Vitamin B6 for Pms?

Some women experience a variety of symptoms a week or 10 days before menstruation. These include bloating, weight gain due to water retention, tender or swollen breasts, headaches, backaches, irritability, depression, joint pains and a craving for sweets.

These short-lived symptoms are part of the premenstrual syndrome (PMS) which is apparently caused by too much estrogen (the female sex hormone) and lack of progesterone (another hormone secreted by the ovaries). Decreased levels of the neurotransmitters (brain chemicals) dopamine and serotonin are other factors.

To prevent this, Kurt Butler and Dr. Lynn Rayner of the University of Hawaii recommend the following in “The Best Medicine”:

Cut down on salt and concentrated sugars to reduce water retention and symptoms of hypoglycemia (a deficiency of glucose in the bloodstream common in diabetes).

Exercise regularly to decrease water retention. Avoid excessive alcohol intake days before your period begins.

Diuretics can reduce water retention and bloating. These are drugs which make the kidney produce more urine, thus getting rid of excess salt and fluid from the body. In
view of their side effects, however, see a doctor for the right medicines.

Some megavitamin advocates believe high doses of vita¬min B6 or pyridoxine can treat PMS. Consumer Reports, a magazine published by Consumers Union which has been providing people with helpful information since 1936 says “the evidence supporting this practice is thin.”

While daily pyridoxine supplements may relieve the symptoms of PMS in some people, mega dosing should be avoided since it can cause severe neurological damage and may harm the fetus of a pregnant woman. This was reported by Drs. Schaumburg and A. Berger in the New England Journal of Medicine.

They observed that seven adults who took daily pyridoxine megadoses of 2,000 to 6,000 milligrams suffered from severe and permanent nerve damage.

Even small doses of pyridoxine can be harmful. Schaum¬burg said 30 people who took 500 milligrams of pyri¬doxine every day also developed neurological disorders. Six¬teen other subjects suffered the same fate with only 200 milligrams a day of vitamin B6, he said.

“Their symptoms, which resembled those of multiple sclerosis, included numbness and tingling of the hands, difficulty in walking, and electric shocks shooting down the spine,” warned Consumer Reports.

If you must take pyridoxine supplements, do so under the guidance of a competent doctor. To help you rest during a PMS attack, take Sedamine – the supplement that will help you sleep naturally. Visit http://sedamine.com/ for details.

Depression Symptoms – What Everyone Needs To Know

Depression may affect each of us at some time in our lives. It could be the result of a trauma, a loss of a loved one or some other traumatic event which will send us into a depression and the classic depression symptoms of loss of interest and incapacity to enjoy life will be present. The good news is that most of us can overcome this acute depression and bounce back. But many people suffer from chronic depression for many years and have to be treated with depression meds which will cause some nasty side effects.

Let us have a look at some figures to see how common this condition is and how it can coexist with many other conditions thereby complicating the diagnosis. A study carried out by the University of Hong Kong on the mental health of drug users found that about 62% were suffering from depression symptoms. Depression is also a common condition among veterans returning from war. About 20% of returning war veterans from Iran and Afghanistan are suffering from either PTSD (post traumatic stress disorder) or major depression. The most shocking figure here is that over 50% of these servicemen and women who are suffering from these conditions have not sought treatment.

The main symptoms of depression are a definite lowering of energy levels which leads to lethargy and loss of interest in all the things one normally does. This can be combined with low esteem, anxiety and increased difficulty on making decision s and getting things done. Insomnia, headaches and suicidal thoughts can also be depression symptoms.

Anti depressant medicines are all based on the SSRI (selective serotonin reuptake inhibitors) and nobody knows exactly how they work! What we do know is that they can cause loss of libido and weight gain which can be a disastrous combination in a relationship and wipe out any positive effects of the drugs.We seem to be replacing one set of main symptoms of depression with another which will only increase our anxiety and pessimism.

Because of the side effects of anti depressants such as Prozac and Tofranil, many patients with depression symptoms are seeking alternative treatments such as a natural herbal one which contains herbal ingredients such as St. John’sWort and Passion Flower extract (often called Nature’s Prozac!) As there are no side effects and the overall mood improves , these natural medicines are becoming more and more popular.

Arachnophobia – an Illogical Fear of Spiders You Can Quickly Conquer

Although it’s natural for everyone to have fears, having a phobia is a more significant issue. A phobia is an irrational fear that a sufferer cannot control. Phobias are considered to be a type of anxiety disorder, and often create nervousness and anxiety attacks in an individual. When someone has an intense phobia, they become so determined to stay away from their fear that it interferes with their daily lives and their ability to enjoy life.

Among the most common phobias are arachnophobia, the fear of spiders, acrophobia, the fear of heights, and claustrophobia, a fear of enclosed spaces. The most common phobia is arachnophobia. Although lots of people have a fear of spiders, people with arachnophobia possess an abnormally high amount of fear. Even a photograph or realistic drawing of an arachnid can make some arachnophobes distressed. Some arachnophobes have anxiety attacks or get hysterical at the sight of an arachnid. They might do anything in order to get away from a spider; for example, people with serious arachnophobia might attempt to get out of a moving car if they see a spider in the car.

Sufferers often feel humiliated by their unrestrained responses. Other people and even the sufferers themselves might find their behavior irrational. Their fear of spiders and their reaction to arachnids may escalate into other problems as well. Arachnophobia and other phobias often lead to a condition known as agoraphobia.

Agoraphobia develops when an individual fears being in any potentially stressful place or situation. For someone with arachnophobia, this can mean avoiding any area a spider might be hiding, new places, and even resisting leaving the house or going outdoors altogether. This can negatively interfere with a person’s quality of life. A person may be afraid of having anxiety attacks or embarrassing him or herself by losing control. Many people find themselves chronically stressed out over these fears.

People with phobias may struggle with the inability to control their fears. This is due to the fact that the root of the phobia lies at the unconscious level of the mind; so conscious effort or willpower can’t work to control a serious phobia. A phobia is best dealt with at the unconscious level, which is why Ericksonian hypnotherapy and Neuro-Linguistic Programming (NLP) techniques are the most effective phobia treatments.

There are many different programs available for handling phobias. Most use older hypnosis techniques that depend on the use of post-hypnotic suggestions with very specific wording to work against fears. These days, post-hypnotic suggestions often do not work because our generation has a tendency to question and analyze everything. And since today’s generation is likely to do the opposite of what they are told, post-hypnotic suggestions are ineffective and they experience a polar response.

Ericksonian hypnosis therapy is different from traditional hypnotherapy because it uses indirect suggestions that are hidden in conversation. That makes them hard for the conscious mind to resist, so they are more likely to make it through to the unconscious mind and be adopted.

The process typically starts by using relaxation hypnosis to make you feel very relaxed and calm. Then, instead of simply “telling” your unconscious mind what to do, Ericksonian techniques use stories and metaphors to guide your mind into a fear-free line of thought.

NLP techniques work by pinpointing the specific thought process that causes an irrational phobia and using it to extinguish the fear. Because of this, NLP can be used on any phobia. 

People respond much better to the combination of NLP and Ericksonian techniques than to traditional hypnosis because instead of getting direct commands, the unconscious mind is convinced to follow a new, more logical line of reasoning. These hypnotherapy programs are most effective for people who are logical, critical thinkers and people who like to think on their own.

You don’t need a different hypnosis program for each different phobia. One program that includes multiple sessions with the right combination of Ericksonian hypnotherapy and NLP techniques can treat any phobia. Furthermore, a well-designed program will work for everyone. The mix of different techniques in several different sessions guarantees success for anyone who uses them. By completing each step of the program, people are often amazed at how quickly they beat their fears.

Ericksonian hypnotherapy and NLP focus on transforming irrational fears and behaviors into calm, collected responses. For many people suffering from crippling fears such as an irrational fear of spiders, this is a life-changing treatment. Hypnosis is a powerful tool for overcoming anxieties and fears to live a better life.

Insomnia – Why Can't I Fall Asleep?

Do you experience trouble falling asleep or staying asleep?   As a former sufferer of Insomnia, I know all about how it can affect your health and your life.

Did you know that Insomnia is the most common type of Sleep Disorder.  Perhaps you have difficulty in falling asleep or you may wake up too early or any of the combinations may occur.  It is a frequent complaint brought to health care providers and many of us experience it at various times in our lives.

WHY DO YOU HAVE INSOMNIA?

  • Insomnia is not a disease and no test can diagnose it; but when you can’t sleep well, it often has to do with some other cause.
  • Those who suffer are 40 times more likely to be depressed than ordinary sleepers and it is said to affect people who are divorced, widowed, or separated rather than those who are married.
  • For many the sleepless nights start after a sudden unexpected stress event such as a job loss or death in the family.  So yes, it is very common in psychological conditions such as depression or anxiety.
  • Insomnia can be a result of ‘heightened arousal’ due to the fear of not sleeping and being unable to function during the day. This sense of ‘arousal’ rather than a sense of ‘calm’ can prevent the usual brain system process which initiates and maintains sleep.  Once this pattern starts it can develop into a habit.
  • Generally speaking Insomnia is more common in women and older adults.  It is so common that about 33% of the general population experiences occasional Insomnia and about 10% are more chronic – meaning it can last more than three weeks.

ARE THERE COMPLICATIONS TO CHRONIC INSOMNIA?

  • Since Insomnia is a main culprit of depression, it can be a risk factor for other diseases.  If someone is depressed they may develop a pattern of not sleeping; which in turn can create further feelings of depression.
  • We all know that rest is critical to our body’s ability to maintain good health both physically and mentally, so it is important to get to the root of the problem and get help.

Stress most commonly triggers short-term or acute Insomnia and can deplete the immune system.

  • Insomnia can frequently interfere with interpersonal relationships or job performance.  Often this will lead the person to seek support from mental health and medical professionals.
  • If you do not address your Insomnia it may develop into a chronic condition which can last for months and years.

GETTING THE HELP YOU NEED

Getting proper rest is vital to maintaining your good health!

With short-term Insomnia the symptoms will usually fade with time once stress is reduced or when the triggering event(s) is over.  On the other hand, Chronic Insomnia is not a quick fix problem and shouldn’t be treated like one. The effects are very taxing on the body, so it is important to first recognize the problem; then take steps to get the necessary help.

The good news is there are Natural Solutions for your Insomnia. Understanding your condition and the underlying cause is the first step to a great nights sleep!

Ingrown Toenails – Causes, Symptoms and Treatment Methods

An ingrown toenail is a painful condition of the toe. The area is usually red and may be warm; if not treated, it is prone to infection. With bacterial invasion, the nail margin becomes red and swollen often demonstrating drainage or pus. Some ingrown toenails are chronic, with repeated episodes of pain and infection. Ingrown toenails can be caused by cutting toenails improperly, by wearing shoes that fit poorly or by injuring the nail bed. While many things can cause ingrown toenails, the major causes are shoes that don’t fit well and improperly trimmed nails. This condition is usually very painful and can be associated with infection of the toe. Ingrown toenails also can run in the family. Some ingrown toenails are chronic, with repeated episodes of pain and infection. Irritation, redness, an uncomfortable sensation of warmth, as well as swelling can result from an ingrown toenail. When the toenail grows into the surrounding tissue, a painful toe is the result. Ingrown nails may produce no symptoms at first but eventually may become painful, especially when pressure is applied to the ingrown area. The great toe is usually affected, but any toenail can become ingrown. In people who have diabetes or poor circulation this relatively minor problem can be become quite severe.

Ingrown nails may develop for many reasons. Some cases are congenital–the nail is just too large for the toe. Ingrown toenails are common in adults but uncommon in children and infants. Any toenail can become ingrown, but the condition is usually found in the big toe. If you have diabetes or another condition that causes poor circulation to your feet, you’re at greater risk of complications from an ingrown toenail. Soaking the foot in warm salty water may relieve the pain temporarily. The toe is not necessarily infected, but this can develop after the nail penetrate the skin to become ingrown. The infection can spread, making the toe red and inflamed (paronychia). A collection of pus may also develop. The condition usually affects your big toe. If left untreated, the inflammation can spread to the rest of your toe and the area becomes infected. It may smell unpleasant. Sometimes initial treatment for ingrown toenails can be safely performed at home.

Causes of Ingrown toenails

The common causes and risk factor’s of Ingrown toenails include the following:

While many things can cause ingrown toenails, the major causes are shoes that don’t fit well and improperly trimmed nails.

Injury to your toenail.

Unusually curved toenails.

Ingrown toenails can be caused by cutting toenails improperly, by wearing shoes that fit poorly or by injuring the nail bed.

Repeated trauma, such as the pounding to which runners typically subject their feet, also can cause ingrown nails.

Nail length: Cutting the nail so short that it is not constrained by the distal portion of the cuticles, allowing side slippage and penetration of the lateral nail bed by the nail substance.

Trauma, such as stubbing the toe or having the toe stepped on, may also cause an ingrown nail.

If a member of your family has an ingrown toenail, then you are more likely to develop one too.

Symptoms of Ingrown toenails

Some sign and symptoms related to Ingrown toenails are as follows:

The most common symptom of an ingrown toenail is pain, especially if the area becomes infected.

Tenderness in your toe along one or both sides of the nail.

Swelling of your toe around the nail.

Infection of the tissue around your toenail.

You may develop a fever, although this is unusual.

In addition, a small amount of pus will come out of the edge.

The infection can spread, making the toe red and inflamed (paronychia).

Treatment of Ingrown toenails

Here is list of the methods for treating Ingrown toenails:

Apply a mild antiseptic solution to the area.

Soak the foot in warm water 4 times a day. You do not need to add soap or antibacterial agents to the water.

Partial nail removal with cauterization of the nail matrix is curative in 70-90% of cases.

Wear comfortable shoes with adequate room for the toes. Consider wearing sandals until the condition clears up.

Putting cotton in the corner.

If home remedies don’t help, your doctor can treat an ingrown toenail by trimming or removing the ingrown portion of your nail to help relieve pain.

Sometimes antibiotics are used to help the infection clear after the nail has been removed.

Surgery may involve numbing the toe and removing a corner of the nail, a larger portion of the nail, or the entire nail.

Toenail Fungus – Leucatin Treatment

The choice of treatment for nail fungus is determined by many other factors. These include how much the problem has spread across the nails, what other remedies have been tried and what is the reaction of the individual to the particular drugs. It is however important to be prevent resistance. Like all other treatment, the use of a particular medicines may not be effective due to poor usage or mutation of the pathogen, in this case the fungi.

The use of natural products and homemade remedies is one solution to the above challenges. These often have limited side effects and can be prepared locally. This makes them safe and cheaper.

Leucatin is a concoction of natural remedies. The ingredients include Jojoba oil, tea tree oil, gingsen roots, ginger roots an, almond oil, ethanol and echinaccea purpurea tops. Each of the ingredients of leucatin is a plant product that has medicinal value.

In treating nail fungus infection, there are several people who have reported great success. This has also been tested scientifically and proven in laboratory set up. It is therefore an effective treatment that you can trust in. There are success rates as high as 90% to 96%. This is an very high success rate for any medicine. There are more clinical trials that are ongoing to further get the facts.

The most important to apply the leucatin cream correctly. When applied on uncleaned wound of the fungal growth, it will only result in coating of the fungus and allow them to grow under the coat. The first thing one must therefore do before applying the cream or lotion containing the leucatin is to clean the affected nail properly. One can clean it with soap and then dry it properly. In addition, the use of vinegar to clean the wound would improve the ability to completely destroy the fungus spores.

You can make your own preparation of leucatin from the various plant sources. This can be done at home and there is not likelihood of experiencing side effects. Leucatin does not have known side effects because of the fact that most of the ingredients are natural. The users of leucatin will have lots of saving s because of the relatively cheaper product yet so effective. You will be expecting to realize changes in the first 3 weeks with limited chance of reversal of the situation.

You can make nail fungus treatment cheaper by buying directly from the manufactures. This you can now easily do by logging to the website of the various manufactures. In choosing where to buy it from, consider the shipment costs. Manufactures in Asia may be cheaper but the shipment costs may be higher depending on where you are.

Related Articles – Nail Fungus Products
Leucatin & Toenail Fungus

Natural Treatment for Sprain

Many a time you woke up and feel a hurt in the area of your neck, the reason behind this may be sprain in your lower back area of neck and this can be caused by bad sleeping posture. This can also be happen while lifting any heavy weight. Neck sprain is called irritation in muscles, tendons and ligaments in upper back and also in neck area. It is an irritation in the tissues of neck.

Now that you understand some of the anatomy involved at the ankle joint, you are ready to learn about the different types of ankle sprain, how they are graded and how they are caused. Once you have a good foundation of the anatomy and the injury we can begin to discuss how to go about minimizing the chances of sustaining this common injury.

Treatment:

1.    Your approach must include a plan, implementation, review of findings and follow-up. For example, if using the job observation program as a reinforcement strategy, first develop a checklist to ensure consistent evaluation of body mechanics. Then determine who will perform the inspections, establish a set frequency (e.g., weekly, monthly) and train them how to perform the observations.

2.    Ice is critical to reducing swelling and using an ice whirlpool definitely has advantages over just ice in a bucket because heat is taken away from the ankle so much faster.

3.    If you have a Grade 2 sprain, your doctor may recommend that you wear an ankle brace until the sprain heals and use crutches for a short time.

4.    As with any injury, recovery time will depend on the seriousness of the sprain. Regardless of the severity, you can speed up the healing process by staying off your ankle and resting it as much as possible. No matter what the grade of injury, unless it is splinted or casted, your doctor will probably tell you to apply ice packs to relieve swelling and pain.

5.    Ankle strengthening is an essential part of recovering from an ankle sprain. The key is to make sure you don’t go too fast. Again, pain is an indicator that you may be doing too much too soon. Elastic band exercises are a good way to work on improving ankle strength. Other exercises like calf raises, lunges, and step ups will also work to strengthen your ankle muscles.

6.    To get rid of neck pain, you can use some simple exercises at home, which may provide relief in pain from neck. You can practice an exercise, which includes moving of shoulders, and turn your head side from left to right, as this may help in providing relax from the pain. You can make a bandage with the black coffee on the neck sprain.

7.    Shoes may increase or decrease your risk for ankle sprains. Some researchers theorize that certain types, such as high-top basketball shoes, may increase proprioceptive feedback from the ankle joint[12]. There is also some evidence that shoes offer some resistance to the excessive range of motion in the ankle[13].

How to Know if it is Nail Fungus or Something Else

You cannot get your eyes off your fingernails and toenails when you notice something different with them. You browsed the Internet and from the information you gathered, it seems you have nail fungus.

You must remember that there are a lot of problems which may happen to your nails. To know if it is just poorly done manicure or really fungal infection, you have to ask yourself some questions and inspect your nails carefully.

Nail Fungus

It is not nail fungus at all if you don’t walk barefoot in the public pool or gym shower or you’re not exposed to warm and humid working environment frequently and you don’t share shoes, nail files and nail cutters with other people.

Onychomycosis or nail fungus first manifests itself as a yellowish or white spot on the nail. As the nail fungus develops, the infected nail will break, thicken, be crumbly, lack luster and be discolored or deformed. The surrounding tissue or skin may also be inflamed. Nail fungus infection may be very painful in the long run, and like athlete’s foot it may emit a very foul odor. Scaling of the sides of the toenails may occur.

The toenails are more prone to nail fungus since it is often inside the shoes, which present a warm and moist environment that perfect for fungal growth.

Distribution of the problem has a pattern. Nail fungus often affect only one hand at a time. However, in the case of feet, it is more often that both will have nail fungus at the same time.

If the symptoms mentioned are not present, most likely it is not nail fungus but another condition.

Signs and Symptoms of Other Nail Conditions

There are other symptoms that will also make you stare at your nails. These are, however, not symptoms of nail fungus:

Ridges and Lines – There is nothing to worry. Appearances of these are part of the normal aging process.

Yellowish or Whitish Nails – This is due to onycholysis or the occurrence of gap between the nail and the nail bed. The normal pinkish color will return after several months.

Green Nails – No, you have not turned into a monster but pseudomonas may have accumulated in the gap in between your nail and nail bed. The greenish shade disappears in around two months.

Black or Red Nails – There is bruising on the nail bed, which is most likely due to trauma. Like any other hematoma, it will repair itself after a few days.

Inflammation of the skin around the nail – This may be caused by yeast that infects the cuticle. There are topical creams that can cure these yeast infections.

To be certain about the symptoms and signs that you notice on your nails, it is best to be diagnosed by a medical doctor.

A proper diagnosis will result in a proper treatment plan. Pain, inflammation and infection can be addressed properly. The treatment regimen for nail fungus or any other nail infection must be followed religiously since these diseases tend to recur.

Medicines for these different conditions can be sourced from your local drugstores or online stores.

Nerve Damage and Medical Malpractice

Nerve damage is a fairly common complaint that comes with a wide variety of symptoms.  Signs of the condition can range from a mild tingling sensation to a complete loss of feeling to the affected area.  In rare cases, nerve damage can cause partial or complete paralysis, and can even lead to death.  While there can be a number of things that can contribute to nerve damage, including injuries such as fractures, severe injuries, and diseases, it is also possible that a medical professionals negligence, inexperience, or recklessness can lead to the damage.

If you or someone you know has been injured and experienced nerve damage because of a mistake on the part of a medical professional, you should contact a personal injury attorney to discuss your legal right and your options for seeking compensation.  You may be able to recover money for your injuries, as well as your pain and suffering.

All surgeries come with a certain amount of risk.  Whether the surgery is to be done for personal reasons, or to improve health, or to repair an injury, each procedure places the patient in harm’s way to a certain extent.  These types of procedures can also cause damage to the nerves if they are not conducted in the proper way.  Some types of mistakes on the part of medical professionals that can lead to nerve damage include the following:  improperly administering various types of local anesthesia, failure to treat or diagnose a condition that when not properly treated leads to damage of the nerves, an incorrect incision, and general negligence.

The consequences of nerve damage can be far reaching.  In some cases the damage causes a minor annoyance, while in other cases it can lead to serious conditions that will last a lifetime.  The severity of the damage, as well as the nerves locations all factor into the consequences.  Consequences can include the following:  acute pain, loss of mobility in a particular area, chronic parasthesia (also known as a burning sensation), loss of sensitivity in a particular area, paralysis, deformity, and cardiac arrest.

While most of the cases of nerve damage cannot be reversed, there are some cases that may be improved with specialized surgeries.  These types of procedures come with their own potential for risks and should be carefully weighed before undergoing.

Nerve damage can be an issue that can be extremely frustrating for those who have been affected.  Patients who have suffered this consequence after a medical procedure often find themselves self medicating, suffering in silence, feeling depressed, and become tired of having to deal with the new issues they are faced with.  This can take a great toll on a patient and can lead to other chronic issues and illnesses.

As devastating as nerve damage can be in and of itself, learning that it was caused because of a medical professional’s negligence, carelessness, or lack of experience can be even more traumatic.  Patients place a high level of trust in these professionals and believe they will do everything in their power to help them and not harm them.  When this trust is broken, there can be a range of emotions felt, including anger, frustration, guilt, and sorrow.  Patients often feel as though they have no recourse and that there is nothing they can do except live with their injuries and cope as best they can.

This does not have to be the case.  It is important to understand that you do have legal rights and that you can take legal action to protect yourself, your family, and help to recoup compensation for your injuries and expenses.

The best course of action you can take is to contact a personal injury attorney who specializes in medical malpractice and negligence as soon as you can following your discovery of nerve damage.  These professionals are quite skilled in this area of the law and will manage your case throughout every phase, from start to finish.  Your attorney will gather medical records, collect evidence, speak with those who are responsible, and take all the appropriate action necessary to yield a favorable outcome.

Doctors, medical personnel, and hospitals are well protected with teams of attorneys who work hard to protect their interests.  The last thing hospitals want is a lawsuit and will do everything in their power to avoid one at all costs.  This can lead to patients being persuaded into signing documents and other documents that may harm their ability to bring forth legal action for damages.  Hiring a personal injury attorney to handle your case avoids this mistake and provides you with the comfort of knowing all of the details associated with your injury are being addressed properly.

Cases such as these should not be attempted on your own without professional assistance.  These types of cases hinge on many small details and missing just one could cost you.  Different jurisdictions vary in their statutes of limitations, which also must be adhered to for a favorable outcome. 

Most personal injury attorneys work on a contingency basis, which means they require no upfront payment to pursue a legal claim.  After reviewing your case, they will make a decision as to whether or not it should move forward, and will advise you on the best way to proceed.  If your attorney decides to file the paperwork to begin the legal process on your behalf, you can rest assured that you will not have to pay expensive legal bills along the way.  This can provide you with a great sense of peace of mind knowing that have one less worry and you can focus your attention on your personal health and recovery. 

Personal injury attorneys specializing in the area of medical malpractice and negligence that handle cases of nerve damage cannot undo the harm that has come to you, but they can help you to obtain the justice that you deserve.  Receiving financial compensation for past, present, and future medical bills, loss of income, and pain and suffering can go a long way in the healing process.

What Can Alternative Medicine Offer For Pancreas?

The pancreas is an elongated and tapered gland that lies across the back of the abdomen behind the stomach in the loop of the duodenum. It secretes digestive enzymes into the duodenum and hormones, such as insulin, into the blood stream.

The enzymes secreted by the pancreas aid in digesting proteins, carbohydrates, and fats. The pancreas also secretes large amounts of sodium bicarbonate, which protects the duodenum by neutralizing the acid that comes from the stomach.

Abundant digestive enzyme production and elimination are crucial for maintaining optimal health. Our diets are composed of protein, fats, carbohydrates, sugars, and fiber. We need the appropriate enzymes for digestion. The enzymes break down the foods we consume into particles small enough to pass through the intestinal wall and be absorbed by the cells. Within the cells, the molecules of food are converted into usable energy. If the Pancreas diminishes digestive enzyme production, none of the food we eat can be properly absorbed and assimilated by the body. A full plate does not always turn into a healthy body and vital life, particularly if pancreatic enzymes are lacking.

Pancreatic enzymes serve several other important functions. For example, the proteases are largely responsible for keeping the small intestine free from parasites, and yeast. The production of digestive enzymes is diminished by the following:

  1. Deficiency of essential minerals, microelements and bicarbonates.
  2. Processed and refined foods that contain preservatives, chemicals, and pesticides and don’t have vital enzymes.
  3. Saturated fat, sugar, and animal protein that accelerate the aging of the pancreas.
  4. Stress.
  5. Age.
  6. Certain drugs, alcohol, and caffeine.
  7. Gallbladder and Liver diseases.
  8. Chronic Pancreatitis

How do you know if you are deficient in pancreatic enzymes? If you have allergies, fatigue, bloating, gas, constipation, diarrhea, indigestion, slow recovery from injury, inflammation, weight problems, or IBS, you most likely have a pancreatic enzyme deficiency. What has to be done? Besides eating raw foods and enzyme supplementation, there is another way to promote pancreatic functioning.

For hundreds of years, Europeans with poor functioning of the pancreas or chronic pancreatitis have been drinking healing mineral water in the mineral spa. The Czech town of Karlovy Vary has been a famous international healing resort since the 1700s. Europeans call the local mineral water the “healing gift from the earth” or the “miracle mineral water.” Visitors throughout Europe and Asia have journeyed to Karlovy Vary for durations of one to six months to drink the Karlovy Vary Healing Mineral Water. This mineral water has become quite popular as a healing remedy for chronic conditions, especially for pancreatitis.

However, in the situations where individuals cannot visit Karlovy Vary, then can now enjoy the same health benefits from their own home.

With the help of technology, the genuine Karlovy Vary thermal spring salt is produced by methods of evaporating mineral waters from the hot spring Vridlo. By dissolving the spring salt in warm water, one can produce the same healing mineral water found in Karlovy Vary at home. Czech doctors determined that the water manufactured from the genuine Karlovy Vary thermal spring salt has identical healing properties as the natural spring.

Czech scientists found also that the water can promote secretion and increase the activity of pancreatic enzymes in healthy volunteers, people with chronic pancreatitis, and patients after gallbladder removal.

In all these studies, Karlovy Vary Healing Mineral Water increased not only the amount of pancreatic juices and activity of enzymes, but also diminishes the pressure inside the pancreatic duct. All these beneficial actions promote healing chronic pancreatitis and other pancreatic problems.

Bad Breath in Morning vs. Bad Breath Caused By Stomach Problems

It is very probable that anyone suffering from chronic constipation is also experiencing bad breath or halitosis. If this is the case a colon cleanse is in order, http://www.choosing-natural-medicines.com/CONSTIPATION.html  and continuing to eat mints, chew on gum and rinse with mouthwashes will only temporarily cover up the underlying internal problem. If you are a long time sufferer of chronic constipation and digestive upset and you cleanse your bowels but still are experiencing bad breath, then a detoxification http://www.choosing-alternative-medicines.com/DETOXIFICATION.html may be in order.

The herb cardamom is a temporary Ayurvedic treatment for bad breath. Cardamom contains a potent antiseptic called cineole proven to kill bacteria that causes bad breath. Most people just chew the seeds and then spit them out. Bad breath herbs also consist of Eucalyptus and Parsley. Eucalyptus also contains cineole and Parsley is a rich source of the plant pigment chlorophyll.

That brings us to the number one best way to get rid of bad breath caused by stomach problems. If you suffer from chronic bad breath, most likely you are also suffering from dysbiosis of your colon and stomach. Bad breath reasons can also stem from a deficiency of digestive enzymes and undigested food particles sitting in both your stomach and intestines putrefying and creating a buildup of bacteria. Chlorophyll is antibacterial, anti-inflammatory, promotes new tissue growth and relieves gas and bloating, thus eliminating bad breath. Chlorella is made up of 58% protein, and contains carbohydrates, all of the B vitamins, vitamin C and E, amino acids and trace minerals. The chlorophyll in chlorella helps cleanse the blood stream, thereby eliminating the buildup of toxins and their offending odors, leading to fresher smelling breath.

Breath mints, gum and mouthwashes will “mask” bad breath or halitosis in a pinch, but they do not treat the underlying cause of the problem. You will have to continually suck on mints, chew gum or use mouthwash to coverup your chronic halitosis temporarily. Keep in mind these just mask the underlying problem of toxin buildup, and do nothing to treat the underlying problem of bad breath in the first place. If you truly want to treat your halitosis (bad breath) the only effective way is to treat your system from the inside through the use of chlorophyll, digestive enzymes and probiotics. Only by restoring normal bacterial flora within your gut can you eliminate bad breath in morning and chronic bad breath caused by stomach problems.

What is Endometriosis?

Endometriosis is a disease that usually affects only women. The women who suffer from endometriosis experience a multitude of symptoms including fatigue, pelvic pain of differing severity, heavy menstrual periods, painful sexual intercourse, lower back pain, painful bowel movements and urination, abdominal bloating, and infertility. Endometriosis occurs when the endometrial cells that normally line the uterus are found outside the uterus in the abdominal cavity. These endometrial cells can implant on any of the reproductive and major organs of the abdominal cavity including the ovaries, fallopian tubes, bladder, rectum, small and large intestines and the colon. Although it rarely happens endometriosis can also find its way to the lungs, skin and inside the vagina and bladder. Because endometrial tissue is the same as that found inside the uterus it reacts to a woman’s monthly menstrual cycle the same way. As a woman’s hormones change during the month the lining of the uterus builds up with blood and other nutrient rich tissue, creating an inviting home for a fertilized egg. The endometrial tissue implanted outside the uterus responds to the monthly hormonal change in the same way. But unlike the tissue lining the uterus which gets flushed out of the vagina each month during a woman’s period the blood and tissue of endometriosis has no where to go. This blood and tissue inside the pelvic cavity causes irritation, inflammation and scar tissue. The endometrial cells themselves will also grow larger and expand within the abdomen, causing the symptoms to worsen over time. The cause or source of endometriosis is unknown. There have been many theories espoused as to the cause of this condition, but scientific research has failed to prove or disprove any of them. The leading theories as to the cause of endometriosis include: 1. Retrograde Menstruation: During menstruation some of the endometrial tissue “back-flows” through the fallopian tubes and into the abdomen. This could account for how the endometrial tissue gets into the pelvic cavity but research has also shown that 90% of all women experience this retrograde flow and the majority of them do not develop endometriosis. 2. Genetically Inherited: Endometriosis is known to run in families. In fact if a woman is 6 times more at risk of getting this condition if her mother or sister has it. 3. Autoimmune Diseases: Many women who have endometriosis also show some sort of immune system dysfunction. In most cases a healthy immune system will find and destroy endometrial cells growing outside the uterus. 4. Xenoestrogens: Endometriosis is a relatively new disorder. Up until 50 to 100 years ago there were very few documented cases of endometriosis. With the coming of the industrial/technical age it is becoming more and more common. Many link this to the plastic and chemical industries, more specifically plastics and synthetic fertilizers and pesticides. These plastics and chemicals release large amounts of Xenoestrogens into the environment, resulting in what is now called estrogen dominance. Research has shown that endometriosis is estrogen dependent and most treatments involve trying to lower a women’s estrogen level. For any women or young girl who feels they have endometriosis it is important that they talk to their gynecologist about this disease. At this time there is no cure but any gynecologist experienced in the diagnosing and treatment of endometriosis can help formulate a treatment plan that will minimize the endometrial growths and the painful symptoms that go along with them.

These 3 Tips Lead to Proper Polypectomy Coding

In case the surgeon devotes double time on 45385, you should bill with modifier 22.

If you are acquainted with how to work out the kind of scope, surgical technique, plus polyp location from your GI’s colonoscopy with- polypectomy claim, you’re half way into coding success. However you also have to identify the dissimilar types of polyp removal, as well as x the removal method used or all your efforts would just go down the drain. Read on this expert gastroenterology coding and billing insight to perfect your claims and ethically maximize your reimbursement.

Following are three gastroenterology coding tips on what you should not do.

1. Don’t Forget Your Physician’s Colonoscopy, Polypectomy Technique

The fundamental point is to understand clearly your GI’s operative report. In case you look thoroughly, you must be able to validate if she really conducted a colonoscopy, and what method were used to remove the polyp (either with biopsy or snare technique). CPT® has different codes for polypectomies, and it’s significant that you know which technique your physician used to bill the service appropriately.

In case of multiple polyp removal, you must know where on the colon each polyp was traced. On the whole, you must be able to tell whether they were in distinct locations or close enough for payers to consider one location. The number of allowable codes would hinge on the number of polyp locations.

2. Don’t Overlook The Difference Between ‘Cold’ and ‘Snare’

When, all through a colonoscopy, the GI takes tissue samples or removes a small polyp by means of cold biopsy (disposable) forceps, it implies she’s carried out 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple). These forceps are mentioned as “cold” as no electric current passes through them. Procedure 45380 generally translates to a partial polypectomy.

Then again, when the gastroenterologist uses snare technique during a total polypectomy, you must report 45385 (Colonoscopy, flexible, proximal to splenic flexure; including removal of tumor[s], polyp[s], or other lesion[s] by snare technique).

3. Don’t Dismiss Cauterization, Ablation Options

At times, the physician would have control over a patient’s bleeding, and carry out cauterization. Irrespective of the method the physician uses (for example, Argon laser), you must report the control-of-bleeding code 45382 (Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding [for instance., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator]).

Surgeons might use numerous of the same techniques meant for cauterization (to control bleeding) and also for ablation. However the defining factor is the diagnosis. For example, use 45382 when controlling bleeding from a polyp removed several days ago or for diverticulosis (562.12, Diverticulosis of colon with hemorrhage; or 562.13, Diverticulitis of colon with hemorrhage). Another application is for angiodysplasia 569.85 (Angiodysplasia of intestine with hemorrhage).

Want to have more expert tips like this and latest gastroenterology Medical billing and coding updates? Click here to read the entire article and to get access to our monthly Gastroenterology Coding Alert: Your practical adviser for ethically optimizing gastroenterology billing and coding, payment and efficiency in gastroenterology practices.

Read on to perfect your gastroenterology billing and coding: http://www.supercoder.com/articles/articles-alerts/gac/polypectomy-45380-45385-3-tips-put-you-in-touch-with-proper-polypectomy-coding-107368/

Fibroid Types

A fibroid is a type of tumor or growth that can be found in a woman’s uterus or ovaries. Fibroids are generally benign, meaning that it is usually not associated with the development of cancer.  Around half of all women have some type of fibroid; however, most fibroids will not cause any symptoms, leaving many women unaware that they even have them until they are encountered by a doctor during a routine pelvic exam. Fibroids are also known by the medical community as Myoma, Leiomyoma and Fibromyoma.

The 5 different types

Fibroids are classified into five separate types depending on where they are located…

  1. Intracavity myomas: These types of growths are located inside the cavity of the uterus and may cause bleeding in between periods along with painful cramping. If intracavity myomas prove to be troublesome, they can usually be removed  through a process known as a hysteroscopic resection
  2. Submucous myomas: These benign tumors can be found growing partly in the cavity and partly in the uteran wall and can also cause pain and bleeding between periods. They can also be removed via hysteroscopic resection.
  3. Unless they get oversized and bothersome, these tumors generally do not cause any symptoms and usually do not need to be treated. Most women will not even know that they have them.
  4. Subseros myomas: The fibroids are found growing on the outside of the uterine wall.
  5. Pendunculated myomas: These are fibroids that are attached to uterus  by a stem or stalk. These type of fibroids are generally easiest to remove through the use of a laparoscopy.

Fibroids can come in many different sizes from pea sized growths to giant tumors that can make a woman look five months pregnant. The growth rate of fibroids can also vary greatly. Some will stay the same small size for years, while others will grow at a rapid rate quickly becoming a problem. Sometimes pregnancy can end up causing preexisting fibroid to three to five fold bigger than it previously was.  This is thought to happen due to the increase levels of estrogen present in the body during a pregnancy as well as other pregnancy related factors that contribute to the increase in size. These fibroids will generally shrink back to their previous size after the pregnancy.  While some fibroids grow with pregnancy, other fibroids can make it difficult for pregnancy to happen.  The most common sympyoms associated with fibroids are pelvic pain and heavy menstrual bleeding.

80% of women over the age of 50 have uterine fibroids and if you include the smallest of growths, some studies suggest that all women have them by the time they reach menopause. Most women that have fibroids generally have more than one type and sometimes there can be many as fifty different fibroids present. In fact, a solitary fibroid is much less likely than multiple ones.  Some menopausal women have shown a slow increase in the size of their fibroids when they take extra estrogen while others have noticed no change at all.

At a 1:750-1000 chance, cancer rarely develops in a fibroid. Some data even suggests that cancer will not form in a preexisting fibroid but develop instead in a a part of a uterus that is not a fibroid.

Forms of treatment:

Hysteroscopic resection: this process involves a doctor inserting a tool into the cervix that has a camera attached to it which allows the doctor to spot any fibroids. The doctor can then used a feature on the tool that  produces an electrical current in order to kill the fibroid tissue.

Hormone therapy: Hormones can also be used to shrink fibroids

Hysterectomy: This is considered a last result and will only be done if the fibroids are causing a lot of pain and bleeding and nothing else can be done.

Speaking to your doctor about your symptoms and getting the right kind of tests will help determine which type of treatment is ideal for you.

CYSTS OF MAXILLOFACIAL REGION

CYSTS OF MAXILLOFACIAL REGION

Author:

Dr. Altaf H Malik

Dept. of Oral and Maxillofacial Surgery,

Govt. Dental College, Srinagar.

Co authors: 

Dr. Ajaz A Shah

Associate Professor and Head,

Dept. of Oral and Maxillofacial Surgery,

Govt. Dental College, Srinagar.

Dr. Suhail Latoo

Lecturer

Department of Oral Pathology and Microbiology,

Govt. Dental College, Srinagar.

Dr. Manzoor Ahmad Malik

J & K Health Services, SDH Banipora

Dr. Rubeena Tabasum

Resident

C.D Hospital, Srinagar.

Dr. Shazia Qadir

Dept. of Oral and Maxillofacial Surgery,

Govt. Dental College, Srinagar.

Introduction

            A cyst has been traditionally defined as a pathologic epithelium-lined cavity usually containing fluid or semisolid material (Killey and Kay – 1966). The presently accepted definition is the one coined by Kramer in 1974 as ‘a pathologic cavity having fluid, semisolid or gaseous content and it is frequently, but not always lined by epithelium’.

            Cysts of the jaws are often lined by a layer of epithelium and a layer of subjacent connective tissue and these layers can be dissected easily from bone. The thickness and configuration of this lining varies with the type of the cyst. These cysts develop either by the proliferation of epithelial remnants in the jaw or by cystic transformation of neoplastic tissue.

Classification

            Numerous classifications have been published of cysts of the jaws. Most of them are perfectly satisfactory in clinical evaluation and practise.

I.                    Robinson’s classification (1945)

  Developmental cysts

A)     from odontogenic tissue

  1. Periodontal cyst

(a)     radicular or root apex type

(b)    lateral type

(c)     residual type

  1. Dentigerous cyst
  2. Primordial cyst

B)      from non-dental type of tissue

  1. Median cyst (median palatal cyst)
  2. Incisive canal cyst
  3. Globulomaxillary cyst

II.                  Kruger’s classification (1964)

A)     Congenital cyst

  1. Thyroglossal
  2. Branchiogenic
  3. Dermoid

B)      Developmental cyst

  1. non-dental origin

a)       fissural type           

  1. Naso-alveolar
  2. Median
  3. Incisive canal cyst (Naso-palatine)
  4. Globulomaxillary

b)      retention type

  1. mucocoele
  2. ranula
  3. dental origin

a)       periodontal

  1. periapical
  2. lateral
  3. residual

b)      primordial

c)       dentigerous

III.                Lucas’ classification (1964)

  Intra-osseous cysts

A)                 Fissural cysts

a)       median mandibular

b)      median palatal

c)       naso-palatine

d)      globulomaxillary

e)       naso-labial

B)                  Odontogenic cysts

a)       Developmental

  1. primordial
  2. dentigerous

b)      inflammatory

c)       radicular

C)                 Non-epithelial bone cysts

a)       solitary bone cyst

b)      aneurysmal bone cyst

IV.              Gorlin’s classification (1970)

A)                 Odontogenic cysts

  1. dentigerous cyst
  2. eruption cyst
  3. gingival cyst of the new-born infants
  4. lateral periodontal and gingival cyst
  5. keratinising and calcifying odontogenic cysts

(cystic keratinising tumour)

  1. radicular (periapical cyst)
  2. odontogenic keratocyst

a)       primordial cyst

b)      Gorlin-Goltz syndrome

B)                  Non-odontogenic and fissural cysts

  1. globulomaxillary (premaxilla-maxillary) cyst
  2. naso-alveolar (naso-labial / Klestadt’s) cyst
  3. naso-palatine (median anterior maxillary) cyst
  4. median mandibular cyst
  5. anterior lingual cyst
  6. dermoid and epidermoid cyst
  7. palatal cysts of new-born infants

C)                 Cysts of neck, oral floor and salivary glands

  1. thyroglossal duct cyst
  2. lymphoepithelial (branchial cleft) cyst
  3. oral cyst with gastric / epithelial epithelium
  4. salivary gland cyst – mucocoele and ranula

D)                Pseudocysts of jaws

  1. aneurysmal bone cyst
  2. static (developmental / lateral) bone cyst
  3. traumatic (haemorrhagic / solitary) bone cyst

V.                  WHO classification published in ‘Histologic typing of odontogenic tumours’ (Kramer, Pindborg, Shear – 1992)

I.  Cysts of the jaws

A)     Epithelial

  1. developmental

a)       odontogenic

  1. gingival cysts of infants
  2. odontogenic keratocyst (primordial cyst)
  3. dentigerous (follicular) cyst
  4. eruption cyst
  5. lateral periodontal cyst
  6. gingival cyst of the adults
  7. botryoid odontogenic cysts
  8. glandular odontogenic (sialo-odontogenic / mucoepidermoid-odontogenic) cyst
  9. calcifying odontogenic cyst

b)      non-odontogenic

  1. naso-palatine duct (incisive canal) cyst
  2. naso-labial (naso-alveolar) cyst
  3. midpalatine raphae cyst of infants
  4. median palatine, median alveolar and median mandibular cysts
  5. globulomaxillary cyst
  6. inflammatory
    1. radicular cyst (apical / lateral)
    2. residual cyst
    3. paradental (mandibular infected buccal) cyst
    4. inflammatory collateral cyst

B)      Non-epithelial

  1. solitary (traumatic/simple/haemorrhagic) bone cyst
  2. aneurysmal bone cyst

II. Cysts associated with the maxillary antrum

a)                   benign mucosal cyst of the maxillary antrum

b)                  post-operative maxillary cyst (surgical ciliated cyst of the maxilla)

III.Cysts of the soft tissues of the mouth, face and neck 

a)                   dermoid and epidermoid cyst

b)                  lymphoepithelial (branchial cleft) cyst

c)                   thyroglossal duct cyst

d)                  anterior median lingual cyst (intralingual cyst of fore-gut origin)

e)                   oral cyst with gastric / intestinal epithelium (oral alimentary tract cyst)

f)                   cystic hygroma

g)                  naso-pharyngeal cysts

h)                  thymic cysts

i)                    cysts of the salivary glands

  1. mucous extravasation cyst
  2. mucous retention cyst
  3. ranula
  4. polycystic (degenerative) disease of parotid

j)                    parasitic cysts

  1. hydatid cyst
  2. cysticerus cellulosae
  3. trichinosis

Signs and symptoms

Signs

            The physical sign of a cyst in the jaw depends on the size of the cyst. Small cysts do not produce any clinical signs. They may be discovered only on a routine radiologic examination. As the cyst becomes larger, expansion of alveolar bone occurs, usually on buccal / labial aspect. This expansion takes place as a result of continuous deposition of sub-periosteal bone in response to the bone resorption caused by the expanding cyst. This produces a bulged convex contour.

            At an early stage, this lateral expansion produces a smooth, hard, painless prominence. As the cyst grows, the bone at the centre of the convexity becomes soft in consistency. This stage is described as ‘tennis ball’ feeling.

            Further thinning of the cortical plate causes the bone to become fragile and outer shell of bone becomes fragmented on pressure producing a sound or feeling of ‘egg-shell crackling’. Later, this bone completely disappears, causing the cyst wall to be attached to the periosteum. At this stage, the cyst appears as a smooth, shining, bluish swelling with a soft, fluctuent consistency.

            The way and degree of expansion and clinical signs vary with the type of cyst. Keratocysts and dentigerous cysts commonly cause less expansion and more bone destruction. The enlargement of the cyst is at the expense of cancellous bone.

            Mobility of teeth rarely occurs with periapical cyst whereas dentigerous cyst and odontogenic keratocyst may cause mobility of teeth because of their high degree of bone resorption. Absence of teeth generally indicates a dentigerous cyst or a primordial cyst. Displacement of teeth rarely occurs in cases of odontogenic cysts whereas developmental cysts such as globulomaxillary cyst can cause displacement of roots of adjacent teeth.

            Large mandibular cysts invariably involve the neurovascular bundle and may even deflect this structure to an abnormal position. It is unusual to find anaesthesia of mental nerve, but it may occur in cases of acute infection and sudden increase in intra-cystic pressure. This may produce nerve compression and paresthesia, which is relieved on decompression by surgical drainage.

            Periapical cysts are always associated with one or more non-vital teeth. In other cysts also, an increase in the intra-cystic pressure may cause loss of response of adjacent teeth to vitality tests, even though they have vital pulps.

            A large maxillary anterior cyst will expand under nasal floor causing distortion of nostril and nasal congestion. Involvement of antrum by an infected cyst will show features of maxillary sinusitis.

Symptoms

            Most of the cysts are asymptomatic till it expands the jaw or gets infected. When infected, it causes severe pain and swelling of the involved region. Sometimes the patient notices a lump, which is painless. If the cyst has discharged in to the mouth or has become infected, the patient may complain of bad taste and pain.

            Any cyst may cause displacement of adjacent teeth causing convergence of crowns of teeth. In case of cysts in the anterior region, discoloration, extrusion or malalignment of teeth will be the symptoms.

Radiologic features

            The classic appearance of a common odontogenic cyst in the jaw is a well-defined round / oval radiolucency, circumscribed by a sharp radio-opaque margin. However, there are variations depending on site and type of cyst. Also there are some other lesion

which may produce radiolucency similar to that of a cyst (e.g. some benign tumours may produce radiolucency similar to that of a cyst).

A small cyst in the marrow space normally round in shape and as it enlarges, become oval in shape. Later, resorption and expansions of cortical plates take place. Generally, buccal cortical plate expands fast. Exceptions are mandibular 3rd molar region where the lingual cortical plate is thin, and maxillary anterior region which produces a palatal expansion. A cyst in the maxillary molar region may involve maxillary sinus and enlarge within the sinus without producing much expansion of cortical plates. 

            When the perforation of cortical plates occur, it appears as a window, or a radiolucency inside a radiolucency.

            A large mandibular cyst may displace the shadow of inferior alveolar canal downward and laterally. Large cysts cause unequal resorption at different margins, and a scalloped or a lobulated margin may be formed. 

            If an unerupted tooth with a large follicular space is seen on a radiograph, it should be compared with the radiograph of opposite side before the diagnosis of a dentigerous cyst is made, because the size of follicular space can vary. A difference of more than three times that of the opposite side indicates a cyst.

            Infection of a cyst causes a decrease in radiolucency and it blurs the radio-opaque margin. Rare malignant transformation also produces similar results. While the cyst heals after treatment, the radio-opaque line fades, as the cancellous bone deposits from the periphery.

Aspiration

            Apart from signs, symptoms and radiologic feature, an important aid in the diagnosis of a cyst is aspiration technique. This also helps to distinguish between a cyst and the maxillary sinus.

            A wide bore needle should be used for the procedure, which may be done under local anaesthesia. A diagnosis of a cyst can be confirmed if aspirate is light straw coloured fluid containing cholesterol crystals. These crystals appear shining when the fluid is taken on a dry swab.

            When infected, the fluid becomes turbid and yellow. In OKC, the colour and consistency of fluid vary depending on the concentration of suspended keratin. Sometimes, it will be too thick. Aspiration of pure blood raises the possibility of central haemangioma or aneurysmal bone cyst.  A serosanguinous fluid or gas may be withdrawn from simple bone cyst.  Aspiration of air shows that needles may be in maxillary sinus.  It can be confirmed by injection of 20 ml of sterile water, which would come at through the nostrils. 

            There is a risk of introducing infection during aspiration and ideally when this is performed, it should be at least 48 hours preoperatively and only under antibiotic cover.

Potential complications

            Apart from the obvious problem of cystic enlargement causing weakness of jaw, certain particular potential complication, need to be mentioned, considering their clinical relevance.

I.                    Infection:

Infection is the most complication of a cyst in the jaw.  Normally, if the cyst is totally confined inside a bony cavity or within the soft tissues, there is no chance of it getting infected.  Microbes gain access to the cyst through odontogenic passages (i.e. carious cavities, periodontal pockets etc.) or through minor external injuries.  Cysts of inflammatory origin, like periapical cyst, are always infected.  Infection causes the sclerotic border of the lesion to get blurred in radiograph.

Normally asymptomatic lesions are rendered painful by infection, which prompts the patient to seek treatment.  Treatment includes antibiotic therapy and drainage, if necessary, followed by extraction or root filling of associated teeth, and complete curettage of cyst cavity.  On opening into the cavity, an intact lining is not usually obtained.

II.                  Effects on associated teeth

Cysts usually do not cause resorption of the roots of associated teeth, and the vitality of these teeth is not affected in most of the cases.  Surgical enucleation of large lesions is associated with teeth can cause disruption of blood supply leading to pulp death and non-response to vitality tests.

Odontogenic cysts are frequently found to cause displacement of the roots of associated teeth.  Globulomaxillary cyst that causes divergence of maxillary lateral incisor and canine roots, is a typical example. Others like OKC also may cause displacement of multiple teeth even though externally discernible swelling may be minimal.

III.                Pathologic fracture

This is a direct sequel of the jaw rendered weak by the expanding cyst.  This may be caused by the duct enlargement and perforation of a cyst or from minor trauma, to the weakened bone.  Surprisingly, some fractures may be asymptomatic since the cyst tissue acts as a splint between the fractured segments.

A pathologic fracture is also a possibility in case a large defect is not adequately managed by filling or grafting, after surgical enucleation.

IV.              Recurrence after treatment

Recurrence of the lesion after treatment by enucleation is a relatively common occurrence. The odontogenic keratocysts are especially notorious for this. This complication has much to do with the perfection of surgical procedure. If the cyst lining is not completely removed during treatment, the remnants of the lining may proliferate to cause recurrence.

V.                Malignant transformation

Most workers advise removal of the cyst lining as early as possible after the lesion is diagnosed, because of the capability to undergo pathologic change in course of time.  The occurrences of ameloblastoma, squamous cell carcinoma and mucoepidermoid carcinoma have been well documented.

Specific cyst types

Odontogenic keratocyst (OKC; primordial cyst)

            In earlier literature, the keratocyst is described as a cholesteatoma (Hauer- 1926; Kostecka-1929). The first account is by Mikulicz in 1876 and the term odontogenic keratocyst was introduced by Philipsen (1956).

Previous authors have tended to denote all cysts containing keratin as keratocysts. But the one under discussion here is a distinct entity of developmental origin, arising from primordial odontogenic epithelium.

Incidence

Browne (1969,1972) has shown that the OKC has a particular age distribution, the mean age being 32.1 years with a peak in 2nd and 3rd decades. 40-60% of all patients falls in this age group. It is estimated that OKC account for about 11 percent of all the cysts of the jaws. It occurs more in whites than in blacks.

Keratocysts are generally found more frequently in males than in females and this sex predilection is more pronounced in blacks than in whites. The mandible is found to be involved far more frequently than the maxilla (about 75%). About one-half of all keratocysts occur at the angle of the mandible extending to various distances.

Clinical features

Patients with keratocysts complain of pain, swelling or discharge. Paresthesia of lower lip and teeth and pathologic fractures do occur, but are rare. Many patients are free of symptoms until the cyst has reached a large size, involving the entire maxillary sinus or mandibular ramus, including the condylar and coronoid processes. This is because the keratocyst tends to extend in the medullary cavity and clinically observable expansion of bone occurs late.

The occurrence of large keratocysts that involved the maxillary sinus and led to destruction of the floor of the orbit and caused proptosis of the eyeball have been reported (Voorsmit-1984).

Maxillary cysts may cause buccal expansion, but palatal expansion is also rarely seen. Mandibular lesions may cause buccal or lingual expansions.

Gorlin-Goltz syndrome (first described by Binkley and Johnson –1951) is transmitted as an autosomal dominant trait and is characterised by

1)      cutaneous anomalies including basal cell carcinoma, other benign dermal cysts and tumours, palmar pitting, palmar and plantar keratosis and dermal calcinosis

2)      dental and osseous anomalies including odontogenic keratocysts (often multiple), mild mandibular prognathism, rib anomalies (often bifid), vertebral anomalies and brachymetacarpalism.

3)      ophthalmologic abnormalities including hypertelorism with wide nasal bridge, dystopia canthorum, congenital blindness and internal strabismus.

4)      neurologic anomalies including mental retardation, dural calcification, agenesis of corpus callosum, congenital hydrocephalus and occurrence of medulloblastomas with greater than normal frequency and

5)      sexual abnormalities including hypogonadism in males and ovarian tumours.

Recurrences

The keratocyst has a particular tendency to recur after surgical treatment. The recurrence rate in various reported series is found to vary between 11 and 62%. A high recurrence rate was noticed when cysts were located in the angle or ascending ramus of the mandible. Those whose radiographic appearances are multilocular have a higher recurrence rate than those with a unilocular appearance.

Possible reasons for recurrences are

1)      occurrence of satellite cysts, which are retained during enucleation procedures,

2)      thin and fragile linings, which causes difficulty to enucleate completely,

3)      epithelial linings of OKCs have intrinsic growth potential (Toller-1967) and they may be regarded as benign neoplasms,

4)      innate tendency in some patients to develop OKC from remnants of dental lamina and

5)      new cysts may develop from epithelial offshoots of the basal layer of the oral epithelium.

Enlargement

Toller (1967) viewed keratocysts as benign neoplasms. They tend to extend along cancellous component of the bone without producing noteworthy expansion of cortical plates. They frequently reach a large size, particularly at the angle of the mandible, before they are diagnosed. Main (1970) showed that the mitotic value of the keratocyst linings ranged from 0 to 19 with a mean of 8.0. this figure is similar to that in ameloblastomas and in dental lamina, and higher than that found in non-odontogenic cysts (2.3) and radicular cysts (4.5).

While Toller postulated that the raised osmolarities (when compared to serum osmolarity) play an important part in expansive growth of keratocysts, Main felt that mural growth in the form of epithelial proliferation is the essential process involved.

Radiologic features

Radiologically, early keratocysts appear as small, round or ovoid radiolucent areas that are well demarcated with a distinct sclerotic margin. Some of these unilocular lesions have scalloped margins and these may be misdiagnosed as multilocular lesions. However, true multilocular lesions are not uncommon. Various studies have shown about 23% of all OKCs to be multilocular. Generally, these are significantly larger than the unilocular ones. The multilocular variety is liable to be misdiagnosed as ameloblastoma.

Further, OKCs may occur in the periapical regions of vital standing teeth, giving the appearance of a radicular cyst. In other cases, they may impede the eruption of related teeth and this results in a ‘dentigerous’ appearance radiologically.

Pathogenesis

            It is generally agreed that a keratocyst is a developmental abnormality arising from odontogenic epithelium, the sources being dental lamina or its remnants. The term ‘primordial cyst’ was first used by Robinson to describe a cyst of the jaw which he suggested was derived from the enamel organ in its early stages of development by degeneration of stellate reticulum before any calcified structures had been laid down. It is now generally agreed that most of the so-called primordial cysts may, in fact, be keratocysts.

Pathology

            The linings of odontogenic keratocysts are rarely received intact in the laboratory. They are usually thin-walled, collapsed and folded. The histologic features are characteristic.

1)      They are lined by a regular keratinised stratified squamous epithelium, which is usually about 5-8 cell layers thick and without rete pegs. The tyre of keratinisation is parakeratin in 80-90% of cases.

2)      The epithelium is uniformly thick, with a well-defined, often palisaded basal layer consisting of columnar or cuboidal cells, or a mixture of both.

3)      The nuclei of columnar basal cells tend to be oriented away from the basement membrane, and in the majority of cases, are intensely basophilic.

4)      Desquamated keratin is present in most of the cyst cavities.

Treatment

            Because of the high recurrence rate, simple enucleation is not considered to be sufficient. Excision of the lesion along with a small margin of surrounding bone would be a more reasonable plan.

Gingival cyst and midpalatine raphae cyst of infants

            These two cyst types are discussed together because of the clinical features they share, although one is of odontogenic origin and the latter, of developmental non-odontogenic origin. Two specific varieties which may be included in this category are ‘Epstein’s pearls’ which occur along midpalatine raphae and Bohn’s nodules, which are seen around dental ridges.

Clinical features

            The frequency of gingival cysts is high in new-born infants but they are rarely seen after 3 months of age. It is apparent that most of them undergo involution and disappear, or rupture though the surface epithelium and exfoliate.

            The nodules are 2-3 mm in diameter. They are white or cream-coloured.

            Some of the gingival cysts open into the surface or may be involved by developing teeth. Very few become clinical problems.

Pathogenesis

            Gingival cysts of infants arise from the dental lamina. The epithelial remnants of dental lamina (glands of Serres) have the capacity, from as early a stage in development as 10 weeks in utero to proliferate, keratinise and form small cysts.

            In the morphodifferentiation stage (late bell stage) of tooth development, the disintegration of dental lamina begins to occur and many islands and strands of odontogenic epithelium are seen between the tooth germ and oral epithelium. The epithelial remnants which have already formed microcysts, expand rapidly at this stage (15-20 weeks in utero)

            The cysts along midpalatine raphae arise from epithelial inclusions at the line of fusion of the palatal folds and the nasal process. These usually atrophy and become resorbed after birth. Some may, however, produce keratin-containing microcysts.

Pathology

            Both the types of cysts under discussion have similar histologic features. The cysts are round or ovoid and may have a smooth or undulating outline in histologic sections. There is a thin lining of stratified squamous epithelium, and keratin fills the cavity. The basal cells are flat.

Treatment

            There is no indication for treatment of gingival cysts or midpalatine raphae cysts.

Gingival cysts of adults

            This rare condition accounts for only 0.5% of all the cysts of the jaws. The actual incidence may be more, as many patients do not report for treatment. Most cases occur in 5th and 6th decades and there has been no significant gender predilection. Gingival cysts occur much more frequently in mandible than in maxilla.

            The patient may give a history of a slowly enlarging, painless swelling. The cysts are well-circumscribed swellings, usually less than 1 cm in diameter and may occur in attached gingiva or interdental papilla, always on the facial aspect. There may be no radiographic change or only a faint round shadow indicating superficial bone erosion.

            A number of suggestions have been made about the pathogenesis. The most favoured theory is that they arise from odontogenic epithelial nest cells derived from dental lamina.

            Gingival cysts have a variable histologic pattern. The epithelium may be thin, of thicker stratified squamous nature, or even atrophic. Some may have epithelial thickenings, which may be small and flat, or may protrude into the cyst lumen. The fibrous connective tissue wall is usually relatively uninflamed.

            The gingival cyst is removed by local excision.

Lateral periodontal cyst

            The designation is confined to those cysts which occur in the lateral periodontal position, which is not of inflammatory origin and in which case, a diagnosis of OKC is excluded. This is also a rare condition, accounting for less than 1% of all cysts of the jaws. The patients are usually adults (mean of 50 years) with a peak in the age group of 40-69 years.

            The most frequent location is the mandibular premolar area, followed by the anterior region of maxilla. The lateral periodontal cyst may be symptomless. Sometimes, a gingival selling may arise in the facial aspect. Pain and tenderness at the site have been reported.

            Radiographs show a round or oval well-circumscribed radiolucent area, usually with a sclerotic margin. The cysts lie between the apex and cervical margin of the tooth.

            The lateral periodontal cyst is of odontogenic origin and the general agreement is that they are of developmental origin. An expanded follicle on the lateral surface of the  erupting crown may be the cause.

            Microscopically, it is lined by a thin, non-keratinising layer of squamous or cuboidal epithelium with small and pyknotic nuclei. Localised plaques and thickenings are common.

            The lesion is treated by surgical enucleation without, if possible, removing the associated tooth.

Botryoid odontogenic cyst

            Widely regarded as a variant of lateral periodontal cyst, the botryoid odontogenic cyst is multilocular and hence the term ‘botryoid’ which means ‘cluster of grapes’. This cyst occurs in adults, mainly in anterior region of the mandible.

            The cyst cavities are varied in size and are lined by thin non-keratinising epithelium with thin fibrous connective tissue septa.

            The lesion requires careful excision because there have been numerous  reports of recurrences.

Glandular odontogenic cyst

            This has some characteristics of lateral periodontal cyst and botryoid odontogenic cyst, but has fairly typical histologic features. Secretory elements and stratified squamous epithelium are seen in the lining.

Dentigerous (follicular) cyst

            This type of cyst typically encloses the crown of an unerupted tooth by expansion of its follicle and is attached to the neck of the tooth.

            The dentigerous cyst accounts for about 16% of all jaw cysts. It is seen more in2nd and 3rd decades of life and the frequency is greater in males and in whites. A very substantial majority involve the mandibular 3rd molar.

Clinical and radiographic presentation

            Dentigerous cysts may grow to a  large size before they are diagnosed. Many patients first become aware of the cyst as a slowly enlarging swelling. An unerupted tooth is a mandatory feature.

            Radiographically, the common finding is a unilocular radiolucent area associated with crowns of unerupted teeth. They have well-defined sclerotic margins unless they become infected. There are three radiological variants.

1)      The crown is enveloped symmetrically.

2)      Expanded follicle is seen on one side of the crown (lateral dentigerous cyst).

3)      Entire tooth is involved (circumferential dentigerous cyst).

Dentigerous cyst has a greater tendency than other cysts to produce resorption of roots of adjacent teeth.

Pathogenesis

            It has been suggested that dentigerous cysts may be of either extra-follicular or intra-follicular origin, and the latter may develop by accumulation of fluid between the reduced enamel epithelium and enamel or within the enamel organ itself. It is suggested that the pressure exerted by a potentially erupting  tooth  on an impacted follicle obstructs the venous outflow thereby inducing rapid transduction of serum across the capillary walls.

Pathology

            The thin fibrous cyst wall, being derived from dental follicle, consists of young fibroblasts widely separated by stroma and ground substance rich in acid mucopolysaccharide. The epithelial lining consists of 2-4 cell layers of flat or cuboidal cells. Characteristically, the epithelial lining is keratinised.

Treatment

            Small lesions can be surgically removed in their entirety. Larger cysts that involve serious loss of bone are often treated by the insertion of a surgical drain or marsupialisation.

Potential complications

            Several relatively potential complications exists, which can arise from the dentigerous cysts, apart from the possibility of recurrence. These include

a)       development of ameloblastoma,

b)      development of epidermoid carcinoma and

c)       development of mucoepidermoid carcinoma.

Eruption cyst

            A dentigerous cyst occurring in soft tissues, the eruption cyst is formed when a tooth is impeded in its path of eruption with in the soft tissues overlying the bone.

            This cyst is found in children of different ages. Deciduous and  permanent teeth may be involved, most frequently anterior to the first permanent molar.

            It produces a smooth swelling over the erupting tooth which may be either the colour of normal gingiva or blue. It is usually painless unless infected, and is soft and fluctuent. There is no bone involvement, but the cyst may throw a soft tissue shadow in radiographs. Transillumination would help to distinguish it from an eruption haematoma.

            The pathogenesis is similar to that of the dentigerous cyst

            The superficial part is covered by the keratinised stratified squamous epithelium of the overlying gingiva. This is separated from the cyst by a strip of dense connective tissue which usually shows a chronic inflammatory cell infiltrate.

Calcifying odontogenic cyst (COC)

            Though a well-recognised lesion, a COC is not commonly encountered (about 1% of all jaw cysts). This cyst occurs over a wide age range but here is a distinct peak in the 2nd decade. There is an equal sex distribution and no racial predilection is apparent. Maxilla and mandible are involved with almost equal frequency but anterior part of either is a more common site.

            Swelling is the most frequent symptom. Intra-osseous lesions may produce a hard bony expansion, which may be extensive. Occasionally, cortical plate may be perforated. Pain is a rare symptom and many cases have been asymptomatic.

            The calcifying odontogenic cyst appears  in the radiographs essentially as a radiolucent area with regular or poorly defined margins. Irregular calcified bodies of varying size and opacity may be seen in the radiolucent area.

            Histologically, the epithelial lining has characteristic odontogenic features with a prominent basal layer consisting of palisaded columnar or cuboidal cells and hyperchromatic nuclei, polarised away from the basement membrane. the most remarkable feature of COC is the presence of ghost cells, which are enlarged, ballooned, ovoid or elongated cells with thin epithelium. Calcification may occur in some of the ghost cells, initially as fine powdery or coarse basophilic granules and later as spherical bodies.

            The COC is treated by surgical enucleation. If associated with an odontogenic tumour, a wider excision is required.

Nasopalatine duct (incisive canal) cyst

            Derived from embryonic epithelial residues in the nasopalatine canal or from epithelium included in the lines of fusion of facial processes, it occurs within the nasopalatine canal or in the soft tissues of the palate.

            This is the most common of the non-odontogenic cysts. Majority occurs in 4th, 5th and 6th decades. The most common symptom is swelling, usually in the anterior region of the midline of the palate. Swelling may also occur in the midline on the labial aspect of alveolar ridge. There may be a bulge on the floor of the nose. There may be pain and /or discharge. Salty taste and displacement of teeth may be other features.

            It may be difficult to determine Radiographically whether a radiolucency in the area is a cyst or a large incisive fossa. Any radiograph of the fossa which shows a shadow less than 6 mm wide can be considered to be within normal limits. Incisive canal cysts are found in the midline of the palate, above or between the roots of the central incisor teeth. They are round, ovoid or sometimes heart-shaped. The margins are well-demarcated.

            The incisive canal cyst is treated by surgical enucleation.

Median palatine and median alveolar cysts

            In recent years, the existence of these cysts as separate entities have been questioned and they have subsequently been excluded from the WHO classification (1992). Previously it was thought that these cysts developed from epithelium entrapped in the process of fusion of embryonic processes. It is now felt that they represent posterior extension of an incisive canal cyst in the case of a median palatal cyst, and anterior extension in case of median alveolar cyst. The so-called median alveolar cyst may also, in a number of instances, be a keratocyst derived from dental lamina in the midline of the maxilla.

Median mandibular cyst

            A cyst occasionally occurs in the midline of the mandible. It produces a well-defined round, ovoid or irregular radiolucent area and may separate the roots of the lower teeth. The presence of such a cyst associated with vital teeth tempted some to propose its origin from epithelial inclusions trapped in the area during embryonic development. The concept is not tenable as the as the mandible forms in the mandibular process which develops as a single unit. Most of the cysts considered to be median mandibular cysts are of radicular, lateral periodontal , intra-osseous dermoid or keratocyst variety.

Globulomaxillary cyst

            This has been traditionally described as a fissural cyst found within the  bone between upper lateral incisor and canine. It causes the roots of these teeth to diverge. There is now considerable opinion against the theory that it is a fissural cyst.

            A wide variety of lesions presenting clinically and radiographically as globulomaxillary cyst have been found to be OKCs, adenoameloblastoma, myxoma and heamorrhagic bone cyst.

Nasolabial (nasoalveolar) cyst

            The nasolabial cyst occurs outside the bone in the nasolabial folds below the alae nasi. These are very rare lesions with a wide age distribution (peak in 40-60 years age group) and a predilection to occur in females (75-80%).

            Clinically, a swelling in the nasolabial fold is the most common complaint. Some patients complain of pain and difficulty in nasal breathing. The cyst grows slowly.

            Radiographically, there may be a localised increased radiolucency of the alveolar process which results from a depression on the labial surface of the maxilla.

            The pathogenesis of nasolabial cyst is unresolved, though it is generally agreed to be of developmental origin.

            Histologically, it is lined by non-ciliated pseudo-stratified columnar epithelium and has collaginous or loose connective tissue walls.

Radicular (periapical) and residual cysts

            A radicular cyst is one which arises from the epithelial remnants in the periodontal ligament as a result of inflammation. The inflammation usually follows the death of the dental pulp and the cysts arising in this way are found most commonly at the apices of involved teeth.

Clinical presentation

            The radicular cyst is the most common type among jaw cysts. They occur in all tooth-bearing areas, but more commonly they seem to occur in maxillary anterior region. Many radicular cysts are symptomless but slowly enlarging swellings are often complained of. At first, the swelling is bony-hard but as it becomes bigger, sponginess and fluctuence are elicited. In the maxilla, the swelling may be buccal/labial. Pain and infection are other likely features. A non-vital tooth is a central finding. In the case of residual cysts, a history of extracted tooth.

Radiographic features

            Radiologically, it is difficult to differentiate between radicular cysts and periapical granulomas. But when the lesion is 2 mm in diameter or larger, the diagnosis of a cyst may be made.

Pathogenesis

            The pathogenesis of radicular cysts may be considered in three phases

a)       phase of initiation – inflammatory infiltrate from non-vital cause proliferation of epithelial cells.

b)      phase of cyst formation – a cyst cavity is formed within the proliferating epithelial mass by degeneration and death of cells in the centre.

c)       phase of enlargement – osmolarity difference between the cystic fluid and serum plays a part in the enlargement of the cyst.

Pathology

            Radicular cysts are lined by stratified squamous epithelium. Inflammatory infiltrate is a common finding. Hyaline bodies and secretory cells are also frequently found.

Treatment

            Radicular cysts are treated by enucleation with extraction or root-filling of associated teeth. An intact lining may not be obtained because of infection.

Solitary bone cyst

            This lesion, which occurs in mandible and very seldom in maxilla, is very rare and it occurs in young individuals (peak frequency in second decade).

            Swelling, pain and labial paresthesia are the presenting symptoms but in most cases, there will not be any symptoms. More than half of the patients have given a history of trauma to the region.

            Radiographically, the cyst appears as a radiolucent area with an irregular but definite edge, and slight cortication. Marginal condensation and scalloping also may be seen.

            Pathogenesis of the solitary bone cyst is not known, though general agreement is of a traumatic aetiology. This states that (Olech, Sicher and Weinmann) following trauma to a bone, which causes intramedullary haemorrhage, a failure of early organisation of the haematoma in marrow spaces and subsequent liquefaction of the clot, lead to the formation of traumatic bone cyst.

            When the cyst cavity is opened at operation, they are frequently found to be empty. The cyst consists of a loose vascular fibrous tissue membrane. Adjacent bone may show osteoclastic resorption.

Aneurysmal bone cyst

            This is an uncommon lesion occurring in the first three decades of life. More cases are seen in the mandible than in the maxilla.

            Clinically, the aneurysmal bone cyst produces a firm swelling which is painful in some of the cases. Sometimes the swelling and malocclusion becomes progressively worse. This cyst produces a radiolucent area which produces an ovoid of fusiform expansion of bone. Some are multilocular or honeycomb-like.

            When the covering bone is removed, the bleeding may be profuse.

            It is generally agreed that the treatment is curettage. Usually there is no communication with any large vessels.

Management of cysts

            Some small radicular cysts regress if the necrotic pulp remnants and/or bacteria are removed from the root canal of the causative tooth and the canal effectively filled. This approach should be used only in small lesions with discretion and has to be monitored by careful follow-up.

 Surgical treatment should be based on conservation of dental and osseous structures as far as possible. Wherever possible, the functional teeth should be preserved. This will require careful assessment of all teeth related to the cyst. Pulpless teeth should be root-filled within 24 hours prior to the operation.

Regardless of aetiology, nature or location of the cyst, two methods of treatment are generally accepted. They are

  1. enucleation of the cyst sac and
  2. marsupialisation (Partsch operation).

Marsupialisation

            The name of Partsch (1892) is normally associated with this operation although he also described enucleation. Very large cysts may be treated by making an opening into the cyst as large as is practical and packing the cavity. This ensures complete drainage and decompression.

Advantages

a)                   Technically simple

b)                  Local anaesthesia is enough even for large cysts since anaesthesia for deeper tissues is not necessary.

c)                   Associated vital structures are not damaged.

d)                  Tooth in a dentigerous cyst may be conserved and its eruption permitted.

e)                   Since the pack may act as a splint, it may be a favourable procedure in case of pathologic fractures.

Disadvantages

a)       The need for regular post-operative care.

b)      Long duration of treatment.

c)       Pathologic tissue is left behind, which may result in unfavourable complications.

d)      Normal contour may not be achieved leading to a depression which is not self-cleansing. This may lead to recurrence.

Procedure

            A U-shaped incision outlines the area which is slightly larger than the eventual bony opening. This will leave a narrow rim of oral mucosa which can roll over the edge of the bone to become united to the cut edge of the cyst lining. Elevation of the mucoperiosteal flap starts on intact bone. In case of perforation, periosteum should be carefully dissected off the cyst lining without damaging it. A cross incision is made in the lining to expose the cyst lumen and cystic contents are evacuated. The cavity is flushed gently with saline.

            The flap is now turned into the cavity and is sutured to the cyst lining along the bony margin. The excess flap and cyst lining are trimmed away. The cavity is flushed again with sterile saline and is packed with iodoform or tincture benzoate pack. Whitehead varnish pack may also be used.

            After completely flushing the gauze with the chemical (iodoform etc.), excess fluid is squeezed out. The pack is then unrolled and carefully placed into the cavity with two pairs of forceps. The gauze strip is first laid along the floor of the cavity and the remainder is inserted systematically in layers running from side to side. This pack is left in place for 7- 14 days. By this time, the junction between the lining and mucosal flap will be healed and an acrylic plug can be fabricated.

            This plug maintains the patency of the opening and prevents the foods particles from entering the cavity. If the patient is denture wearing, this plug can be attached to the denture. The plug should be stable, adequately retained and large enough to prevent accidental swallowing.

            After this, daily irrigation should be done for a prolonged period.

            Waldron (1941) recommended enucleation of cystic lining after the cavity is partially filled following marsupialisation. That is when considerable thickness of bone is formed or when the cyst becomes relatively smaller and there is no danger of damaging important structures or rendering the jaw weaker by enucleation. This will reduce the healing time and help to avoid the chance of residual defect.

Enucleation

            This is the most rational and most popular method employed for the treatment of cysts. After removal of the cyst lining and primary closure, the bony cavity fills with blood clot, which eventually organises to form normal bone.

Advantages

a)       Whole lining is removed and comprehensive histopathologic examination is possible.

b)      Less chance of occurrences of residual deformity.

c)       Lessens patient’s discomfort (of using a plug).

d)      Less overall treatment time

e)       No need of frequent follow-ups and irrigation.

f)       Less chances of future complications like malignant transformation.

Procedure

            Enucleation can be done under general or local anaesthesia. In any case, before the incision is demarcated, the area should be infiltrated with a local anaesthetic solution with a vasoconstrictor. This helps in easy separation of cystic lining from the periosteum. Whenever possible, a buccal or labial approach is preferable because of superior visibility and accessibility. However, a cyst causing palatal expansion alone should be approached through this direction the associated pulpless teeth should be extracted or root-filled.

            A wide mucoperiosteal flap with margins on intact bone should be reflected. If the bone is intact, a window cut is made with chisel or bur without perforating the cystic wall. If the bone is thin, it can be peeled off with a periosteal elevator. Further clearance is done using bone roungers till adequate access is obtained.

            The cyst lining is gently separated from the cavity with the broad end of periosteal elevator. Depending upon the size of the cyst and its position, other instruments such as spoon escavator and Mitchell’s trimmer can be used. Edge of the instrument is applied on cavity wall with the concave surface facing the lining.

            Careful dissection should be done to separate the lining from the structures like periosteum, nasal cavity wall, maxillary sinus, neurovascular bundles etc. Undue pressure should not be used while doing this.

            After removing the cyst lining, the cavity is irrigated and well debrided and inspected for any remnants of cyst lining. Hemostasis should be achieved before closing. In large cysts, immediate control of bleeding may not be enough and further oozing is managed by placing a gauze pack in the cavity till complete hemostasis occurs. This pack is removed after 24 hours.

            An alternate way is to pack the cavity loosely with iodoform gauze and to keep the pack for 7-10 days. A low-pressure suction drainage system may be used.

Voorsmit, Stoelinga and van Haelst (1981) advised devitalising any fragments of lining left in the cavity after enucleation, either by swabbing the cavity with Carnoy’s solution or by freezing the bony wall. Carnoy’s solution is a powerful histological fixative made by mixing chloroform (3 parts), absolute alcohol (6 parts) and glacial acetic acid (1 part).

An approach that recently has gained popularity in the management of keratocysts is a combination of methods. The first step is to decompress the cyst. A plastic (or other suitable material) drain is secured in place to ensure that the opening remains patent. After 6 to 8 weeks, the lining of the cyst becomes generally thick and tough. The second step is to carefully enucleate the cyst. At this time, the thickened cyst wall is much more easily removed than is the usual OKC. The next step is to perform a peripheral ostectomy with a large bone bur. A margin of 2 to 3 mm is taken, depending on adjacent vital structures involved. The final step is to treat the residual bone bed with chemical cautery (Carnoy’s solution). This systematically thorough method, although time consuming and demanding much patient co-operation, has achieved good results.

To obliterate the cavity after cyst enucleation, various filling materials have been recommended for packing into the defect prior to closure of the wound. Primarily, these are forms of haemostatic resorbable sponge, some of which may be soaked in a solution containing an antibiotic or thrombin. These materials are inserted to prevent excessive bleeding and to form a scaffold into which granulation tissue can migrate.

It is now recognised that grafting with autogenous cancellous bone can be performed successfully within oral wounds. In case of large defects, when pathologic fractures are possible or there would be considerable loss of contour in a future denture-bearing area, this procedure can be used to obliterate the cavity and stimulate osteogenesis. Should grafting be indicated, autogenous bone provides the best results if a second wound is not a major consideration (Boyne-1970; Flint-1964; Mowlem-1944; Scott, Peterson and Grant-1949).

A risk of bone grafting cyst cavities is the possibility of bone fragments becoming infected if wound breakdown occurs. The risk of failure in these cases is greater than when grafts are introduced after resection of a segment of mandible, because of the greater difficulty in ensuring watertight wound closure.

Enucleation and package

This is an improvised method devised to combine the advantages of the two main techniques, but in fact it combines the disadvantages of both enucleation and marsupialisation, yet the advantages of primary closure are not achieved.

Treatment of large maxillary cysts

            Marsupialisation and complete removal of cyst lining and opening the cystic cavity into nose, was described by Seward (1969). It is done through an intra-oral incision on either buccal/labial or palatal aspect. After reflecting the flap, the cyst lining is carefully detached from maxillary sinus and from the floor of the orbit. Care should be taken not to damage the floor of the orbit and infra-orbital nerve.

            Along with the cyst lining, the whole adjacent antral mucosa is removed. The cavity is packed with iodoform gauze. An intranasal antrostomy is done just below the anterior part of inferior turbinate. The end of the pack or a drainage tube can be drawn through this and pasted over skin. The intraoral flap is sutured by interrupted mattress suture. The drain or gauze can be removed after 24 hours.

Post-operative care

            All the patients treated for cysts should be observed post-operatively for a long time to make sure proper healing occurs. This includes clinical examination, and radiographic examination at regular intervals. The vitality of the retained teeth should be checked during recall visits. If vitality is not regained, adequate treatment should be given.

    Conclusion

Cystic lesions are very common in jawbones and it includes those of both odontogenic and non-odontogenic origin. Odontogenic cysts are unique to the jawbones, and it often results in considerable destruction of these bones. The diagnosis of these lesions is often delayed because of their innocent presentation. By the time of diagnosis, most of the cyst will be enlarged considerably weakening the bones. This leads to various sequelae such as fractures. Other complications eventhough rare such as malignant transformation of cystic lining is of considerable importance of various surgical modalities available, enucleation with primary closure should be treatment of choice wherever possible because of the least unfavourable sequelae.

    References

  1. H.C. Killey & Kay
  2. H.C. Killey, G. R. Seward & L. W. Kay (1992), An outline of oral surgery –Part II.
  3. Geoffrey L. Howe, Textbook of minor oral surgery.
  4. Moore (1985), Surgery of the mouth and jaws.
  5. Gustav O. Kruger (1990), Textbook of oral and maxillofacial surgery.
  6. R. B. Lucas (1984), Pathology of tumours of the oral tissues.
  7. Leon A Assael. Surgical management of odontogenic cysts and tumours. In Principles of Oral and Maxillofacial Surgery Vol. II. (eds) Peterson, Marciani, Indresano. 1997.

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