is the preferred prophylactic agent for people who do not have a history of type I hypersensitivity reaction to a penicillin, such as anaphylaxis, urticaria or angioedema.”2 Furthermore, the NICE clinical guidelines report specifically notes on page 76 that, “the studies included in this review that considered antibiotic prophylaxis against IE did not . identify any episodes of anaphylaxis.”3 Arthur H. Friedlander, DMD Associate Chief of Staff Director, Graduate Medical Education VA Greater Los Angeles Healthcare System Los Angeles, CA and Professor-in-Residence Oral & Maxillofacial Surgery and Director Quality Assurance Hospital Dental Service UCLA Dental School and Medical Center Los Angeles, CA Renna C. Hazboun, DMD Oral & Maxillofacial Surgery Research Fellow VA Greater Los Angeles Healthcare System Los Angeles, CA
http://dx.doi.org/10.1016/j.adaj.2015.01.008 Copyright ª 2015 American Dental Association. All rights reserved.
1. Esposito M, Grusovin MG, Worthington HV. Interventions for replacing missing teeth: antibiotics at dental implant placement to prevent complications. Cochrane Database Syst Rev. 2013; 7:CD004152. 2. Wilson W, Taubert KA, Gewitz M, et al; American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research
March 2015
Interdisciplinary Working Group. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group [published correction appears in Circulation. 2007;116(5):e376-377]. Circulation. 2007; 116(15):1736-1754. 3. Centre for Clinical Practice at NICE (UK). Prophylaxis against infective endocarditis: Antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures. London, United Kingdom: National Institute for Health and Clinical Excellence (UK); 2008. Available at: www.nice.org.uk/guidance/cg64. Accessed October 20, 2014.
Author’s response: I welcome the opportunity to respond to Dr. Friedlander and Dr. Hazboun regarding my article. The systematic review reported that implant success rate can improve by approximately a 4% arithmetic difference in the first 5 months after placement with the administration of antibiotic prophylaxis at the time of placement.1 In their letter, Drs. Friedlander and Hazboun cite reports by the American Heart Association (AHA)2 and the National Institute for Health and Clinic Excellence (NICE),3 which state that, after many years of administering antibiotic prophylaxis to patients undergoing surgery, including dental and oral surgery, no cases of fatal anaphylaxis have been reported. Subsequently, Drs. Friedlander and Hazboun take exception to my claim that “the sample size of all the trials together is far too small to allow for the identification of rare—and even life-threatening— adverse events such as anaphylactic shock.” It is my opinion that Drs. Friedlander and Hazboun have taken the AHA report out of context and, furthermore, have misquoted the NICE report. I would like to address these issues now. First, the AHA report also states on pages 1743-1744, “Nonfatal adverse reactions, such as rash,