Biomedical subjects
Publications and source records attributed to D A Keith.
The differential diagnosis of pain in the face and dysfunction of the masticatory system is complex. Although most diagnoses are readily made, common symptoms can occasionally belie more serious diseases. Each patient was originally treated for TMJ dysfunctions and subsequently was diagnosed as suffering from pathosis of the infratemporal space.
Chronic orofacial pain often requires pharmacologic treatment in conjunction with surgical, physical, and psychologic treatments. Myofascial pain, neuralgias, vascular pain, and limbic system dysfunction are the elements of orofacial pain that may respond to treatment with nonsteroidal anti-inflammatory drugs, anticonvulsants, membrane-stabilizing and monoaminergic medicines, respectively.
Surgical intervention may be necessary for some patients with specific pathology or derangement of the temporomandibular joint as part of an overall management protocol. The current literature discusses the efficacy of arthroscopy, the treatment of the difficult problem of ankylosis, and the use of implants and autogenous and allogenic materials to replace the disk.
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A case of orbital abscess complicated by unilateral blindness and CST as a result of an odontogenic infection is reported. The patient eventually recovered her sight. This case illustrates how appropriate consultations and prompt interventions are beneficial in giving total care to a critically ill patient.
Neonatal rats exposed prenatally to phenytoin (PHT) have been reported to have craniofacial abnormalities and growth retardation [Lorente et al.: Teratology 24:169-180, 1981]. This study reports on the persistence of these effects in the adult rat. Pregnant Sprague-Dawley rats were intubated on gestational days 9, 11, and 13 with 1,000 mg/kg PHT suspended in 1% carboxymethylcellulose (CMC). Six male and six female exposed offspring (PHT) and an equal number of control animals (CMC) were weighed through postnatal day 135, at which point they were killed and the skeletons were prepared for analysis. The PHT-exposed animals had reduced weights at all time points with the males more severely affected. A normal adolescent growth spurt was not observed in the exposed group. Absent or rudimentary lacrimal bones and nasolacrimal canals were note in all PHT-exposed rats. This contributed to the recessed positioning of the eyes that was grossly apparent. In addition, shorter and broader frontal bones in the PHT animals led to the appearance of hypertelorism. Ratios of craniofacial dimensions obtained by direct measurement of the skulls showed that the PHT offspring were significantly different in proportion from their control counterparts. The PHT skulls were smaller for body size with reduced facial height and broader midfacial regions. A unique craniofacial pattern was observed in the experimental offspring. Normal sexual dimorphism in craniofacial pattern was not expressed in the PHT group. These studies suggest that prenatal phenytoin exposure in the rat may interfere with the full expression of normal dimorphism based on gender and confirms the toxic effect of this drug on postnatal growth, adult body proportion, and craniofacial geometry.
This paper describes the results of a clinical study that recorded and analyzed sounds emitted from the temporomandibular joint (TMJ) during simple function as a means for differentially diagnosing disorders of the joint. The technique is based on the principle that each different disorder of the TMJ produces a different effect on the mechanical relationship between the articulating surfaces of the joint, and that these mechanical effects can be determined by analyzing joint sounds in relation to joint movement. A total of 79 patients (101 joints) were studied; 32 (46 joints) were diagnosed as having extracapsular disorders, (primarily MPD), 27 (32 joints) were diagnosed as having a displaced disc with reduction, nine (10 joints) were diagnosed as having a displaced disc without reduction, and 11 (13 joints) were diagnosed as degenerative disease (osteoarthritis/arthrosis). In addition, 25 adults (50 joints) with normal TMJs were included as controls. The results of this study demonstrated that each specific disease of the TMJ is characterized by a unique relationship between the sounds propagated by the joint and the movement of the joint. Essentially, an extracapsular disease was characterized by acoustic quiescence during natural (as opposed to maximal) jaw movement, an internal derangement by a usually symmetrical short duration click/reciprocal click, or random click complex, depending on the subcategory of the disorder, and a degenerative disease by a long duration noise during either or both jaw opening and closing. The data further suggest that the technique serves to reflect the mechanical events (and abnormalities) that are involved in function of the diseased joint and has potential for use as a clinical diagnostic tool.
Twenty-five cases in which a lower border threaded rod was used for fracture fixation and mandibular reconstruction were reviewed. These cases were performed during the last 11 years and have been followed for periods of up to five years and ten months. The fixation technique, originally reported in 1978, is well tolerated and provides excellent mechanical stability when enhanced security of fixation is indicated. Three unusual cases are reported in detail.
One hundred thirty-six patients who had been diagnosed as having internal derangements of the temporomandibular joint by history, clinical examination, and arthrotomography were retrospectively evaluated. Fifty-two patients had been treated by nonsurgical and 84 by surgical methods. A case review was conducted and a self-administered survey was distributed to patients to assess response to treatment. The results indicated that for a majority of the patients surgery had significantly reduced TMJ symptoms. Patients who had been treated nonsurgically also reported fewer symptoms following treatment, but the improvement was not as great as that of the surgical group.
Four siblings exposed to phenytoin or primidone or both in utero are reported. Each has craniofacial features consistent with fetal hydantoin syndrome. Two of the siblings were exposed to primidone alone, indicating that phenytoin and primidone may have similar teratogenic effects.
It has been widely reported that some children exposed to anticonvulsants in utero have a characteristic pattern of craniofacial anomalies including a broad, low nasal bridge with a short upturned nose, wide mouth, low set ears, epicanthal folds, and ocular hypertelorism, while others show no evidence of craniofacial abnormalities. The purpose of this paper is to define the craniofacial features in nine exposed children using anthropometric measurements and frontal and lateral cephalometric radiographs. These children were identified at birth as part of a prospective study of infants exposed to anticonvulsants at the Boston Hospital for Women (now part of the Brigham and Women's Hospital). At birth, none of these infants had any major malformations; at 4 to 10 years of age, none demonstrated any growth deficiency or mental deficiency, and all external craniofacial measurements were within the normal range. However, cephalometric analyses demonstrated a pattern of reduced bony interorbital distance, maxillary size, mandibular length, cranial base and skull size, and a reduction in nose dimensions when compared to data of normal populations. This study demonstrates the inadequacy of external measurements in determining the details of underlying craniofacial architecture. The data also suggest that a subtle craniofacial change occurs in exposed children which is characterized by a decrease in bony interorbital distance and the size of the cranial base and maxilla with concomitant decreases in nose and mandibular dimensions.
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The long-term behavioral outcome subsequent to prenatal exposure to phenytoin was examined in an animal model for the Fetal Hydantoin Syndrome. Behavioral outcome was determined by two different techniques--the residential maze, which provided a 24-hour measure of horizontal movement frequency in a group of animals, and time-lapse photography, which allowed quantification of frequency, duration, distribution, and sequencing of 15 motor acts performed by individual rats. Phenytoin induced significant, sex-related changes in motor behavior. Ten-week-old females exposed in utero to phenytoin displayed hypoactivity comprised of a longer duration, greater frequency, and more random distribution of grooming behaviors. Prenatally exposed males at that age displayed an opposite effect of hyperactivity consisting of a longer duration and greater frequency of exploratory behaviors. It appears that prenatal exposure to phenytoin may affect normal maturational changes in motor behavior so that immature activity levels are maintained in the adult animal.
Subjects experiencing painful dysfunction of the TMJ and diagnosed by arthrography to have displacements of the meniscus were compared to normal or asymptomatic subjects to assess condyle-fossa relationships. The groups did not differ by linear or area determinations of the P/A ratio. The use of plain film alone is not adequate for diagnosis or assessment of treatment if abnormalities of meniscus function are the primary etiology.
Certain anticonvulsant drugs, especially phenytoin and phenobarbital, interfere with vitamin K metabolism as indicated by a raised serum osteocalcin level. This finding may be of importance in the pathogenesis of side effects of these medications.
Internal derangements of the temporomandibular joint (TMJ) may be a significant factor in the etiology of painful dysfunction of the jaw and associated clinical symptoms. In a two-year prospective investigation, 170 TMJs in 85 patients were studied with plain tomography prior to arthrotomography. Arthritis was detected in 19 patients (22%), predominantly in the second to fourth decade of life, which correlated with internal derangements depicted by arthrotomography, operative findings, and histopathological examination of the condylar surface. The authors suggest that internal derangements related to meniscal dysfunction may be an important factor in the etiology of TMJ arthritis.
The objective of this clinical study was to determine the relationship between condylar translation on plain tomographic radiographs and internal derangements assessed by a clinical and arthrographic evaluation. One hundred two joints in sixty-two patients were evaluated by linear tomography in closed versus opened positions and classified according to the type of internal derangement depicted by arthrotomography in sixty-two cases. A decrease in condylar translation was noted in patients diagnosed as having meniscus displacement without reduction. Patients who had meniscus displacement with reduction (painful clicking) were found to have hypermobility of the condyle on the symptomatic side. Meniscus displacement without reduction, which appears to be an advanced stage of internal derangement, is a serious sequela leading to marked restriction of condylar motion.
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