Unanswered Questions in Oral and Maxillofacial Infections, An Issue of Oral and Maxillofacial Surgery Clinics

Thomas R. Flynn

Description

This special issue will review the many unanswered questions regarding oral and maxillofacial infections. Questions include: Should we extract teeth in the presence of infection? Should we wait for development of an abscess before we perform incision and drainage? What are the antibiotics of choice for odontogenic infections, and how long should the treatment course last? Is clindamycin losing its effectiveness in odontogenic infections? Should we use prophylactic antibiotics for removal of erupted teeth, impacted teeth, dental implants, or other dentoalveolar surgery? How can we as dentists minimize our contribution to the problem of antibiotic resistance? How will culture and antibiotic sensitivity testing be done in the foreseeable future? How can osteomyelitis of the jaws be diagnosed at the earliest possible time? How should the practicing oral and maxillofacial surgeon manage cases of odontogenic deep neck infections that extend beyond his/her area of expertise? Do dental infections really cause central nervous system infections? What are the lessons we can glean from review of recent closed malpractice cases involving oral and maxillofacial infections? How do we manage oral infections in the severely immunocompromised host, such as in chemotherapy for blood cancers or in bone marrow transplant patients? What is the role of biofilms in severe head and neck infections? How strong is the evidence supporting oral inflammation as a cause of systemic disease?

Sujets

• Oral Surgery
• Medical
• Médecine
• Dentistry

Informations

• Publié par: Saunders
• Date de parution: 28 novembre 2011
• Nombre de lectures: 0
• EAN13: 9781455709427
• Langue: English
• Poids de l'ouvrage: 1 Mo

Extrait

Oral and Maxillofacial Surgery Clinics of North America , Vol. 23, No. 4, November 2011
ISSN: 1042-3699
doi: 10.1016/S1042-3699(11)00157-9

Contributors
Oral and Maxillofacial Surgery Clinics of North America
Oral and Maxillofacial Infections: 15 Unanswered Questions
Guest Editor: Dr. Thomas R. Flynn, DMD
1055 Waverly Drive, Reno, NV 89519, USA
Consulting Editor: Richard H. Haug, DDS
ISSN  1042-3699
Volume 23 • Number 4 • November 2011

Contents
Cover
Contributors
Forthcoming Issues
Oral and Maxillofacial Infections: 15 Unanswered Questions
What is Evidence-Based Dentistry, and Do Oral Infections Increase Systemic Morbidity or Mortality?
What is the Role of Biofilms in Severe Head and Neck Infections?
Should Teeth Be Extracted Immediately in the Presence of Acute Infection?
Should We Wait for Development of an Abscess Before We Perform Incision and Drainage?
What are the Antibiotics of Choice for Odontogenic Infections, and How Long Should the Treatment Course Last?
Should Prophylactic Antibiotics Be Used for Patients Having Removal of Erupted Teeth?
Do Antibiotics Reduce the Frequency of Surgical Site Infections After Impacted Mandibular Third Molar Surgery?
Does the Use of Prophylactic Antibiotics Decrease Implant Failure?
How Can We As Dentists Minimize Our Contribution to the Problem of Antibiotic Resistance?
How Can We Diagnose and Treat Osteomyelitis of the Jaws as Early as Possible?
Do Dental Infections Really Cause Central Nervous System Infections?
How Do We Manage Oral Infections in Allogeneic Stem Cell Transplantation and Other Severely Immunocompromised Patients?
What are the Lessons We Can Glean from a Review of Recent Closed Malpractice Cases Involving Oral and Maxillofacial Infections?
Index
Oral and Maxillofacial Surgery Clinics of North America , Vol. 23, No. 4, November 2011
ISSN: 1042-3699
doi: 10.1016/S1042-3699(11)00159-2

Forthcoming Issues
Oral and Maxillofacial Surgery Clinics of North America , Vol. 23, No. 4, November 2011
ISSN: 1042-3699
doi: 10.1016/j.coms.2011.08.002

Preface
Oral and Maxillofacial Infections: 15 Unanswered Questions

Thomas R. Flynn, DMD
1055 Waverly Drive, Reno, NV 89519, USA
E-mail address: [e-mail]


Thomas R. Flynn, DMD, Guest Editor


In all affairs it’s a healthy thing now and then to hang a question mark on the things you have long taken for granted.
—Bertrand Russell (1872–1970)
Every day as clinicians, we must make decisions in the face of uncertainty. We have so many questions, and so few answers. Are there antibiotic-resistant organisms in this infection? Should I do surgery now, later, or not at all? Does this patient really need a prophylactic antibiotic? Is this really an osteomyelitis? Might this infection spread into the brain or migrate into the heart? Which antibiotic is best for this patient?
Nonetheless, we must act in the present in order to protect our patient’s future. Therefore, we make rules. We accept the rules we were taught without question. They give us certainty in the face of no information.
This issue of the Oral and Maxillofacial Surgery Clinics of North America examines 15 questions that linger in the back of our heads as we make our daily decisions. Some of those questions have already been answered with good research, yet the knowledge is not widely appreciated. Some of these questions have not been answered by definitive research. Yet they have been explored, and we do have limited answers for them. We have attempted, to the best of our ability, to “hang a question mark on the things you have long taken for granted,” as Bertrand Russell said, and to examine the best available scientific evidence on the unanswered questions about the infections we treat every day.
Evidence Level Type of Research 1a Meta-analyses and systematic reviews of multiple randomized clinical trials (RCT) 1b Individual RCTs 2 Quasi-experimental research: cohort studies, low-quality RCTs, outcomes research 3 Case-control studies 4 Case series 5 Expert opinion, practice guidelines, experimental laboratory research
You will see references throughout this issue to “levels of evidence.” Where possible, we have tried to rate the available evidence on this scale. In simplified fashion, the dependability of the scientific evidence of causation can be graded according to the following table adapted from multiple sources. The first article in this issue fully explains evidence-based dentistry and evaluates the evidence on whether oral inflammation plays a significant role in systemic disease.
This is also very much a generational issue of the Oral and Maxillofacial Surgery Clinics of North America . The authors of these articles range from its pioneers, to its giants, to its young lions, and to its rising stars. If you do not know the names of these contributors, learn them. You will see them again; so much of the future of our specialty is in their hands. By asking and answering these questions to the best of our current knowledge, they have done us all a great service. They have put into action the principle so beautifully stated below by Sophocles so long ago.

Knowledge must come through action; you can have no test which is not fanciful, save by trial.
—Sophocles, 496 BC-406 BC
The contributors to this issue have done us a great service. Thank you, colleagues!
Oral and Maxillofacial Surgery Clinics of North America , Vol. 23, No. 4, November 2011
ISSN: 1042-3699
doi: 10.1016/j.coms.2011.07.001

What is Evidence-Based Dentistry, and Do Oral Infections Increase Systemic Morbidity or Mortality?

Richard Niederman, DMD, MA a , * , Derek Richards, BDS, MSc, DPPH, FDS (DPH) b
a Center for Evidence-Based Dentistry, The Forsyth Institute, 245 First Street, Cambridge, MA 02142, USA
b Centre for Evidence-based Dentistry, University of Oxford, Rewley House, 1 Wellington Square, Oxford OX1 2JA, UK
* Corresponding author.
E-mail address: [e-mail]

Abstract
From Celsus' first reports of rubor, calor, dolor, tumor, and functio laesa, has come an understanding of inflammation's manifestations at the organ, tissue, vascular, cellular, genetic, and molecular levels. Molecular medicine now raises the opposite question: can local oral infections and their inflammatory mediators increase systemic morbidity or mortality? From these perspectives we examine the clinical evidence relating caries, periodontal disease, and pericoronitis to systemic disease. Widespread affirmation of an oral-systemic linkage remains elusive, raising sobering cautions.

Keywords
• Evidence-based dentistry • Oral infections • Molecular medicine • Inflammation
The goal of evidence-based health care, and more specifically evidence-based dentistry (EBD), is to improve health. The mechanism for accomplishing this is by integrating: the current best evidence with clinical judgment, and the patient needs, values, and circumstances. 1
Over the last 20 years, clinicians at the Institute of Healthcare Improvement (IHI) successfully developed, tested, and implemented a process to continually improve health. The concepts IHI employs derive from the quality improvement methods embedded in Toyota’s Lean Processing (waste reduction), and Motorola’s 6-Sigma (variation reduction) programs. And, interestingly, Toyota and Motorola developed their systems from the work of Walter Shewhart and Edwards Deming, who first applied quality improvement methods at Bell Telephone to improve the reliability of their transmission systems.
Quality improvement programs ask 3 conceptual questions:
1. What do I want to improve?
2. What can I do to improve?
3. How will I know that I improved?
In healthcare, the first and third questions require assessments of patient values and clinical judgment, respectively, and can be characterized as “know what” and “know how.” 2
The second question is the challenge addressed here. To improve health, one needs access to the current best evidence. Yet, it is highly unlikely that practicing clinicians can stay current. Estimates from 10 years ago indicated that more than 800 clinical articles are published annually in oral and maxillofacial surgery, and that the number of articles was increasing at approximately 10% per year. In other words, to stay current, a clinician would need to identify, obtain, read, appraise, and decide whether to implement more than 2 articles per day, 365 days per year for the rest of their clinical lives. 3 This was a Herculean task 10 years ago, more so today, and one unlikely to be fulfilled by most clinicians. Making clinical life more complicated is deciding among conflicting results of clinical publications, which lead to variability in clinical care (see below).
Fortunately, knowledge creators provide guidance for this in the context of an evidence pyramid and tools to use it ( Fig. 1 ). In this pyramid, the higher the level of evidence, the more likely the evidence is to predict cause–effect and what would occur in one’s practice. And conversely, the lower the level of evidence, the less likely it is to predict cause–effect and what would occur in one’s practice. In other words, a higher level of evidence trumps a lower level of evidence. The figure captures both the concept of a fair test of treatments a