Antiresorptive and anti-angiogenic drug therapy in the pediatric population with reference to medication-related osteonecrosis of the jaw

The objective of this study was to identify the prevalence of osteonecrosis of the jaw in a pediatric population with systemic therapeutic exposure to an antiresorptive, anti-angiogenic, and/or immunomodulating drug (ARAID), and in particular in the subgroup of patients who had undergone invasive dental treatment. This was a retrospective cohort study performed at a single center. The investigation included pediatric patients who had undergone systemic therapy with ARAIDs and who began receiving ARAID therapy at ≤16 years of age. The study included 482 patients who received ARAIDs between January 2011 and January 2021. The most common medication class was bisphosphonates (45.0%), followed by mTOR inhibitors (30.1%) and anti-angiogenics (17.8%). No diagnosis of osteonecrosis of the jaw was observed. From this population, 26 patients were noted to have undergone invasive dental treatment. The duration from treatment to the invasive procedure ranged from 0 to 5.9 years. Medication-related osteonecrosis of the jaw is extremely rare among the pediatric population - much less common when compared to the adult population. Prospective cohort studies and continued evaluation will help determine the incidence and prevalence of medication-related osteonecrosis of the jaw in pediatric patients.

What Is the Incidence of Anesthesia-Related Adverse Events in Oral and Maxillofacial Surgery Offices? A Review of 61,237 Sedation Cases From a Large Private Practice Consortium

BACKGROUND

The safety of the anesthesia team model performed in oral and maxillofacial surgery (OMS) offices has been criticized by professional and mainstream media.

PURPOSE

This study aims to assess the incidence of adverse events (AEs) associated with the OMS anesthesia team model and identify risk factors associated with AEs.

STUDY DESIGN, SETTING, SAMPLE

This was a retrospective cohort study utilizing a patient database from Paradigm Oral Health, Lincoln, Nebraska, a managed service organization (MSO). Subjects included were 14 and older, undergoing open-airway intravenous anesthesia for ambulatory OMS procedures using the OMS anesthesia team model at multiple private practices in the MSO network between June 30, 2010, and September 30, 2022. Exclusion criteria included patients younger than 14 or patients with incomplete medical records.

PREDICTOR VARIABLE

Primary predictor variables were age, sex, American Society of Anesthesiologists physical status classification system (ASA) score, type of surgical procedure performed, and the types of medications administered during sedation.

MAIN OUTCOME VARIABLE(S)

The presence of an AE. The definition of an AE was modeled on the World Society of Intravenous Anesthesia definition. All AEs were identified through surrogate markers, which were identified through chart review. One example of an AE is ventricular fibrillation, which necessitates the application of medications; here the medication is the surrogate marker.

COVARIATES

None.

ANALYSES

The data were analyzed using t-tests and χ2 tests. P values ≤ .05 were considered statistically significant.

RESULTS

Included in the study were 61,237 sedation cases (53.87% female and 46.13% male), for 56,076 unique patients ranging from 14 to 98 years of age (mean 33.26 ± 18.35). An AE incidence of 3 per 100,000 per year (25 total events) was observed. Neither age, sex, ASA score, nor type of surgical procedure exhibited statistically significant associations with AEs. A statistically significant association was found between AEs and fentanyl (P = .0008).

CONCLUSION AND RELEVANCE

This investigation shows a smaller incidence of AEs than previous studies of the OMS anesthesia team model.

Do Patients With Mental Illness Undergoing Office-Based Sedation Require an Increased Propofol Dosage?

BACKGROUND

Providers report needing higher sedative doses to achieve adequate sedation in patients with mental illnesses. These claims, however, have not been thoroughly assessed.

PURPOSE

The purpose of the study was to measure the association between mental illness and the propofol dosage necessary to achieve a satisfactory level of anesthesia.

STUDY DESIGN, SETTING, SAMPLE

The study consisted of a single-center, retrospective cohort consisting of patients treated by oral and maxillofacial surgery at the University of Cincinnati Medical Center in 2020. The study was comprised of subjects 15 or older who were American Society of Anesthesiologists (ASA) classification I or II. Subjects under 15 or ASA III or higher were excluded from the study.

PREDICTOR VARIABLE

The predictor variable was the presence or absence of mental illness.

MAIN OUTCOME VARIABLE(S)

The primary outcome was the total dose of propofol, measured as the total amount of propofol administered divided by the patient's weight in kilograms divided by the length of the procedure in minutes (mg/kg/min). The secondary outcome was the Richmond Agitation-Sedation Scale (RASS) score achieved during sedation.

COVARIATES

Sex, race, ethnicity, age, weight, body mass index, ASA score, prior tobacco use, marijuana use, use of adjunct midazolam, fentanyl, and ketamine during the procedure, and type of procedure served as covariates.

ANALYSES

Test statistics were calculated using the Wilcoxon rank-sum test, Kruskal-Wallis test, Spearman rank correlation test, and χ2 test for bivariate analyses. Linear and logistic regression models were used to estimate association while controlling for confounding. P values ≤ .05 were considered statistically significant.

RESULTS

The study sample was 409 subjects (36.92% male, mean age 28.27 ± 12.20 years). In bivariate analysis, mental illness did not show any association with propofol dose (mean dose with mental illness 150.85 ± 143.97 mg/kg/min, mean dose without mental illness 116.54 ± 104.16, P = .08) or RASS score (sufficiently sedated with mental illness 63.38%, sufficiently sedated without mental illness 58.80%, P = .36). After adjusting for all previously mentioned covariates, mental illness was statistically associated with propofol dose (P < .01). Adjusting for covariates, only sex had a statistically significant association with the RASS score (P < .05).

CONCLUSION AND RELEVANCE

The findings suggest that a patient's mental illness may influence the amount of sedative required to achieve satisfactory anesthesia.

Facial Appearance as Core Expression Scale: Benchmarks and Properties

Objective

Patients presenting for corrective facial surgery may have ideals that are not congruent with their surgeon's expectations for surgical outcomes. To identify and reduce disparities in expectations, the Facial Appearance as Core Expression Scale (FACES) was developed to assess the extent to which individuals identify their own faces as representing their ideal self.

Method

In Study 1, 504 healthy young adult participants answered online questions about their own faces. In Study 2, 165 participants rated their own faces, digitally manipulated images of four patients before and after surgery, and two digitally averaged benchmark images.

Results

In Study 1, the final FACES instrument had seven items and was highly reliable across genders and races. Study 2 replicated reliability findings. The before surgery and after surgery pictures yielded significant improvements in ratings, suggesting scale validity.

Conclusions

The FACES consists of 14 items including a benchmark image to detect unusual responding. Results indicate the measure is reliable and sensitive to perceptions of surgical changes to faces. While the scale needs to be validated in a clinical sample, the measure may help identify patients with atypical ideal expectations for their face and may be used to quantify surgical outcomes.

Proceedings of the Third American Association of Oral and Maxillofacial Surgeons Anesthesia Patient Safety Conference

The 3rd Anesthesia Patient Safety Conference of the American Association of Oral and Maxillofacial Surgeons was held at the Daniel M Laskin Institute for Oral and Maxillofacial Surgery Education and Innovation at American Association of Oral and Maxillofacial Surgeons headquarters in Rosemont, Illinois on June 6, 2022. The conference provided a platform to scrutinize collective errors, explore optimal practices, comprehend the concepts and principles of human complacency, assessing the system's capacity to handle deviations from the norm, and contemplate ideas and initiatives to enhance our practice model. These safety conferences are designed to foster collaborative, proactive conversations and understand best practices in safe delivery of anesthetic care to our patients.

Iontophoresis on Porcine and Human Gingiva

PURPOSE

Iontophoresis is a noninvasive method that enhances drug delivery using an electric field. This method can improve drug delivery to the tissues in the oral cavity. The effects of iontophoresis on gingival drug delivery have not been investigated. The objectives of this study were to (a) determine the flux enhancement of model permeants across porcine and human gingiva during iontophoresis, (b) examine the transport mechanisms of gingival iontophoresis, and (c) evaluate the potential of iontophoretically enhanced delivery for three model drugs lidocaine, ketorolac, and chlorhexidine.

METHODS

Passive and iontophoretic fluxes were determined with porcine and human gingiva using a modified Franz diffusion cell and model drugs and permeants. To investigate the transport mechanisms of iontophoresis, the enhancement from the direct-field effect was determined by positively and negatively charged model permeants. The electroosmosis enhancement effect was determined with neutral permeants of different molecular weight. The alteration of the gingival barrier due to electropermeabilization was evaluated using electrical resistance measurements.

RESULTS

Significant flux enhancement was observed during gingival iontophoresis. The direct-field effect was the major mechanism governing the iontophoretic transport of the charged permeants. Electroosmosis was from anode to cathode. The effective pore radius of the iontophoretic transport pathways in the porcine gingiva was ~0.68 nm. Irreversible electropermeabilization was observed after 2 and 4 h of iontophoresis under the conditions studied.

CONCLUSION

Iontophoresis could enhance drug delivery and reduce transport lag time, showing promise for gingival drug delivery.

Permeability of Fresh and Frozen Porcine and Human Gingiva and the Effect of Storage Duration

The gingiva is the target site for some topical drugs, but the permeability of human gingiva has not been systematically evaluated. Pigs are a common animal model for in vitro membrane transport studies. The objectives of this study were to: (a) determine the permeability coefficients of freshly excised human gingiva using model permeants, (b) compare the permeability coefficients of fresh human gingiva with those of fresh porcine gingiva, (c) evaluate the effect of freezing duration on the permeability of porcine gingiva, and (d) compare the permeability coefficients of fresh and cadaver (frozen) human gingiva. A goal was to examine the feasibility of using porcine gingiva as a surrogate for human gingiva. The potential of using frozen tissues in permeability studies of gingiva was also examined. Fresh and frozen porcine gingiva, fresh human gingiva, and frozen cadaver human gingiva were compared in the transport study with model polar and lipophilic permeants. The fresh porcine and human tissues showed similarities in the "permeability coefficient vs. octanol-water distribution coefficient" relationship. The porcine gingiva had a lower permeability than that of the human, with a moderate correlation between the permeability of the fresh porcine and fresh human tissues. The permeability of the porcine tissues for the model polar permeants increased significantly after the tissues were frozen in storage. Moreover, the frozen human cadaver tissue could not be utilized due to the high and indiscriminating permeability of the tissue for the permeants and large tissue sample-to-sample variabilities.

Multiorganizational consensus to define guiding principles for perioperative pain management in patients with chronic pain, preoperative opioid tolerance, or substance use disorder

Significant knowledge gaps exist in the perioperative pain management of patients with a history of chronic pain, substance use disorder, and/or opioid tolerance as highlighted in the US Health and Human Services Pain Management Best Practices Inter-Agency Task Force 2019 report. The report emphasized the challenges of caring for these populations and the need for multidisciplinary care and a comprehensive approach. Such care requires stakeholder alignment across multiple specialties and care settings. With the intention of codifying this alignment into a reliable and efficient processes, a consortium of 15 professional healthcare societies was convened in a year-long modified Delphi consensus process and summit. This process produced seven guiding principles for the perioperative care of patients with chronic pain, substance use disorder, and/or preoperative opioid tolerance. These principles provide a framework and direction for future improvement in the optimization and care of 'complex' patients as they undergo surgical procedures.

Artificial Intelligence in Oral and Maxillofacial Surgery Education

Artificial intelligence has become ubiquitous with modern technology. Digital transformations are occurring in every field including medicine, surgery, and education. Computers and computer programs are getting sophisticated to form neural networks globally. These algorithms allow for sophisticated and complex pattern recognitions and make accurate predictions. This allows for both accurate diagnosis and prognostication in medicine and opens opportunities for medical and surgical education. Oral and Maxillofacial surgeons and OMS education like all of the surgery are adapting well to the world of AI, incorporating machine learning into simulation, and attaching sensors to master surgeons to understand motion economy.

Influence of Residency Training Program on Pursuit of Academic Career and Academic Productivity Among Oral and Maxillofacial Surgeons

PURPOSE

The purpose of the study was to examine the impact of residency training institutions on the pursuit of a career in academic oral and maxillofacial surgery and assess variables associated with academic productivity.

MATERIALS AND METHODS

This was a cross-sectional study of full-time academic oral and maxillofacial surgeons (OMSs) in the United States. The primary predictor variable was program of residency training. Secondary predictors included gender, fellowship training, advanced degrees, and private practice affiliation. The primary outcome variable was the number of graduates in a ful-time academic position. Academic productivity (h-index, publication number) was a secondary outcome. Descriptive, logistic and linear regression analyses were computed.

RESULTS

The study sample consisted of 294 full-time academic OMSs in 82 training programs. The top 10 high-output residency programs were identified and graduates from these programs were more likely to have a medical degree (OR = 1.99, 9% CI: 1.17 - 3.36, p=0.0108), higher h-indices (11.03 vs 7.96, p = 0.0032) and higher number of publications (40.3 vs 25.6, p = 0.003). Faculty characteristics associated with higher h-indices included a medical degree (10.33 vs 7.66, p = 0.0067), PhD (15.23 vs 8.38, p = 0.0002), MPH (17.47 vs 8.66, p = 0.0040) and fellowship training (11.15 vs 7.76, p = 0.0012). There were no significant differences between genders in having a medical degree, completing a subspecialty fellowship, or academic productivity. Female surgeons represented 16.33% of academic OMSs and were more likely to have entered academia more recently based on duration in years of academic appointment (12.48 versus 21.08; p < 0.001).

CONCLUSIONS

Ten programs have trained 29.6% (n = 87) of all full-time academic OMSs. These programs' graduates were more likely to have a medical degree, higher h-indices, and greater number of publications.

A multisociety organizational consensus process to define guiding principles for acute perioperative pain management

The US Health and Human Services Pain Management Best Practices Inter-Agency Task Force initiated a public-private partnership which led to the publication of its report in 2019. The report emphasized the need for individualized, multimodal, and multidisciplinary approaches to pain management that decrease the over-reliance on opioids, increase access to care, and promote widespread education on pain and substance use disorders. The Task Force specifically called on specialty organizations to work together to develop evidence-based guidelines. In response to this report's recommendations, a consortium of 14 professional healthcare societies committed to a 2-year project to advance pain management for the surgical patient and improve opioid safety. The modified Delphi process included two rounds of electronic voting and culminated in a live virtual event in February 2021, during which seven common guiding principles were established for acute perioperative pain management. These principles should help to inform local action and future development of clinical practice recommendations.

Osteoradionecrosis: Exposing the Evidence Not the Bone

Osteoradionecrosis is a relatively rare but potentially morbid and costly complication of radiation therapy for head and neck cancer. Multidisciplinary diagnosis and treatment are essential. Despite evidence guiding individual aspects of care for osteoradionecrosis, there is a lack of broad consensus on the overall diagnosis and management of this condition. This study comprehensively reviews the literature, with a focus on the past 10 years, to guide evaluation and treatment.

Considerations for Oral and Maxillofacial Surgeons in COVID-19 Era: Can We Sustain the Solutions to Keep Our Patients and Healthcare Personnel Safe?

Several uncertainties exist regarding how we will conduct our clinical, didactic, business, and social activities as the coronavirus disease 2019 (COVID-19) global pandemic abates and social distancing guidelines are relaxed. We anticipate changes in how we interact with our patients and other providers, how patient workflow is designed, the methods used to conduct our teaching sessions, and how we perform procedures in different clinical settings. The objective of the present report is to review some of the changes to consider in the clinical and academic oral and maxillofacial surgery workflow and, allow for a smoother transition, with less risk to our patients and healthcare personnel. New infection control policies should be strictly enforced and monitored in all clinical and nonclinical settings, with an overall goal to decrease the risk of exposure and transmission. Screening for COVID-19 symptoms, testing when indicated, and establishing the epidemiologic linkage will be crucial to containing and preventing new COVID-19 cases until a vaccine or an alternate solution is available. Additionally, the shortage of essential supplies such as drugs and personal protective equipment, the design and ventilation of workspaces and waiting areas, the increase in overhead costs, and the possible absence of staff, if quarantine is necessary, must be considered. This shift in our workflow and patient care paths will likely continue in the short-term at least through 2021 or the next 12 to 24 months. Thus, we must prioritize surgery, balancing patient preferences and healthcare personnel risks. We have an opportunity now to make changes and embrace telemedicine and other collaborative virtual platforms for teaching and clinical care. It is crucial that we maintain COVID-19 awareness, proper surveillance in our microenvironments, good clinical judgment, and ethical values to continue to deliver high-quality, economical, and accessible patient care.

Contemporary management of an orthodontic-orthognathic patient with limited time availability in an orthodontic office setting: Case report

INTRODUCTION

This case report describes the treatment of a 21-year-old man who presented in an orthodontic office for treatment but lived in a city 100 miles away and wanted the orthognathic surgery in another state in America. The patient presented with an anterior open bite and skeletal Class III relationship.

METHODS

The treatment plan included: (1) effective and careful communication of the treatment plan with the patient, orthodontist and oral and maxillofacial surgeon; (2) pre-surgical alignment and levelling of the teeth in both arches with Invisalign; (3) a long-distance communication between the orthodontist and the surgeon for surgical plan with virtual surgical planning (VSP Orthognathics; 3D Systems, www.3Dsystem.com) online; (4) maxillary advancement (LeFort I osteotomy) with mandibular set-back (bilateral sagittal split osteotomy); (5) postsurgical correction of the malocclusion with clear brackets and aligners; and (6) retention and final small tooth movement adjustments with aligners/clear retainers.

RESULTS

The anterior open bite was treated, crowding was eliminated in the upper and lower anterior segment, correction of skeletal and dental Class III malocclusion was obtained, mandibular plane angle was reduced and facial profile improved.

CONCLUSIONS

The results suggest that aesthetic and functional results can be achieved with long-distance communication of two specialties and with the combined use of clear aligners and clear fixed appliances.

Anesthesia for the Pediatric Oral and Maxillofacial Surgery Patient

Pediatric patients present to the oral and maxillofacial surgeon for surgical services that can be performed safely and efficiently. Children and parents tend to be anxious; achieving cooperation is paramount for successful procedures. Several techniques can be used to alleviate anxiety and provide analgesia and anesthesia. This article outlines the anatomy and physiology of children and the preoperative anesthetic preparation and techniques unique to pediatric anesthesia. It discusses standards in training in pediatric anesthesia and current recommendations for monitoring. Management of children with autism spectrum disorders and attention deficit hyperactivity disorders highlights special considerations in the management of these children.

Controversies in Dentoalveolar and Preprosthetic Surgery

Dentoalveolar surgeries are among the more common procedures performed by oral maxillofacial surgeons. It is only natural that there are several controversies associated with many aspects of this type of surgery. Although good scientific evidence is the basis of most oral maxillofacial procedures, some of what is accepted as common wisdom may not meet strict guidelines of evidence-based practice. This article explores some controversies that are relevant to the current practice of dentoalveolar surgery.

Outcomes of mandible fracture treatment at an academic tertiary hospital: a 5-year analysis

PURPOSE

To analyze the outcomes of mandible fractures treated using open reduction and internal fixation.

PATIENTS AND METHODS

We performed a retrospective chart review of the medical records from patients with mandibular fractures treated surgically during a 5-year period for demographics, systemic illness, history of substance abuse, etiology, fracture location, any associated facial injury, type and timing of repair, antibiotic treatment, and interval to repair. The development of complications such as infection, malunion or nonunion, hardware failure, and wound dehiscence were recorded.

RESULTS

Of the 560 patients, adequate data were collected for 363 patients. Of the patients, 60% were white. The male/female ratio was 7.4:1. Systemic illness was noted in 10.5% of the cohort. More than 80% of the subjects had sustained their injury because of assault. The mandible angle was the most common site of fracture (56%). Most (64%) of the patients had sustained multiple fractures. When multiple sites were involved, the angle and body were more commonly involved. The overall complication rate was 26.45%. Hardware failure (15.4%) was the most common complication, followed by infection (15.15%). The revision rate was 8.1% in this cohort. Antibiotic usage and the infection rate were not statistically associated with each other. A greater complication rate was noted among smokers (P = .0072) and patients with systemic illness (P = .0495).

CONCLUSIONS

A greater rate of hardware failure was noted in our study. The use of antibiotics did not decrease the incidence of infections. Smokers and patients with systemic medical conditions had a greater risk of complications. Finally, a slight delay in surgical repair was not related to an increased complication rate.

Depth of penetration of methylene blue in mandibular cortical bone

BACKGROUND

Surgeons treating keratinizing odontogenic tumors (KOT) and other intrabony lesions frequently use methylene blue as an adjunct in peripheral ostectomy in estimating the depth of bone that has been removed. Depth of methylene blue penetration in cortical bone has not been evaluated.

STUDY DESIGN

Specimens of mandible harvested from 9 fresh unembalmed cadaveric mandibles were stained with methylene blue. A microcaliper was used to measure total thickness of the cortical specimen along with the amount of dye penetration within the cortical block to the nearest 0.1 mm.

RESULTS

Average depth of dye penetration was 0.48 mm in the symphysis. Average dye penetration was 0.53 mm in the body. Average depth of penetration of 0.42 mm in the angle.

CONCLUSIONS

The use of methylene blue as a depth gauge to ensure adequate ostectomy with a single application of the dye may be inadequate to ensure complete removal of lesion from bony wall.