Miloš Tijanić

Background: This randomized parallel-group clinical study evaluated salivary cortisol as a biomarker of perioperative stress response during surgical extraction of impacted mandibular third molars performed under local anesthesia administration of ropivacaine and dexamethasone. Methods: The trial was registered in the ISRCTN registry (ISRCTN87752106). Ninety patients undergoing impacted mandibular third molar surgery were randomly assigned (1:1:1; n = 30/group) to receive inferior alveolar nerve block with 0.5% ropivacaine plus dexamethasone (R+D group), 0.5% ropivacaine (R group), or 0.5% bupivacaine (B group). Salivary cortisol as the primary outcome was measured at 15 min before anesthesia, and 15 min and 24 h postoperatively. Preoperative psychological stress was assessed using the Revised Norman Corah Dental Anxiety Scale. Results: No significant differences were observed between groups in preoperative anxiety (p = 0.890) or baseline salivary cortisol levels (p = 0.984). Significant intergroup differences in cortisol levels were observed at 15 min (p = 0.002) and 24 h postoperatively (p = 0.001). Cortisol levels at 15 min postoperatively were significantly lower in the R+D group compared to the R (p = 0.001) and B groups (p = 0.004) and after 24 h (R+D vs. R: p = 0.005; R+D vs. B: p < 0.001). Conclusions: The ropivacaine–dexamethasone administration significantly reduced perioperative salivary cortisol levels compared to ropivacaine alone or bupivacaine alone during impacted mandibular third molar surgery. This modulation of the neuroendocrine response likely results from dexamethasone-induced suppression of hypothalamic–pituitary–adrenal axis and the improved analgesic effects of this combination. The observed results may contribute to improved physiological stability, postoperative recovery and the clinical benefit of this anesthetic approach in oral surgery.

Introduction. The use of the modified mylohyoid nerve anesthesia (MMA) technique for dentoalveolar surgery is uncommon. Case outline. We present a 51-year-old Caucasian female patient experiencing chronic inflammation and pain in the area of the missing lower left second premolar and molars. Cone-beam CT imaging of the mandible revealed impaction of the mandibular permanent second premolar; 3.5 mL of 4% articaine and 1:100,000 epinephrine were administered with 0.5 mL of dexamethasone using the MMA technique behind the site of the third molar. The pain was measured through the visual analog scale and recorded a value of 8 mm, with the duration of anesthesia being 270 minutes. Conclusion. Modified mylohyoid nerve anesthesia can be utilized independently as a primary anesthesia or as a supplementary option for insufficiently effective or failed Halsted anesthesia.

Introduction: Primary immune thrombocytopenia (ITP) is an acquired autoimmune disorder characterised by an isolated decrease in the platelet count below 100×10, in the absence of other identifiable causes of thrombocytopenia. The decrease in platelet numbers in patients with ITP results from both accelerated platelet destruction and impaired platelet production. The diagnosis is established by excluding other causes of thrombocytopenia. In adult patients, the chronic form is most often encountered, characterised by periods of remission and relapse of the disease. Aim: This informative paperwork aims to highlight the principles of oral surgical treatment of patients with ITP. Material and Methods: The available literature was analysed to identify the basic characteristics of ITP, with special reference to its specificity and principles of dental and oral surgical treatment of patients with ITP. Conclusion: There are no guidelines for preparing patients for surgical interventions. Personalised therapeutic protocols with high doses of corticosteroids, immunoglobulins, along with postoperative anticoagulant protocols, are recommended. In recent years, thrombopoietin receptor agonists have also been increasingly used with success. The application of all therapeutic measures, both systemic and local, is necessary before, during, and after the oral surgical procedure. Numerous new medications enable the appropriate preparation of ITP patients for oral surgical interventions. In addition, close collaboration between oral surgeons and haematologists is considered imperative.

Introduction Medication-related osteonecrosis of the jaw (MRONJ) represents a new pathological entity that appears as a side effect of medications used in various diseases disrupting the normal homeostasis of bone tissue. This type of osteonecrosis occurs as consequence of antiresorptive drugs, primarily from the bisphosphonate group, but also other drugs that have a different mechanism of action on bone tissue. Aim was to point out the factors leading to the development of MRONJ. Results: There are many systemic factors, primarily endocrine and hormonal disorders, as well as the body's immunodeficiency. Risk factors for the development of MRONJ are interventions that involve the bone tissue of the jaws, primarily tooth extraction, implant procedures, curettage of the periodontal pocket, periapical operations, etc. Prevention from MRONJ is carried out with a multidisciplinary approach that involves the cooperation of rheumatologists, oncologists and dentists. Coordinately applied multidisciplinary premedication treatment reduces the incidence of MRONJ by 77.3%. Depending on the stage of development of MRONJ, there are conservative and surgical methods of treatment, which must be performed in a timely manner, because the progression of the lesion leads to significant consequences for the patient's health and life. Conclusion: Osteonecrosis of the jaw associated with the use of medicaments can be an asymptomatic, indeterminate lesion that is very difficult to diagnose, but without proper diagnosis and therapy it can develop and turn into a more severe form, complicated for treatment, with a pathological fracture of the jaw, mucocutaneous fistulas and large scars and mutilation. Prevention and multidisciplinary pretreatment and treatment are of key importance for reducing the occurrence and progression of this lesion.

Introduction: Anterior Middle Superior Anesthesia (AMSA) is considered a conductive technique for the first five maxillary teeth (from central incisors to the second premolar). This alternative anesthesia is considered a supplementary technique targeting the subneural dental plexus located near the root apices of the premolars. The study aimed to determine whether AMSA anesthesia technique can serve as a primary and independent method for extracting of the first five upper jaw teeth (incisors, canines, and premolars). Materials and methods: The study included 24 healthy patients allocated in the group I (received 4% articaine with adrenaline) and the group II (received lidocaine with adrenaline). The patients had avital maxillary teeth (from incisors to premolars). AMSA technique was used as primary anesthesia for extraction. The monitored anesthesia parameters included: pain perception during the application of anesthesia and the surgical procedure, overall success of anesthesia, onset time, and duration of anesthesia and post extraction complications. Results: The duration of anesthesia was 52±17,10 min in the first group, while it was 40,25±7,629 min (p=0,044). The level of pain during the extraction was 3,42± 1,73in the first group, while it was 5,25±2,41 in the second, with statistically significant difference between groups (p=0,046). The need for additional anesthesia was 2 (16,66%), in the first and 5 (41,66%). in the second group. Conclusion: The AMSA technique has demonstrated high efficacy for simple extractions when articaine is used; it shows less anesthetic efficacy when lidocaine is used. The AMSA anesthesia technique with articaine may be considered a primary local anesthesia technique for the extraction of the first five maxillary teeth when they are not vital.

Introduction: Haemophilia is one of the most common haemorrhagic diseases from the group of coagulopathies and results from a deficiency of factors responsible for the first phase of coagulation. Aim: This informative paperwork aims to highlight the principles of oral surgical treatment of patients with haemophilia. Material and methods: The available literature was analysed to indicate the basic characteristics of haemophilia (clinical manifestation, possibilities of treatment and prophylaxis of the disease) with special reference to specificity and principles of dental oral surgical treatment of patients with haemophilia. Conclusion: The treatment of patients with haemophilia is considered one of the riskiest in everyday dental practice. Despite this, dental interventions can be successfully and safely performed. However, the dentist must be acquainted with the nature of the disease, its symptoms and the severity of the clinical picture. Furthermore, the dentist needs to know what kind of therapy the patient receives for the treatment of haemophilia, whether the patient has been diagnosed with inhibitors to the coagulation factor, and whether the patient has concomitant diseases with special reference to possible infectious diseases. Along with that, the key to a successful and safe intervention lies in a well-planned preoperative, perioperative and postoperative treatment of patients with haemophilia.

Introduction: Mylohyoid mandibular anesthesia is not a standard and independent primary anesthesia for performing surgery on mandibular teeth. Objective: The objective was to examine the success of achieved mylohyoid anesthesia for mandibular molar surgery, by injecting an anesthetic that could penetrate the bone in the lingual region of the mandible, using the technique for modified mylohyoid mandibular anesthesia. Materials and methods: In the pilot study, 10 patients were divided into 2 equal groups (of 5 patients each), of both sexes and aged 18-75, who required mandibular anesthesia owing to mandibular molar surgery. In group I, 3.5 ml of 4% articaine with 1:100000 adrenaline, and the addition of 0.5 ml/4 mg of dexamethasone, was injected into the sublingual region of the corner of the mandible using a modified mylohyoid approach; in group II, 4 ml of 2% lidocaine with 1:100000 adrenaline was injected into the region of the mandibular foramen using the approach for standard mandibular conduction direct anesthesia. A visual analogue scale (VAS) was used for the subjective assessment of the pain during surgery in patients, the recorded duration of the realized mandibular anesthesia, as well as the total effectiveness of the achieved anesthesia, expressed in percentages. Results: A successful intervention was achieved in all patients, with different VAS scores, but within the values indicating successful anesthesia (group I: 17.40±11.10mm; group II: 12.80±4.55mm). A longer duration of anesthesia was achieved in the first group-205.2 min (3h 25 min), compared to the second group-182 min (3h 2 min). Conclusion: Mylohyoid mandibular anesthesia with 4% articaine and with adrenaline and dexamethasone could be applied as primary anesthesia for the purpose of successfully achieving standard mandibular anesthesia.

Background: Perineurally adding dexamethasone to local anesthetics could enable postoperative analgesia. Our aim was to investigate the efficacy of 4 mg dexamethasone and 0.5% ropivacaine on the prolonged duration of mandibular anesthesia for postoperative analgesia during third molar surgery. Materials and method: The patients of both sexes, and in the age range of 17 to 50 yrs of age, received the Gow-Gates anesthesia. Group I received 4 mL of plain 0.5% ropivacaine, with perineurally added 1 mL/4 mg of dexamethasone; group II received 4 mL of plain 0.5% ropivacaine with perineurally added 1 mL of 0.9% saline; group III received 4 mL of plain 0.5 bupivacaine with perineurally added 1 mL of 0.9% saline. The prime anesthesia outcome was the duration of conduction anesthesia (DCA); the secondary outcome was the duration of analgesia (DAN) and analgesia before analgesic intake. Results: In 45 randomly selected subjects (mean age 27.06 ± 8.20), DCA was statistically longest in group I (n = 15) (592.50 ± 161.75 min, p = 0.001), collated with groups II (n = 15) and III (n = 15) (307.40 ± 84.71 and 367.07 ± 170.52 min, respectively). DAN was significantly the longest in group I (mean: 654.9 ± 198.4 min, p = 0.001), compared with group II (345.4 ± 88.0 min) and group III (413.7 ± 152.3 min), with insignificant adverse reactions. One-third of the operated patients absented from the use of analgesics. Conclusion: A amount 0.5% ropivacaine with dexamethasone usefully served as an analgesic with a success rate of 93.4% of the given anesthesia.

Introduction: Permanent tooth avulsions (traumatic extraction; total luxation) are one ofthe most severe permanent tooth injuries and can occur as single injuries or associated with other dental injuries or injuries to the face and jaws region. They are defined as the luxation of teeth from the alveoli with complete rupture of periodontal fibres, or with one part attached to the rootcementum and the other to the alveolar bone, thus compromising the dental pulp, root cementum,and alveolar bone. The high prevalence and numerous negative consequences on the stomatognathic systems they have suggest permanent tooth avulsions should be regarded as an important public health problem. The aim: is to point out the therapeutic possibilities of permanent tooth avulsion that can ensure their longer survival in the oral cavity. Conclusion: The treatment strategy for avulsed permanent teeth is always based on limiting root canal infection and periradicular inflammation, shifting the balance from unfavourable (replacement resorption) to favourable (periodontal) healing. The success of therapy and periodontal healing depend on the duration and conditions of extraoral tooth preservation, the degree of damage to the periodontal ligament, and the condition of the pulp.

Introduction: The oral health of children with special needs is most often impaired, with a high prevalence of caries and its complications. Due to the impossibility of establishing an adequate child-dentist contact and a large number of carious teeth, dental treatment under general anesthesia is often indicated in this population of children. Aim: To perform a comprehensive analysis of the dental treatment of children with special needs under general anesthesia at the Clinic of Dental Medicine in Niš over a period of ten years. Material and methods: A retrospective study analyzed the dental documentation of children with special needs in whom dental treatment was performed under general anesthesia at the Clinic of Dental Medicine in Niš in the period from January 1, 2010 to December 31, 2019. Results: 286 children with special needs (14.7%) out of a total number of 1943 admitted at the Department for Preventive and Pediatric Dentistry of the Clinic of Dental Medicne in Niš during the analyzed period, originally from Nišava, Jablanica, Pčinja, Toplica, Rasina, and other administrative districts of Serbia, were treated under general anesthesia. In the second half of the ten-year follow-up period, almost twice as many children were treated regarding the first five years. The records show that 1754 teeth were restored, 28 endodontically treated, and 1417 extracted. Conclusion: A high percentage of children with special needs treated under general anesthesia and a constant increase in the number of such children in Southeastern Serbia suggest the need for close cooperation between dentists of health care centers in Southeastern Serbia and dentists at the Clinic of Dental Medicine in Niš, a tertiary dental health care center towards which patients of this part of Serbia gravitate.