- Email: [email protected]
Localization of maxillary third molar immobilized within an infected maxillary sinus
B R IE F
REPORTS
35. Craig, K.D., and Best, A.J. Perceived control over pain: individual differences and situational de terminants. Pain 3:127-135, 1977. 36. Zborowski, M. People in pain. San Francisco, Jossey-Bass, 1969. 37. Sternbach, R.A., and Tursky, B. Ethnic dif ferences among housewives in psychophysical and skin potential responses to electric shock. Psycho physiology 1:241-246, 1965. 38. Bass, A.H., and Portnoy, M.W. Pain tolerance and group identification. J Pers Soc Psychol 6:106-
108,1967. 39. Weisenberg, M. Pain and pain control. Psychol Bull 84:1008-1044, 1977. 40. Sterbach, R.A. Pain: a psychophysiological analysis. New York, Academic Press, 1968. 41. Fordyce, W.E. Behavioral methods for chronic pain and illness. St. Louis, C. V. Mosby Co, 1976. 42. Fiset, L.O., and Weinstein, P. Preliminary evi dence of validity for clinical measure of patient anxi ety. J Dent Res, abstract 62(46):175,1983. 43. Bobey, M., and Davidson, P. Psychological fac
tors affecting pain tolerance. J Psycho Soc Res 14:371-376, 1970. 44. Jacobson, E. Progressive relaxation. Chicago, University of Chicago Press, 1938. 45. Chaves, J.F., and Barber, T.X. Hypnotism and surgical pain. In Barber, T.X.; Spanos, N.P.; Chaves, J.F., eds. Hypnosis, imagination and human poten tialities. New York, Pergamon Press, 1974. 46. Milgrom, P., and others. Treating fearful dental patients: a patient management handbook. Reston, Va, Reston Publishing Co, to be published, 1984.
Localization of m axillary third molar immobilized within an infected m axillary sinus John D. McKenna, DDS Stephen A. Chidyllo, DDS
he panoramic radiograph is a valu able diagnostic instrument for localizing the causes of facial, sinus, or dental pain that are not evident on intraoral ra diographs. Panoramic radiographs are used when a patient has a problem that cannot be diagnosed during a clinical ex amination or from periapical or bitewing radiographs.
Report of case A 33-year-old white female came to the emer gency clinic w ith soreness in the maxillary right quadrant and a foul taste in her mouth. Exam ination showed that the sore area was edentulous. The rem aining teeth were not sen sitive to percussion. G ingival pocket depths were between 4 and 5 m m , and periodontal pro bin g caused bleeding. A periapical ra d iograph of the right m ax illary tuberosity showed no abnormality. No definite pulpal, occlusal, or p e rio d o n ta l a b n o rm a lity that could cause the stated symptoms could be found; therefore, the patient was referred to the division of oral diagnostic services. The soreness in the area of an edentulous maxillary ridge may indicate several problems: im pacted molars, sinusitis, cystic involvement of residual root tips or residual cysts from pre vious infections. The foul taste in the patient’s m outh could be characteristic of an infection connected w ith the dentition, periodontium , sinuses, or the respiratory or gastric systems. A m onth later, a panoram ic radiograph (Fig 1) was taken in conjunction w ith a clinical oral examination. The radiograph showed an u n kn o w n object w ith in the m axillary right an trum . We assumed that the object was the maxillary right third molar. The patient returned to the c lin ic two weeks later for an additional exam ination and consul 208 ■ JADA, Vol. 108, February 1984
Fig 1 ■ Panoramic radiograph of maxillary right third molar (arrow) w ithin maxillary sinus.
tation w ith the oral surgery department. M e d i cal and dental histories disclosed that the pa tient had never been told and was not aware that the third molar was present, and no extraoral radiographs had been taken. Her dental treatment in clud e d an extraction from the maxillary right quadrant, done ten years ago in the Soviet U nion. W e assumed that the extrac ted tooth was the m axillary right second molar and that the trauma from the extraction dis lodged the third molar, w h ich ultim ately m ig rated to its current position. In January 1981, the patient visited a dentist to determine the cause of discom fort in the m axillary right quadrant. The dentist took a biopsy specimen from tissue over the right tuberosity and sub mitted it for histologic evaluation. The pathol ogy report noted that the specimen consisted of infected residual cyst, epithelial lin in g w ith aggregation of inflam m atory tissue, and some ameloblastic proliferation. A la te ra l s k u ll ra d io g ra p h w as reco m m ended to determine the anteroposterior posi tio n o f the tooth (Fig 2). The rad iog rap h showed the tooth to be located on the distal w all of the m axillary sinus. D uring the oral ex am ination, the patient was asked to perform Valsalva’s maneuver. The internal pressure
Fig 2 ■ Lateral skull radiograph showing maxillary right third molar and cystic involvement in sinus (arrow).
B R IE F
that this maneuver creates in the maxillary sinus caused a perculation of bubbles to appear on the m axillary ridge. A blanching of the m u cosa over the tuberosity also occurred. This maneuver forces air into the sinuses, and, if there is a fistulous tract between the m axillary sinus and the m outh, a perculation of bubbles w ill be noticed on the m axillary ridge. The diagnosis was chronic sinusitis w ith cystic involvem ent of an im pacted third molar in the m axillary right antrum, and an oral an tral fistula. Two months later, the patient was admitted to the hospital and routine preopera tive tests were done. The m olar was removed surgically, the cyst was enucleated, and the oral antral fistula was closed. The three- and
six-month recall examinations showed that the area was healing w ith in normal lim its and all symptoms were gone.
Sum m ary Because a condition of this type could not be detected with intraoral radiographs, the panoramic radiograph was the logical choice for further diagnostic information w ithout resorting to the specialized extraoral radiographs of the maxillary sinus (Waters’ view or anteroposterior extraoral radiograph, for example). As the
REPORTS
panoramic radiograph is a fast, simple, and relatively inexpensive procedure, all dentists should make use of this tech n iq u e w h e n a p a tie n t w ith these symptoms is involved. ___ _ , L _ L __________________________ J'A O A Dr. McKenna is clinical assistant professor, and di rector, section of patient evaluation and management, division of oral diagnostic services, State University of New York, School of Dentistry, Buffalo. Dr. Chidyllo was a senior dental student, State University of New York, School of Dentistry, Buffalo, and is now in private practice, New York City. Address requests for reprints to Dr. Chidyllo, 149-35 15 Drive, Whitestone, NY 11357.
Ingestion of mandibular complete denture Charles O. Hazelrigg, DDS
A
JL
56-year-old white woman, who had a chronic, undifferen tiated type of schizophrenia, was receiving her after noon medication when a member of the nursing staff noticed that she was not wearing her mandibular denture. The pa tient stated that she had accidentally bro ken the denture on a cherry pit during lunch. She had evidently swallowed the denture. The patient was referred to the dental and radiology departments of the hospi tal. There were no oral lesions to suggest trauma or hemorrhaging in the oral cav ity. She was breathing well and could speak without difficulty. The Heimlich maneuver was not applied.1 The patient was experiencing no distress. The results of a radiographic examination confirmed that two pieces of a denture had been swallowed by the patient (Fig 1). No at tempt was made to retrieve the denture pieces.2Two days later the patient was re ferred to the radiology department for a kidney, ureter, bladder (KUB) radiograph that showed a piece of the denture in the stomach and the other piece possibly in the colon (Fig 2). Four days later, another KUB ra diograph was taken and the denture pieces could no longer be seen in the gastrointestinal tract. The patient was unaware that she had passed the denture pieces as she experienced no discomfort at any time. The patient was seen several times by the dental staff for the construc tion of a new denture.
*
J p I• i l
~- 1 8 Mi J r
Fig 1 ■ R a d io g ra p h ic exam ination confirm s that
Fig 2 ■ O n e piece o f denture is seen in stom ach,
tw o denture pieces were sw allow ed by patient.
w hereas other piece is in colon.
Summ ary A broken mandibular denture was acci dentally swallowed by a mentally incom petent patient. Dentists and nursing staff must be aware of the problems encoun tered in the care of such patients who wear removable dental prostheses. To aid in radiologic diagnosis, an opaque disk3 or foil should be used in the construction of an acrylic or plastic dental prosthesis. All removable dental prostheses should have additional patient identification4
that can be easily detected in radiographs. _______________________________ JAD)A Dr. Hazelrigg is director, dental services, Central State Hospital, 3000 W Washington St, Indianapolis, 46222. Address requests for reprints to the author. 1. Heimlich, H.J. A life-saving maneuver to pre vent food-choking. JAMA 234(4):398-401, 1975. 2. Jacobs, L.I. Ingestion of partial denture. JADA 101(5):801, 1980. 3. Perenack, D.M. Ingestion of mandibular com plete denture. JADA 101(5):802, 1980. 4. Operation Ident. Council on Prosthetic Services and Dental Laboratory Relations. Chicago, American Dental Association, 1982. H azelrigg : IN G E S T IO N OF DENTURES ■ 209
REPORTS
35. Craig, K.D., and Best, A.J. Perceived control over pain: individual differences and situational de terminants. Pain 3:127-135, 1977. 36. Zborowski, M. People in pain. San Francisco, Jossey-Bass, 1969. 37. Sternbach, R.A., and Tursky, B. Ethnic dif ferences among housewives in psychophysical and skin potential responses to electric shock. Psycho physiology 1:241-246, 1965. 38. Bass, A.H., and Portnoy, M.W. Pain tolerance and group identification. J Pers Soc Psychol 6:106-
108,1967. 39. Weisenberg, M. Pain and pain control. Psychol Bull 84:1008-1044, 1977. 40. Sterbach, R.A. Pain: a psychophysiological analysis. New York, Academic Press, 1968. 41. Fordyce, W.E. Behavioral methods for chronic pain and illness. St. Louis, C. V. Mosby Co, 1976. 42. Fiset, L.O., and Weinstein, P. Preliminary evi dence of validity for clinical measure of patient anxi ety. J Dent Res, abstract 62(46):175,1983. 43. Bobey, M., and Davidson, P. Psychological fac
tors affecting pain tolerance. J Psycho Soc Res 14:371-376, 1970. 44. Jacobson, E. Progressive relaxation. Chicago, University of Chicago Press, 1938. 45. Chaves, J.F., and Barber, T.X. Hypnotism and surgical pain. In Barber, T.X.; Spanos, N.P.; Chaves, J.F., eds. Hypnosis, imagination and human poten tialities. New York, Pergamon Press, 1974. 46. Milgrom, P., and others. Treating fearful dental patients: a patient management handbook. Reston, Va, Reston Publishing Co, to be published, 1984.
Localization of m axillary third molar immobilized within an infected m axillary sinus John D. McKenna, DDS Stephen A. Chidyllo, DDS
he panoramic radiograph is a valu able diagnostic instrument for localizing the causes of facial, sinus, or dental pain that are not evident on intraoral ra diographs. Panoramic radiographs are used when a patient has a problem that cannot be diagnosed during a clinical ex amination or from periapical or bitewing radiographs.
Report of case A 33-year-old white female came to the emer gency clinic w ith soreness in the maxillary right quadrant and a foul taste in her mouth. Exam ination showed that the sore area was edentulous. The rem aining teeth were not sen sitive to percussion. G ingival pocket depths were between 4 and 5 m m , and periodontal pro bin g caused bleeding. A periapical ra d iograph of the right m ax illary tuberosity showed no abnormality. No definite pulpal, occlusal, or p e rio d o n ta l a b n o rm a lity that could cause the stated symptoms could be found; therefore, the patient was referred to the division of oral diagnostic services. The soreness in the area of an edentulous maxillary ridge may indicate several problems: im pacted molars, sinusitis, cystic involvement of residual root tips or residual cysts from pre vious infections. The foul taste in the patient’s m outh could be characteristic of an infection connected w ith the dentition, periodontium , sinuses, or the respiratory or gastric systems. A m onth later, a panoram ic radiograph (Fig 1) was taken in conjunction w ith a clinical oral examination. The radiograph showed an u n kn o w n object w ith in the m axillary right an trum . We assumed that the object was the maxillary right third molar. The patient returned to the c lin ic two weeks later for an additional exam ination and consul 208 ■ JADA, Vol. 108, February 1984
Fig 1 ■ Panoramic radiograph of maxillary right third molar (arrow) w ithin maxillary sinus.
tation w ith the oral surgery department. M e d i cal and dental histories disclosed that the pa tient had never been told and was not aware that the third molar was present, and no extraoral radiographs had been taken. Her dental treatment in clud e d an extraction from the maxillary right quadrant, done ten years ago in the Soviet U nion. W e assumed that the extrac ted tooth was the m axillary right second molar and that the trauma from the extraction dis lodged the third molar, w h ich ultim ately m ig rated to its current position. In January 1981, the patient visited a dentist to determine the cause of discom fort in the m axillary right quadrant. The dentist took a biopsy specimen from tissue over the right tuberosity and sub mitted it for histologic evaluation. The pathol ogy report noted that the specimen consisted of infected residual cyst, epithelial lin in g w ith aggregation of inflam m atory tissue, and some ameloblastic proliferation. A la te ra l s k u ll ra d io g ra p h w as reco m m ended to determine the anteroposterior posi tio n o f the tooth (Fig 2). The rad iog rap h showed the tooth to be located on the distal w all of the m axillary sinus. D uring the oral ex am ination, the patient was asked to perform Valsalva’s maneuver. The internal pressure
Fig 2 ■ Lateral skull radiograph showing maxillary right third molar and cystic involvement in sinus (arrow).
B R IE F
that this maneuver creates in the maxillary sinus caused a perculation of bubbles to appear on the m axillary ridge. A blanching of the m u cosa over the tuberosity also occurred. This maneuver forces air into the sinuses, and, if there is a fistulous tract between the m axillary sinus and the m outh, a perculation of bubbles w ill be noticed on the m axillary ridge. The diagnosis was chronic sinusitis w ith cystic involvem ent of an im pacted third molar in the m axillary right antrum, and an oral an tral fistula. Two months later, the patient was admitted to the hospital and routine preopera tive tests were done. The m olar was removed surgically, the cyst was enucleated, and the oral antral fistula was closed. The three- and
six-month recall examinations showed that the area was healing w ith in normal lim its and all symptoms were gone.
Sum m ary Because a condition of this type could not be detected with intraoral radiographs, the panoramic radiograph was the logical choice for further diagnostic information w ithout resorting to the specialized extraoral radiographs of the maxillary sinus (Waters’ view or anteroposterior extraoral radiograph, for example). As the
REPORTS
panoramic radiograph is a fast, simple, and relatively inexpensive procedure, all dentists should make use of this tech n iq u e w h e n a p a tie n t w ith these symptoms is involved. ___ _ , L _ L __________________________ J'A O A Dr. McKenna is clinical assistant professor, and di rector, section of patient evaluation and management, division of oral diagnostic services, State University of New York, School of Dentistry, Buffalo. Dr. Chidyllo was a senior dental student, State University of New York, School of Dentistry, Buffalo, and is now in private practice, New York City. Address requests for reprints to Dr. Chidyllo, 149-35 15 Drive, Whitestone, NY 11357.
Ingestion of mandibular complete denture Charles O. Hazelrigg, DDS
A
JL
56-year-old white woman, who had a chronic, undifferen tiated type of schizophrenia, was receiving her after noon medication when a member of the nursing staff noticed that she was not wearing her mandibular denture. The pa tient stated that she had accidentally bro ken the denture on a cherry pit during lunch. She had evidently swallowed the denture. The patient was referred to the dental and radiology departments of the hospi tal. There were no oral lesions to suggest trauma or hemorrhaging in the oral cav ity. She was breathing well and could speak without difficulty. The Heimlich maneuver was not applied.1 The patient was experiencing no distress. The results of a radiographic examination confirmed that two pieces of a denture had been swallowed by the patient (Fig 1). No at tempt was made to retrieve the denture pieces.2Two days later the patient was re ferred to the radiology department for a kidney, ureter, bladder (KUB) radiograph that showed a piece of the denture in the stomach and the other piece possibly in the colon (Fig 2). Four days later, another KUB ra diograph was taken and the denture pieces could no longer be seen in the gastrointestinal tract. The patient was unaware that she had passed the denture pieces as she experienced no discomfort at any time. The patient was seen several times by the dental staff for the construc tion of a new denture.
*
J p I• i l
~- 1 8 Mi J r
Fig 1 ■ R a d io g ra p h ic exam ination confirm s that
Fig 2 ■ O n e piece o f denture is seen in stom ach,
tw o denture pieces were sw allow ed by patient.
w hereas other piece is in colon.
Summ ary A broken mandibular denture was acci dentally swallowed by a mentally incom petent patient. Dentists and nursing staff must be aware of the problems encoun tered in the care of such patients who wear removable dental prostheses. To aid in radiologic diagnosis, an opaque disk3 or foil should be used in the construction of an acrylic or plastic dental prosthesis. All removable dental prostheses should have additional patient identification4
that can be easily detected in radiographs. _______________________________ JAD)A Dr. Hazelrigg is director, dental services, Central State Hospital, 3000 W Washington St, Indianapolis, 46222. Address requests for reprints to the author. 1. Heimlich, H.J. A life-saving maneuver to pre vent food-choking. JAMA 234(4):398-401, 1975. 2. Jacobs, L.I. Ingestion of partial denture. JADA 101(5):801, 1980. 3. Perenack, D.M. Ingestion of mandibular com plete denture. JADA 101(5):802, 1980. 4. Operation Ident. Council on Prosthetic Services and Dental Laboratory Relations. Chicago, American Dental Association, 1982. H azelrigg : IN G E S T IO N OF DENTURES ■ 209