TriangleOMS Newsletter David M. Lambert, DDS, PA
July 2006 Volume 1, Number 3
In This Issue · Coronectomy · Important Dates · Pharmacogenetics of Pain · Welcome to new practitioners · Sweet Utility · What’s New Coronectomy Triangle OMS Referral Resource Site Read several articles about coronectomy from the literature Pharmacogenetics of Pain Genelex Website Click here to read more… Sweet Utility Roboform Find out more about this very cool utility for your computer Contact Us www.TriangleOMS.com dmldds@TriangleOMS.com 919.806.2898	Coronectomy There is often a fine line between risk and benefit with the removal of impacted wisdom teeth. While the overall risk of injury to the inferior alveolar nerve is low, nevertheless we occasionally encounter patients where there exists ominous radiographic signs heralding injury. Approximately 5 years ago, I learned of a procedure commonly offered in Britian – coronectomy – that offers patients an alternative to potentially life long alterations in sensation. Coronectomy – or intentional partial odontectomy – is the intentional removal of only the most coronal aspects of an impacted tooth, leaving behind the most apical aspect of the pulp chamber and roots. The rationale for this procedure is that with pericoronitis or other pathology (i.e. cysts), removing the crown is curative. Obviously, if there exists extensive caries that extends significantly into the pulp – or if other pathology exists where coronectomy will not benefit – the only other option is complete extraction – with the attendant risks. However in the many symptomatic cases where high risk intervention is required coronectomy most often offers an effective alternative. The procedure is straight-forward. The impacted tooth in question is approached surgically. Sufficient bone is removed to guarantee access to the most coronal aspects of the tooth. Then, under copious irrigation, the tooth is sectioned thru the pulp chamber, and the incision is closed. While we all agree the notion of leaving tooth fragments is counter-intuititive, there have nevertheless been several studies published in the surgical literature demonstrating the safety and efficacy of this treatment. Obviously, pulpal necrosis – with resultant infection – is one of the major concerns. If carried out under copious irrigation, in theory, the pulpal tissues are able to maintain their viability. However, the other, more common, concern is for migration of the remaining root trunk. Either complication may require further treatment and possible trunk removal. In our series of 30+ patients undergoing this treatment, only 1 has required retreatment due to chronic infection. In either case (infection and/or migration) removal is much easier with less associated risk for for the complication of nerve injury due to migration and/or loosening of the trunk structure to surrounding bone. Coronectomy is an option we only offer to patients with symptomatic (pericoronitis, cysts, decay without pulpal extention) impacted teeth. Patients with a high potential risk of nerve injury are a primary consideration. A secondary consideration is for that smaller subset of patients with whom even the most remote chance of nerve injury is unacceptible. In either case, coronectomy is fast becoming a standard of care practice which offers a new option for the management of symptomatic impacted teeth. For further information, do not hesitate to contact our office or visit our Referral Resource Site on the web at www.TriangleOMS.com. Important Dates… During the busy summer surgery season, we wish to remind our referring partners of some important dates… · Summer Break - Office will be closed for summer break July 3 – 7 and will reopen for normal office hours Monday July 10, 2006 at 9 am. · Labor Day - Office will be closed in observance of Labor Day Monday September 4 and will reopen for normal office hours Tuesday September 5 at 9 am. Pharmacogenetics in Dentistry?? Pharmacogenetics. Big word right? You’re probably wondering how such psychobabble has relevance in the private practice of Dentistry. Well, it does – follow to find out how… Pharmacogenetics describes how genetics determinates drug action – either thru alterations in intrinsic drug activity or thru metabolism. Still wondering about the connection? There would be little debate that narcotic analgesic agents play a major role in Dentistry. As it turns out, some of the most commonly prescribed combination analgesic agents – Tylenol #3, Vicodin, Percocet, Lortab, etc – have activities that can be altered by variations in metabolism which have a genetic basis. Remember narcotic analgesics such as codeine (Tylenol #3), hydrocodone (Vicodin, Lortab), and oxycodone (Percocet) are alone inactive – they require “activation” by the liver to an active form by the cytochrome P450 (CYP) system. Approximately 50% of patients have genes that alter the function of this enzyme. One-fifth of these patients – or 10% of the population - have genes that result in absent or greatly reducted CYP activity. What does this mean to you, the clinician? It means that 1 out of 10 patients when given a prescription for these drugs will complain their pain is not relieved. The other 40% who are “intermediate” metabolisers – heterozygous for normal and slow activities – may only demonstrate reduction in activity under certain circumstances. For example, prescription antidepressants (SSRIs and tricyclics) are among the most commonly prescribed drugs in the USA. They are also strongly metabolized by the same enzyme that activates the narcotic analgesics noted above. The result may be your patients taking antidepressants (Prozac, Celexa, Zoloft, etc) will too complain of poor pain control because the antidepressants have greater affinity for CYP than does your prescribed narcotic analgesic, and thus the “activation” of narcotic does not occur. The “take home” message is this – listen to your patients and remember these facts. While we all are concerned about those who might malinger, realize under the proper circumstances 5 out of 10 patients may not respond to your prescription narcotic analgesic. The risk may be more relevant if your patient is taking an antidepressant. The solution is to “run an end-around” the metabolic line that prevents your patients from enjoying pain relief, i.e. prescribe the metabolic “activated” end-product of your preferred analgesic (e.g. hydromorphone for hydrocodone, morphine for codeine, and oxymorphone for oxycodone) – or prescribe a completely synthetic narcotic analgesic (propoxyphene or meperidine) which does not require the same metabolic activation. New In Practice… We wish to recognize the following new members in the professional community: · Dr. Andrew Wagoner will join Dr. Joel Wagoner’s general dental practice in Chapel Hill. Andrew is Joel Wagoner’s son. · Dr. A. K. “Bobby” Mallik has joined the endodontic practice of Dr. Joel Leeb in Durham. Best wishes for success in your new endeavors! Sweet Utility Ever get tired of remembering all those user identities and passwords to access your favorite online websites? Try a free utility called “Roboform” (www.roboform.com). It seamlessly integrates into your web browser (Internet Explorer, Firefox) memorizes your passwords and logs you in automatically, fills long registration and check-out forms with one click, encrypts your passwords to achieve complete security, etc. This utility is a “must have”. If you have been using the same user identity/password or writing them all down – get Roboform! Very sweet utility! What’s New UNC UPDATE IN GENERAL PRACTICE 2006 – Dr. Lambert gave a presentation at the annual UNC UPDATE IN GENERAL PRACTICE on June 2, 2006. The presentation was entitled “Contemporary Management of Anticoagulation in the Dental Patient”. We support our partners in practice. We exist to serve you and your patients. We appreciate the opportunity to participate in your patients care.