- Email: [email protected]
Chronic temporal abscess resulting from a periapical abscess of the upper right first molar
332
Letters to the Editor / British Journal of Oral and Maxillofacial Surgery 47 (2009) 331–334
of the type of pathway that we developed years ago with the Academic Advisory Committee for Oral and Maxillofacial Surgery. It seems the obvious way to integrate dually qualified oral and maxillofacial surgeons in a medical academic base. In hand with these developments we should facilitate the easy passage of our trainees through their second degree and back into mainstream oral and maxillofacial surgery. There is no reason why doctors who study dentistry could not formally acquire their basic maxillofacial skills during their dental course. By definition they will be working in large medical or dental schools where there are resident oral and maxillofacial teams. Ideally all dually qualified graduates should move directly into oral and maxillofacial-themed CT3 posts. With this in mind there will be a tranche of 10–15 highly motivated and qualified people coming on to the market in a year or 2. Are there decoupled ST2 and CT3 posts available? There should be: who is going to tackle this problem?
References 1. Brennan PA, McCaul JA. The future of academic surgery—a consensus conference held at the Royal College of Surgeons of England, 2 September 2005. Br J Oral Maxillofac Surg 2007;45:488–9. 2. McKechnie A, McCaul J. Research training for oral and maxillofacial surgery. Br J Oral Maxillofac Surg 2007;45:478–83. 3. Shepherd J, Re: Brennan PA, McCaul JA. The future of academic oral and maxillofacial surgery. Br J Oral Maxillofac Surg 2007;45: 488–9. 4. McKechnie A, McCaul J. Research training for oral and maxillofacial surgery. Br J Oral Maxillofac Surg 2008;46:342–3.
M. McGurk ∗ Department of Oral & Maxillofacial Surgery, At Guy’s, King’s College and St Thomas’ Hospital, Floor 23, Guy’s Hospital, London SE1 9RT, United Kingdom ∗ Tel.: +44 20 7188 4348; fax: +44 20 7188 4360. E-mail address: [email protected] Available online 20 March 2009 doi:10.1016/j.bjoms.2009.01.020
Re: Shearer J, McManners J. Comparison between the use of an ultrasonic tip and a microhead handpiece in periradicular surgery: a prospective randomised trial. Br J Oral Maxillofac Surg in press, doi:10.1016/j.bjoms. 2008.09.015
were all experienced operators, this does not comply completely with the “quest for uniformity” that is required in such a study. Our main concern about study design is that there was no reference to any calculation of sample size, which is mandatory in a prospective, randomised trial. For a particular finding to be claimed as significant (or not), the analysis must have enough power, but we do not know if this study was sufficiently powered. Had a pre-hoc calculation of sample size been done? We also think that parts of the data analysis and statistics were not clear. Why, or where did the authors use the Student’s t-test? What kind of continuous variables did they test? Were these variables normally distributed? It is interesting to note that the major end-point variables of this study (good apical seal and bony infill) were not recorded and reported as continuous variables but as categorical values (frequency). How was the difference between the microhead group and the ultrasound group tested? While the study is interesting for surgeons and dentists, appropriate statistical analysis of data is essential for accurate conclusions, particularly when new techniques are compared with “older” ones. We hope that our suggestions will be useful to other authors who will be involved in similar studies in the future. A. Mangano a A. Albertin c A. Mangano b C. Mangano d L. La Colla e,∗ a University of Milan Dental School, Milan, Italy b Vita-Salute San Raffaele University School of Medicine IRCCS San Raffaele, Milan, Italy c Department of Anesthesiology, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy d Insubria University Dental School, Varese, Italy e Department of Anesthesiology, Vita-Salute San Raffaele University School of Medicine - IRCCS H San Raffaele, Via Olgettina 60, 20132 Milan, Italy ∗ Corresponding author. Tel.: +39 02 2643 2656; fax: +39 02 2641 2823. E-mail address: [email protected] (L. La Colla) Available online 6 March 2009 doi:10.1016/j.bjoms.2009.02.001
Sir, We read this article with interest. While the authors are to be commended for their aim to conduct the first prospective, randomised trial on the effect of using an ultrasonic technique in periradicular surgery, we have several concerns with both the design of the study and the statistical analysis. Firstly, the authors state that procedures were carried out by three different surgeons in both groups. Even though they
Chronic temporal abscess resulting from a periapical abscess of the upper right first molar Sir, We read the short communication by Adams and Bryant1 with great interest and present a similar case of our own.
Letters to the Editor / British Journal of Oral and Maxillofacial Surgery 47 (2009) 331–334
333
E-mail address: [email protected] (E. Yalc¸ın) Available online 28 March 2009 doi:10.1016/j.bjoms.2009.03.002
Emergency airway management of patients with a RED frame Sir,
Fig. 1. Clinical appearance of the cutaneous fistula.
A 62-year-old woman was referred to the Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ataturk University, with pain in the right temporal region and maxillary right first molar, fever, swelling, and a cutaneous fistula in the right temporal region. Intraoral examination showed caries in the maxillary right first molar. A periapical radiolucency of the maxillary right first molar was present on the plain radiograph. Physical examination showed a cutaneous fistula in the temporal region (Fig. 1), and she had a temperature of 37 ◦ C. She had been treating herself by applying a plant (Plantago asiatica) to the skin of the temporal region. This is a traditional remedy from eastern Asia, and although it is not used in modern medicine, it is used for treatment of various diseases in our region. We diagnosed a chronic temporal abscess resulting from a periapical abscess of the upper right first molar, which was treated with ceftriaxone 2 g/day and metronidazole 1 g/day intravenously together with intraoral drainage. Pus was obtained by needle aspiration for culture and sensitivity testing. The maxillary first molar was removed. We grew Streptococcus viridans from the pus but no pathogens from the blood. The patient’s temperature on the fifth day was 36.5 ◦ C, she had no pain, and the swelling had gone down. Her intravenous drugs were stopped. She was discharged taking amoxicillin/clavulanate potassium 2 g/day orally for 14 days.
Distraction osteogenesis describes the lengthening of bone and soft tissue by gradual movement from an osteotomy. It was first used by Codvilla in 1905 in orthopaedic operations on the long bones, and later popularised by Ilizarov.1 In the 1960s the upper arches were expanded on the facial skeletons of monkeys. The first human mandibular distraction was not until the late 1980s, and the first mandibular distraction was reported in the early 1990s by McCarthy et al.2 The facial skeleton can be distracted using external or internal devices. External distraction is a well-established way of reconstructing maxillary discrepancy or hypoplasia secondary to trauma and congenital anomalies such as cleft palate and Cruzon syndrome. A commonly used external distractor is the rigid external distraction system (RED II, KLS-Martin, Jacksonville, USA). The interconnected components of the RED frame include a halo device anchored to the cranium, a vertical midline facial bar, and a horizontal bar anchored to the maxilla by transcutaneous infranasal wires (Fig. 1). These patients require multiple operations under general anaesthesia, and are managed postoperatively on maxillofacial wards. The bars and infranasal wires obstruct access to the patient’s nose and mouth, which makes management of the airway, particularly with traditional mask ventilation, difficult. To ventilate such a patient efficiently using a standard resuscitation facemask it is necessary to create a seal over both the nose and mouth, but this is not always possible in a patient with an RED frame. The removal of various components of
Reference 1. Adams JR, Bryant DG. Cranial osteomyelitis: a late complication of a dental infection. Br J Oral Maxillofac Surg 2008;46:673–4.
Ümit Ertas¸ Ertan Yalc¸ın ∗ Ataturk University, Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Erzurum, Turkey ∗ Corresponding author. Tel.: +90 4422311747; fax: +90 4422360945.
Fig. 1. A rigid external distraction frame on a patient.
Letters to the Editor / British Journal of Oral and Maxillofacial Surgery 47 (2009) 331–334
of the type of pathway that we developed years ago with the Academic Advisory Committee for Oral and Maxillofacial Surgery. It seems the obvious way to integrate dually qualified oral and maxillofacial surgeons in a medical academic base. In hand with these developments we should facilitate the easy passage of our trainees through their second degree and back into mainstream oral and maxillofacial surgery. There is no reason why doctors who study dentistry could not formally acquire their basic maxillofacial skills during their dental course. By definition they will be working in large medical or dental schools where there are resident oral and maxillofacial teams. Ideally all dually qualified graduates should move directly into oral and maxillofacial-themed CT3 posts. With this in mind there will be a tranche of 10–15 highly motivated and qualified people coming on to the market in a year or 2. Are there decoupled ST2 and CT3 posts available? There should be: who is going to tackle this problem?
References 1. Brennan PA, McCaul JA. The future of academic surgery—a consensus conference held at the Royal College of Surgeons of England, 2 September 2005. Br J Oral Maxillofac Surg 2007;45:488–9. 2. McKechnie A, McCaul J. Research training for oral and maxillofacial surgery. Br J Oral Maxillofac Surg 2007;45:478–83. 3. Shepherd J, Re: Brennan PA, McCaul JA. The future of academic oral and maxillofacial surgery. Br J Oral Maxillofac Surg 2007;45: 488–9. 4. McKechnie A, McCaul J. Research training for oral and maxillofacial surgery. Br J Oral Maxillofac Surg 2008;46:342–3.
M. McGurk ∗ Department of Oral & Maxillofacial Surgery, At Guy’s, King’s College and St Thomas’ Hospital, Floor 23, Guy’s Hospital, London SE1 9RT, United Kingdom ∗ Tel.: +44 20 7188 4348; fax: +44 20 7188 4360. E-mail address: [email protected] Available online 20 March 2009 doi:10.1016/j.bjoms.2009.01.020
Re: Shearer J, McManners J. Comparison between the use of an ultrasonic tip and a microhead handpiece in periradicular surgery: a prospective randomised trial. Br J Oral Maxillofac Surg in press, doi:10.1016/j.bjoms. 2008.09.015
were all experienced operators, this does not comply completely with the “quest for uniformity” that is required in such a study. Our main concern about study design is that there was no reference to any calculation of sample size, which is mandatory in a prospective, randomised trial. For a particular finding to be claimed as significant (or not), the analysis must have enough power, but we do not know if this study was sufficiently powered. Had a pre-hoc calculation of sample size been done? We also think that parts of the data analysis and statistics were not clear. Why, or where did the authors use the Student’s t-test? What kind of continuous variables did they test? Were these variables normally distributed? It is interesting to note that the major end-point variables of this study (good apical seal and bony infill) were not recorded and reported as continuous variables but as categorical values (frequency). How was the difference between the microhead group and the ultrasound group tested? While the study is interesting for surgeons and dentists, appropriate statistical analysis of data is essential for accurate conclusions, particularly when new techniques are compared with “older” ones. We hope that our suggestions will be useful to other authors who will be involved in similar studies in the future. A. Mangano a A. Albertin c A. Mangano b C. Mangano d L. La Colla e,∗ a University of Milan Dental School, Milan, Italy b Vita-Salute San Raffaele University School of Medicine IRCCS San Raffaele, Milan, Italy c Department of Anesthesiology, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy d Insubria University Dental School, Varese, Italy e Department of Anesthesiology, Vita-Salute San Raffaele University School of Medicine - IRCCS H San Raffaele, Via Olgettina 60, 20132 Milan, Italy ∗ Corresponding author. Tel.: +39 02 2643 2656; fax: +39 02 2641 2823. E-mail address: [email protected] (L. La Colla) Available online 6 March 2009 doi:10.1016/j.bjoms.2009.02.001
Sir, We read this article with interest. While the authors are to be commended for their aim to conduct the first prospective, randomised trial on the effect of using an ultrasonic technique in periradicular surgery, we have several concerns with both the design of the study and the statistical analysis. Firstly, the authors state that procedures were carried out by three different surgeons in both groups. Even though they
Chronic temporal abscess resulting from a periapical abscess of the upper right first molar Sir, We read the short communication by Adams and Bryant1 with great interest and present a similar case of our own.
Letters to the Editor / British Journal of Oral and Maxillofacial Surgery 47 (2009) 331–334
333
E-mail address: [email protected] (E. Yalc¸ın) Available online 28 March 2009 doi:10.1016/j.bjoms.2009.03.002
Emergency airway management of patients with a RED frame Sir,
Fig. 1. Clinical appearance of the cutaneous fistula.
A 62-year-old woman was referred to the Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ataturk University, with pain in the right temporal region and maxillary right first molar, fever, swelling, and a cutaneous fistula in the right temporal region. Intraoral examination showed caries in the maxillary right first molar. A periapical radiolucency of the maxillary right first molar was present on the plain radiograph. Physical examination showed a cutaneous fistula in the temporal region (Fig. 1), and she had a temperature of 37 ◦ C. She had been treating herself by applying a plant (Plantago asiatica) to the skin of the temporal region. This is a traditional remedy from eastern Asia, and although it is not used in modern medicine, it is used for treatment of various diseases in our region. We diagnosed a chronic temporal abscess resulting from a periapical abscess of the upper right first molar, which was treated with ceftriaxone 2 g/day and metronidazole 1 g/day intravenously together with intraoral drainage. Pus was obtained by needle aspiration for culture and sensitivity testing. The maxillary first molar was removed. We grew Streptococcus viridans from the pus but no pathogens from the blood. The patient’s temperature on the fifth day was 36.5 ◦ C, she had no pain, and the swelling had gone down. Her intravenous drugs were stopped. She was discharged taking amoxicillin/clavulanate potassium 2 g/day orally for 14 days.
Distraction osteogenesis describes the lengthening of bone and soft tissue by gradual movement from an osteotomy. It was first used by Codvilla in 1905 in orthopaedic operations on the long bones, and later popularised by Ilizarov.1 In the 1960s the upper arches were expanded on the facial skeletons of monkeys. The first human mandibular distraction was not until the late 1980s, and the first mandibular distraction was reported in the early 1990s by McCarthy et al.2 The facial skeleton can be distracted using external or internal devices. External distraction is a well-established way of reconstructing maxillary discrepancy or hypoplasia secondary to trauma and congenital anomalies such as cleft palate and Cruzon syndrome. A commonly used external distractor is the rigid external distraction system (RED II, KLS-Martin, Jacksonville, USA). The interconnected components of the RED frame include a halo device anchored to the cranium, a vertical midline facial bar, and a horizontal bar anchored to the maxilla by transcutaneous infranasal wires (Fig. 1). These patients require multiple operations under general anaesthesia, and are managed postoperatively on maxillofacial wards. The bars and infranasal wires obstruct access to the patient’s nose and mouth, which makes management of the airway, particularly with traditional mask ventilation, difficult. To ventilate such a patient efficiently using a standard resuscitation facemask it is necessary to create a seal over both the nose and mouth, but this is not always possible in a patient with an RED frame. The removal of various components of
Reference 1. Adams JR, Bryant DG. Cranial osteomyelitis: a late complication of a dental infection. Br J Oral Maxillofac Surg 2008;46:673–4.
Ümit Ertas¸ Ertan Yalc¸ın ∗ Ataturk University, Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Erzurum, Turkey ∗ Corresponding author. Tel.: +90 4422311747; fax: +90 4422360945.
Fig. 1. A rigid external distraction frame on a patient.