Surgical orodental implications in ankylosing spondylitis
A 39-year-old Iranian male patient, a known case of AS since 15 years ago, referred to our clinic for his impacted mandibular wisdom tooth. He was operated for lumbar scoliosis and he had total hip replacement. He took 25 mg indomethacin daily, calcium 1000 mg daily, metothrexate 2.5 mg 4 days a week, prednisolone 5 mg daily, and folic acid 1 mg daily. There was no other systemic illness except mentioned including negative history of uveitis. Laboratory data revealed a positive HLA-B27, 1st hour ESR = 24 and 2nd hour ESR = 50, +++ CRP and mild hypochromic RBCs. Other data were within normal limits. Last bone densitometry was performed 10 years ago which was not significant regarding osteopenia or osteoporosis, though recent lateral neck radiography was suggestive of osteopenia of cervical vertebrae []. Oral panogram (OPG) revealed a left mandibular mesio-angular third molar []. Disk space was reduced and the borders of glenoid fossa and condylar head were sclerotic, yet no erosion and osteophyte was evident []. Mandibular border thickness was within normal limits (4-5 mm thick).\nIn oral examination, patient had class I angle occlusion. Mandible was limited in laterusive movement. No click or tenderness was noted examining temporomandibular joint. A 26-mm of maximum mouth opening was clarified. There were no other significant soft-and hard-tissue pathoses.\nA lateral neck X-ray was taken prior to the operation to detect any possible luxation of fracture of the cervical vertebrae which was normal. He got anesthetized using total 4 carpules each containing 1.8 cc of 2% lidocaine with 1:100,000 epinephrine solution. Patient had moderate limitation in cervical flexion and extension and a cushion was inserted behind his head to prevent subluxation or fracture of upper cervical vertebrae while the surgeon exerts unintentional heavy forces during the surgery. During a routine procedure, a flap was elevated and impacted right mesio-angular third molar was removed. A great care was made to avoid any heavy forces and rapid movement of the jaws and neck with regards to antiseptic and low traumatizing maneuver. Afterward, the surgical site was sutured and packed. Surgery was uneventful except for difficulty in accessing the site due to the limited range of mouth opening. The patient was discharged with prescriptions for oral analgesic and 400 mg cefixime for 7 days and 4 mg dexamethasone for injection.