Comparing Treatment Effectiveness and Patient-Reported Outcome Measures of Four Treatment Options for Obstructive Sleep Apnea.

BACKGROUND: Continuous positive airway pressure (CPAP), mandibular advancement device (MAD), upper airway stimulation (UAS), and maxillomandibular advancement (MMA) are techniques to reduce apnea hypopnea index (AHI) in obstructive sleep apnea (OSA) patients. Current literature does not include a direct comparison of the 4 methods. PURPOSE: The purpose of this study is to measure and compare the efficacy of 4 common OSA treatments: CPAP, MAD, UAS, MMA. STUDY DESIGN, SETTING, SAMPLE: This retrospective cohort study examines data from 119 patients treated at Thomas Jefferson University Hospital in Philadelphia receiving CPAP, MAD, UAS, or MMA between January 2018 and December 2020. Patients were excluded for significant medical comorbidities, body mass index ≥45, cognitive limitations, central/mixed apnea history, or pregnancy. PREDICTOR VARIABLES: The primary predictor variable was type of OSA intervention: CPAP, MAD, UAS, MMA. Treatments were assigned by treating physicians per their presenting OSA severity. MAIN OUTCOME VARIABLES: The primary outcome variable was efficacy defined as the therapeutic response to treatment measured using mean disease alleviation, a calculated variable (percentage) which employs post-treatment AHI adjusted by compliance (a measure of a patient's device use). Secondary therapeutic measures included remaining AHI and patient-reported outcome measures: Epworth Sleepiness Scale, Sleep Apnea Quality of Life Index, Patient-reported Apnea Questionnaire. COVARIATES: Demographic covariates included age, sex, height, weight, socioeconomic status, level of education, neck size, race, and body mass index. Clinical covariates included pretreatment AHI, AHI change, O2 nadir, adjusted compliance, and compliance. ANALYSES: Multivariate statistics were computed with alpha level of 0.05, including a regression with the primary outcome variables, treatment variables, and potential covariates. RESULTS: The sample included 119 subjects (mean age = 56.12, standard deviation [SD] = 5.81) with males at n = 72 (60%). MMA demonstrated greatest mean disease alleviation (M = 36.08, SD = 28.56), compared to UAS (M = 22.88, SD = 3.16), MAD (M = 6.80, SD = 8.13), and CPAP (M = 5.00, SD = 14.80), analysis of variance: P < .001. CONCLUSION AND RELEVANCE: Both surgical treatments displayed significantly greater effectiveness than CPAP and MAD, suggesting that offering surgical alternatives sooner, particularly to those with severe OSA, may be logical in formulating more effective treatment guidelines.

Special considerations for clinical trials in fibrodysplasia ossificans progressiva (FOP).

Clinical trials for orphan diseases are critical for developing effective therapies. One such condition, fibrodysplasia ossificans progressiva (FOP; MIM#135100), is characterized by progressive heterotopic ossification (HO) that leads to severe disability. Individuals with FOP are extremely sensitive to even minor traumatic events. There has been substantial recent interest in clinical trials for novel and urgently-needed treatments for FOP. The International Clinical Council on FOP (ICC) was established in 2016 to provide consolidated and coordinated advice on the best practices for clinical care and clinical research for individuals who suffer from FOP. The Clinical Trials Committee of the ICC developed a focused list of key considerations that encompass the specific and unique needs of the FOP community - considerations that are endorsed by the entire ICC. These considerations complement established protocols for developing and executing robust clinical trials by providing a foundation for helping to ensure the safety of subjects with FOP in clinical research trials.

Facial dysmorphology and odontogenic tumor development associated with inborn errors of metabolism: a case report.

PURPOSE: Inborn errors of metabolism (IEMs) are genetic disorders that alter normal physiologic functioning. Deficiency of 3-methylcrotonyl-coenzyme A carboxylase is one such IEM that can lead to major episodes of metabolic dysfunction. Certain IEMs are associated with characteristic congenital dysmorphic facial features. This can be problematic, because these dysmorphisms can mask underlying tumor growth. Literature is lacking on a causal relation between IEM and odontogenic tumor development. MATERIALS AND METHODS: This case was explained in detail and a review of the literature was undertaken. PubMed was used to search for articles involving surgical management of odontogenic myxoma (OM) and associations between odontogenic tumors and IEM. RESULTS: It was determined that the development of odontogenic tumors, specifically OM, is associated with IEMs. These tumors can easily be overlooked as a common dysmorphic feature of an IEM. CONCLUSION: IEMs lead to major metabolic disturbances and, thus, can alter the cellular microenvironment. Hypothetically, these alterations can lead to the development of odontogenic tumors. With the diagnosis of IEM becoming more common owing to improved newborn screening, careful attention should be given to these patients because of the possibility that dysmorphologic facial features could be masking underlying tumor growth.

Gene Therapy for Fibrodysplasia Ossificans Progressiva: Feasibility and Obstacles.

Fibrodysplasia ossificans progressiva (FOP) is a rare and devastating genetic disease, in which soft connective tissue is converted into heterotopic bone through an endochondral ossification process. Patients succumb early as they gradually become trapped in a second skeleton of heterotopic bone. Although the underlying genetic defect is long known, the inherent complexity of the disease has hindered the discovery of effective preventions and treatments. New developments in the gene therapy field have motivated its consideration as an attractive therapeutic option for FOP. However, the immune system's role in FOP activation and the as-yet unknown primary causative cell, are crucial issues which must be taken into account in the therapy design. While gene therapy offers a potential therapeutic solution, more knowledge about FOP is needed to enable its optimal and safe application.

Orbital hemorrhage and compressive optic neuropathy in patients with midfacial fractures receiving low-molecular weight heparin therapy.

While the implementation of deep vein thrombosis (DVT) prophylaxis in the hospital setting is a major concern, the use of antithrombotic agents is fraught with a variety of hemorrhagic complications. Due to increasing reports of adverse reactions to unfractionated heparin (UFH), several manufacturers have initiated product recalls. As a result, the use of low-molecular weight heparins (LMWHs) such as enoxaparin has risen substantially. In this paper, 2 orbital hemorrhagic complications in patients receiving enoxaparin therapy will be presented. The incidence of DVT in the OMS patient, recent prophylactic strategies, and their effectiveness will be reviewed.

Ophthalmic injuries in patients with zygomaticomaxillary complex fractures requiring surgical repair.

PURPOSE: Injuries to the middle third of the face commonly destroy the integrity of the orbital skeleton, and are frequently complicated by injury to the eye, ranging between 2.7% and 90.6% in reported series. This article is a retrospecitve, descriptive case study assessing the spectrum and incidence of ophthalmic involvement in patients presenting with zygomaticomaxillary complex (ZMC) fractures. PATIENTS AND METHODS: Ninety-six patients with ZMC fractures who were surgically treated in 1 academic institution between 1996 and 2006 were assessed pre- and postoperatively by the same oculoplastic surgeon and were included in the study. All patients had a thorough ophthalmologic examination that included assessment of visual acuity, pupillary reactivity, anterior and posterior segment examination, and extraocular motility. In cases of optic neuropathy, automated perimetry was also performed. The variables reviewed included patients' age, gender, mechanism of injury, visual acuity, pupillary reactivity, extraocular motility, presence or absence of diplopia, ocular and orbital findings, and intraorbital hypoesthesia. RESULTS: Gender distribution of the patients was 88% male, with a mean age of 36 years. The most common etiology of trauma was assult (56%), followed by falls (21%). Most patients (66.6%) sustained minor ocular injuries such as subconjuctival hemorrhage, iris sphincter tear, and corneal abrasion. Subconjunctival hemorrhage was the most common minor injury, accounting for 55% of the cases. Major injuries such as ruptured globe and retinal hemorrhage occurred in 10% of the patients. Orbital findings such as restriction of extraocular movement occurred in 15% of cases. Symptomatic diplopia was noted in 16% of the patients and traumatic optic neuropathy occurred in 6%. Diplopia significantly improved in the first 3 postoperative months, dropping from a preoperative incidence of 16% to 2%. CONCLUSION: Comminuted ZMC fractures had been reported to be associated with a signficantly higher incidence of visual sequelae than other forms of midfacial injury. A 10% incidence of major or blinding injuries and a 6% incidence of traumatic optic neuropathy are significant, and warrants a prompt ophthalmologic examination of all patients with ZMC fractures as quickly as possible, and always preoperatively in injuries necessitating surgical repair.

Evaluating a dental practice for purchase or associateship.

Private dental practice can be achieved through either outright ownership or an associateship in conjunction with senior dentists; the decision depends on personal and professional objectives and goals. Once a decision is made, the time and effort required to identify an appropriate practice, negotiate the terms of purchase or associateship, and transition to the new practice can be daunting. This article reviews the process and provides an overview of the general steps involved in the evaluation of a dental practice for purchase or associateship. With appropriate knowledge and preparation, due diligence, and ethical and sensitive behavior, transitioning to private practice can be successful and lead to professional and personal fulfillment.

Oral management in a patient with fibrodysplasia ossificans progressiva.

Fibrodysplasia ossificans progressiva (FOP) is an autosomal dominant disorder of connective tissue. FOP results in debilitating heterotopic ossification of the axial and appendicular skeleton. Permanent ankylosis of the temporomandibular joint (TMJ) is a common late finding, but is usually preceded by specific inciting trauma. Extreme care must be exercised when carrying out routine dental care to prevent soft tissue trauma. Oral health care for patients with FOP is usually complex. There are additional considerations when oral surgical procedures, such as extractions, are needed. Maintaining a balance between oral health and disease progression in these patients is challenging, as they frequently present with advanced oral disease. Fiber optic-assisted placement of the nasoendotracheal tube is the standard of care. Intramuscular injections including mandibular blocks must be avoided. Permanent fusion of the TMJ leads to malnutrition, inanition, and aspiration of food. In patients with complete TMJ ankylosis, dental extractions can be safely and effectively performed while accessing teeth from the buccal aspect. This approach has successfully resulted in decreased morbidity in these patients as well as others with limited oral opening.

Trigeminal nerve injuries after mandibular implant placement--practical knowledge for clinicians.

Endosseous mandibular implant placement can result in injuries to the peripheral branches of the trigeminal nerve even with the most careful preoperative planning and intraoperative technique. In the past, many patients have been discouraged from seeking repair for such injuries because of the unreliability of the techniques for correcting the injury. It is now possible to perform microneurosurgical repair of such injuries. If the repair is done in a timely fashion, sensation can be improved or restored and painful nerve dysesthesia can be relieved. This article reviews the different types of nerve injuries, their symptoms and diagnosis, and provides information for clinicians to manage their implant patients with neurosensory disturbance.