Oral Health Clearance Outcomes for Cardiovascular Surgery.

Objective: To determine the risk of morbidity and mortality in patients receiving dental extractions before planned cardiovascular surgery (CVS) and examine factors that may affect the chance of oral health clearance. Patients and Methods: A retrospective medical record review was performed of patients who underwent dental screening before CVS from January 1, 2015, to December 31, 2021, at a major medical institution. A total of 496 patients met the inclusion criteria and were divided into 2 groups. Group 1 patients were cleared to advance to planned CVS (n=390). Group 2 patients were not cleared for surgery and subsequently underwent dental extractions before planned CVS (n=106). Results: Six patients (5.7%) experienced postoperative complications after dental extraction that resulted in an emergency room visit. No deaths occurred after dental extraction before CVS. However, 4 patients died within 30 days of CVS, 3 from Group 1 (0.77%) and 1 from Group 2 (0.94%). Dental extraction before planned CVS showed a borderline significant association with death based on unadjusted (P=.06) and age-adjusted analysis (P=.05). Patients who reported seeing a dentist routinely had a significantly higher chance of oral health clearance (P <.001). No differences were noted between the 2 groups with regard to age, sex, or 30-day hospital readmission rate. Conclusion: Patients who had dental extractions completed before planned CVS may be at an increased risk of mortality. Further studies are needed to examine this relationship. Emphasis should be on prioritization of routine dental visits before planned CVS.

Safety of Outpatient Procedural Sedation Administered by Oral and Maxillofacial Surgeons: The Mayo Clinic Experience in 17,634 Sedations (2004 to 2019).

PURPOSE: The safety of the team anesthesia model routinely used by the specialty of oral and maxillofacial surgery has recently been called into question. The purpose of this article is to measure the frequency of adverse anesthetic events related to ambulatory surgical procedures performed under intravenous (IV) sedation by the Division of Oral and Maxillofacial Surgery at the Mayo Clinic during a 15-year period using the team anesthesia model. MATERIALS AND METHODS: A retrospective cohort study was designed, and a sample of subjects identified undergoing IV sedation at Mayo Clinic from 2004 to 2019. The primary outcome variable of interest was the presence of anesthetic-related adverse events (AEs) consistent with the World Society of Intravenous Anesthesia International Sedation Task Force's intervention-based definitions of adverse anesthetic events. Additional covariates included patient age, gender, American Society of Anesthesiologists (ASA) score, type of surgical procedure performed, and the type/dosage of medications administered periprocedurally. Univariate logistic regression analysis was used to assess for associations between AEs and covariates. RESULTS: The study identified 17,634 sedations administered to 16,609 unique subjects. In 17,634 sedations, 16 (0.1%) AEs and no subject deaths (0%) were identified. There were no statistically significant associations between AEs and age (hazard ratio [HR], 0.4; 95% confidence interval [95% CI], 0.2 to 1.3; P = .13); gender (HR, 0.9; 95% CI, 0.3 to 2.5; P = .87); ASA 2 classification (HR, 1.6; 95% CI, 0.6 to 4.5; P = .33); ASA 3 classification (HR, 1.3; 95% CI, 0.1 to 22.0; P = .86), or types of IV sedation medications administered during the procedure: fentanyl (HR, 0.4; 95% CI, 0.02 to 6.3; P = .5); midazolam (HR, 1.0; 95% CI, 0.2 to 4.3; P = .98); propofol (HR, 1.0; 95% CI, 0.3 to 3.5; P = .99); or ketamine (HR, 1.0; 95% CI, 0.1 to 7.3; P = .97). CONCLUSIONS: The frequency of AEs (0.1%) and 0% mortality rate reported in this study demonstrate that the anesthesia team model used by oral and maxillofacial surgeons compares favorably to standardized intervention-based adverse anesthetic event outcomes reported by other nonanesthesiology specialties routinely performing outpatient procedural sedation.

Relationship of Number of Missing Teeth to Hip Fracture in Elderly Patients: A Cohort Pilot Study.

PURPOSE: To determine the relationship between the number of missing natural teeth or remaining natural teeth and osteoporotic hip fracture in elderly patients and to determine the relationship between the number of missing teeth or remaining teeth and osteoporotic fracture risk assessment (FRAX) probability. MATERIALS AND METHODS: Number of missing teeth was determined by clinical oral exam on a total of 100 subjects, 50 with hip fractures and 50 without. Ten-year fracture risk and hip fracture risk probabilities were calculated using the FRAX tool. Statistical analyses were performed to determine strength of associations between number of missing natural teeth and likelihood of experiencing a fracture. Degree of correlation between number of missing natural teeth and FRAX probabilities were calculated. RESULTS: There appears to be an association between the number of missing natural teeth and hip fractures. For every 5-tooth increase in the number of missing teeth, the likelihood of being a subject in the hip fracture group increased by 26%. Number of missing natural teeth was positively correlated with FRAX overall fracture and hip fracture probability. CONCLUSIONS: Number of missing natural teeth may be a valuable tool to assist members of medical and dental teams in identifying patients with higher FRAX scores and higher likelihood of experiencing a hip fracture. Additional research is necessary to validate these findings.

Maxillomandibular Advancement Improves Multiple Health-Related and Functional Outcomes in Patients With Obstructive Sleep Apnea: A Multicenter Study.

PURPOSE: To comprehensively determine the effectiveness and safety of maxillomandibular advancement (MMA) for the treatment of obstructive sleep apnea (OSA). PATIENTS AND METHODS: We designed and implemented a prospective multicenter cohort study to evaluate OSA patients who underwent MMA. The primary outcome measures and associated instruments included sleepiness (Epworth Sleepiness Scale [ESS]), quality of life (QOL) (Functional Outcomes of Sleep Questionnaire [FOSQ]), sleep-disordered breathing (apnea-hypopnea index), cardiovascular risk (office blood pressure and levels of high-sensitivity C-reactive protein), and neurocognitive performance (psychomotor vigilance testing [PVT]). The outcomes were measured preoperatively and approximately 6 months postoperatively. Other variables were grouped into the following categories: demographic and pre-MMA use of continuous positive airway pressure. Descriptive and bivariate statistics were computed. RESULTS: The sample was composed of 30 adult patients (63% men; mean age, 45.9 ± 9.8 years). The median length of follow-up was 6.7 months (range, 4.3 to 12.7 months). The ESS score decreased from a mean of 13.3 to 4.9 (P < .001). The FOSQ score increased from a mean of 14.1 to 18.3 (P < .001). The apnea-hypopnea index decreased from a mean of 39.6 to 7.9 events per hour (P < .001). Mean diastolic blood pressure decreased from 83 to 79.7 mm Hg (P = .025). PVT response times improved after MMA (P = .04). Few treatment-related adverse events occurred, which had minimal impact on the QOL. Additional improvements in sleepiness (mean ESS score change, -7.6; P < .001), QOL (mean FOSQ score change, 3.9; P < .001), and PVT (mean change, 0.5; P = .004) occurred after MMA for patients using continuous positive airway pressure before surgery. CONCLUSIONS: MMA is a highly effective and safe treatment for OSA, which predictably leads to significant improvements in sleepiness, QOL, sleep-disordered breathing, and neurocognitive performance, as well as a reduction in cardiovascular risk (blood pressure).

Does Administration of Oral Versus Intravenous Antibiotics for Third Molar Removal Have an Effect on the Incidence of Alveolar Osteitis or Postoperative Surgical Site Infections?

PURPOSE: To compare the incidence of postoperative alveolar osteitis (AO) and surgical site infections (SSIs) in 2 separate cohorts of patients undergoing elective third molar removal: those who received postoperative oral (PO) antibiotics and those who received perioperative intravenous (IV) antibiotics. MATERIALS AND METHODS: A retrospective cohort study of all patients 14 to 30 years old undergoing elective outpatient third molar removal under a single surgeon's service over a 12-year period was completed. Patients undergoing third molar removal during the first 72 months received postoperative PO antibiotics alone. Patients undergoing third molar removal during the second 72 months received perioperative IV antibiotics alone. The primary predictor variable for the study was the antibiotic regimen used at the time of third molar removal. The primary outcome variable was the postoperative development of AO or SSI. Covariates included age and gender. Univariable and multivariable regression models assessed for associations between the antibiotic regimen used and the presence of AO and SSI. RESULTS: The study sample consisted of 1,895 patients (1,020 patients receiving postoperative PO antibiotics and 875 patients receiving perioperative IV antibiotics). Of patients receiving postoperative PO antibiotics, 6.4% developed AO an average of 5.7 days after the procedure and 2.6% developed an SSI an average of 23.2 days after the procedure. Of patients receiving perioperative IV antibiotics, 5.5% developed AO an average of 6.2 days after the procedure and 3.3% developed an SSI an average of 18.2 days after the procedure. No statistically significant associations between the antibiotic regimen used and the presence of AO or SSI were identified in univariable (P = 0.42 for AO, P = 0.32 for SSI) or multivariable (P = 0.65 for AO, P = 0.26 for SSI) analyses. In the postoperative PO antibiotic cohort, older age (P < .001) and female gender (P < .001) were significantly associated with the development of AO, and female gender (P = .015) was significantly associated with the presence of an SSI. In the perioperative IV antibiotic cohort, female gender was significantly associated with the development of AO (P = .011), and younger age was significantly associated with the presence of an SSI (P = .011). CONCLUSION: The use of a postoperative PO versus a perioperative IV antibiotic regimen does not significantly alter the incidence of AO or SSI after elective third molar removal. If the surgeon chooses to use antibiotics in the setting of third molar surgery, then perioperative IV antibiotics are preferable over postoperative PO antibiotics because they obviate any issues with patient compliance and might be less costly.

Maxillofacial and Mandibular Fractures in Sports.

Sports account for 3% to 29% of facial injuries and 10% to 42% of facial fractures. Fractures of the facial skeleton most commonly occur owing to interpersonal violence or motor vehicle crashes. Facial fractures from sporting activities has clearly decreased over time owing to better preventive measures. However, this decreasing trend is offset by the emergence of more dangerous sports activities, or "pushing the envelope" of traditional sports activities. Fractures can occur from contact between athletes, and between athletes and their surroundings. Football, soccer, hockey, and baseball most frequently are involved in sports-related cases of facial bone fracture.

Does the Amount of Screw Fixation Utilized for the Condylar Component of the TMJ Concepts Total Temporomandibular Joint Reconstruction Predispose to Hardware Loss or Postoperative Complications?

PURPOSE: To determine whether the number of screws used to fixate a TMJ Concepts total joint prosthesis correlates with loss of hardware fixation or postoperative complications. MATERIALS AND METHODS: A retrospective cohort study of patients undergoing total temporomandibular joint (TMJ) reconstruction with the TMJ Concepts custom prosthesis at the Mayo Clinic from 2005 to 2015 was undertaken. The primary predictor variable was the percentage of screw fixation used in the condylar component. The primary outcome variable was loss of hardware fixation. Secondary outcome variables included postoperative wound infection, removal of hardware, and return to the operating room. Covariates abstracted included patient demographics, comorbidity indices, preoperative occlusion, contralateral TMJ reconstruction, performing surgeon, duration of procedure and anesthesia, intraoperative fluid administration, concomitant surgical procedures, perioperative antibiotics, prior TMJ surgeries, prior Proplast Teflon implantation, prior head and neck radiation, use of heterotopic ossification radiation protocol, and use of the 2 most superior screw holes in the condylar component. RESULTS: The study sample was composed of 45 patients representing 64 TMJ Concepts reconstructions. Mean age was 49.1 years (standard deviation, 13.4 yr; range, 19 to 85 yr). The female distribution was 86%. There were 15 simultaneous bilateral reconstructions, 26 unilateral reconstructions, and 4 staged bilateral reconstructions. Eighteen reconstructions (28%) were placed using 100% of the available screw holes in the condylar component. Forty-six reconstructions (72%) were placed using fewer than 100% of the available screw holes in the condylar component (range of screw fixation, 56 to 89%). The minimum number of screws used to fixate the condylar component was 5, which was observed in 9 reconstructions (14%). There was no postoperative loss of hardware fixation in any reconstruction under study. Six reconstructions showed a postoperative complication defined by the secondary outcomes. Univariable or multivariable modeling was precluded for the primary and secondary outcomes owing to the low frequency of observed complications. CONCLUSION: Fixating the condylar component of the TMJ Concepts total joint prosthesis using fewer than 100% of the available screw holes does not predispose the reconstruction to hardware loss, particularly if greater than 50% screw fixation can be achieved or a minimum of 5 screws are used.

Hypotensive Anesthesia Is Associated With Shortened Length of Hospital Stay Following Orthognathic Surgery.

PURPOSE: To evaluate the impact of induced hypotensive anesthesia on length of hospital stay (LOS) for patients undergoing maxillary Le Fort I osteotomy in isolation or in combination with mandibular orthognathic surgery. MATERIALS AND METHODS: A retrospective cohort study design was implemented and patients undergoing a Le Fort I osteotomy as a component of orthognathic surgery at the Mayo Clinic from 2010 through 2014 were identified. The primary predictor variable was the presence of induced hypotensive anesthesia during orthognathic surgery. Hypotensive anesthesia was defined as at least 10 consecutive minutes of a mean arterial pressure no higher than 60 mmHg documented within the anesthetic record. The primary outcome variable was LOS in hours after completion of orthognathic surgery. The secondary outcome variable was the duration of surgery in hours. Multiple covariates also abstracted included patient age, patient gender, American Society of Anesthesiologists score, complexity of surgical procedure, and volume of intraoperative fluids administered during surgery. Univariable and multivariable models were developed to evaluate associations between the primary predictor variable and covariates relative to the primary and secondary outcome variables. RESULTS: A total of 117 patients were identified undergoing Le Fort I orthognathic surgery in isolation or in combination with mandibular surgery. Induced hypotensive anesthesia was significantly associated with shortened LOS (odds ratio [OR] = 0.33; 95% confidence interval [CI], 0.12-0.88; P = .026) relative to patients with normotensive regimens. This association between hypotensive anesthesia and LOS remained statistically significant in a subgroup analysis of 47 patients in whom isolated Le Fort I surgery was performed (OR = 0.13; 95% CI, 0.03-0.62; P = .010). Induced hypotensive anesthesia was not statistically associated with shorter duration of surgery. CONCLUSION: Induced hypotensive anesthesia represents a potential factor that minimizes postoperative LOS for patients undergoing routine maxillary orthognathic surgery alone or in combination with mandibular procedures. Hypotensive anesthesia does not appear to be effective in minimizing the duration of surgery within this same patient population.

Does Intravenous Midazolam Dose Influence the Duration of Recovery Room Stay Following Outpatient Third Molar Surgery?

PURPOSE: To evaluate the impact of intravenous midazolam dose on the duration of recovery room stay for patients undergoing outpatient third molar surgery. MATERIALS AND METHODS: Using a retrospective cohort study design, a sample of patients undergoing outpatient third molar surgery under intravenous sedation at Mayo Clinic from 2010 to 2014 was identified. All patients underwent extraction of all 4 third molars during a single operative procedure and the age range was limited to 14 to 29 years. The primary predictor variable was the total dose of intravenous midazolam administered during sedation. The primary outcome variable was recovery room length of stay (LOS) after completion of surgery. Multiple covariates also abstracted included patient age, gender, American Society of Anesthesiologists (ASA) score, duration of surgical procedure, complexity of surgical procedure, types and dosages of all intravenous medications administered during sedation, and volume of crystalloid fluid administered perioperatively. Univariable and multivariable models were developed to evaluate associations between the primary predictor variable and covariates relative to the primary outcome variable. RESULTS: The study sample was composed of 2,610 patients. Mean age was 18.3 years (SD, 3.0 yr; range, 14 to 29 yr) and gender distribution was 52% female. Mean dosage of midazolam administered was 4.1 mg (SD, 1.1 mg; range, 0.5 to 10.0 mg). Variables predicting shorter LOS at multivariable analysis included older age (P < .001), male gender (P = .004), and administration of larger crystalloid fluid volumes (P < .001). Variables predicting longer LOS included higher ASA score (P < .001), administration of ketamine (P < .001), and administration of ketorolac (P < .001). The dose of midazolam administered during sedation was not found to be significantly associated with prolonged recovery room LOS in univariable or multivariable settings. CONCLUSION: Dosage of intravenous midazolam does not appear to significantly impact the duration of recovery room stay in the prototypical patients undergoing sedation for outpatient third molar surgery.

Impact of Perioperative Fluid Administration on Postoperative Morbidity and Length of Hospital Stay Following Maxillomandibular Advancement for Obstructive Sleep Apnea.

PURPOSE: The purpose of this study was to evaluate whether the volume of perioperative fluids administered to patients undergoing maxillomandibular advancement (MMA) for treatment of obstructive sleep apnea (OSA) is associated with an increased incidence of postoperative complications and prolonged length of hospital stay. MATERIALS AND METHODS: A retrospective cohort study design was implemented and patients undergoing MMA for OSA at the Mayo Clinic were identified from 2001 through 2014. The primary predictor variable was the total volume of intravenous fluids administered during MMA. The primary outcome variable was length of hospital stay in hours. Secondary outcome variables included the presence of complications incurred during postoperative hospitalization. Additional covariates abstracted included basic demographic data, preoperative body mass index, preoperative apnea-hypopnea index, preoperative Charlson comorbidity index, preoperative American Society of Anesthesiologists score, type of intravenous fluid administered, surgical complexity score, duration of anesthesia, duration of surgery, and the use of planned intensive care unit admission. Univariate and multivariable models were developed to assess associations between the primary predictor variable and covariates relative to the primary and secondary outcome variables. RESULTS: Eighty-eight patients undergoing MMA for OSA were identified. Total fluid volume was significantly associated with increased length of stay (odds ratio [OR] = 1.34, 95% confidence interval [CI], 1.05-1.71; P = .020) in univariate analysis. Total fluid volume did not remain significantly associated with increased length of hospital stay in stepwise multivariable modeling. Total fluid volume was significantly associated with the presence of postoperative complications (OR = 1.69; 95% CI, 1.08-2.63; P = .021) in univariate logistic regression. CONCLUSION: Fluid administration was not found to be significantly associated with increased length of hospital stay after MMA for OSA. Increased fluid administration might be associated with the presence of postoperative complications after MMA; however, future large multicenter studies will be required to more comprehensively assess this association.

Impact of intraoperative fluid administration on length of postoperative hospital stay following orthognathic surgery.

PURPOSE: The purpose of this study was to evaluate whether the volume of intraoperative fluids administered to patients during routine orthognathic surgery is associated with increased length of hospital stay for postoperative convalescence. MATERIALS AND METHODS: A retrospective cohort study design was used to identify 168 patients undergoing routine orthognathic surgery at Mayo Clinic from 2010 through 2014. The primary predictor variable was total volume of intravenous fluids administered during orthognathic surgery. The primary outcome variable was the length of hospital stay in hours as measured from the completion of the procedure to patient dismissal from the hospital. Additional covariates were collected including patient demographic data, preoperative American Society of Anesthesiologists (ASA) score, type of intravenous fluid administered, complexity of surgical procedure, and duration of anesthesia. RESULTS: On univariate analysis, total fluid was significantly associated with increased length of stay (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.42 to 2.33; P < .001). After adjustment for surgical complexity and duration of anesthesia on multivariable regression analysis, the association of fluid level with length of hospital stay was no longer statistically significant (OR, 0.86; 95% CI, 0.61 to 1.22; P = .39). Duration of anesthesia remained the only covariate that was significantly associated with increased length of hospital stay in the multivariable regression model (OR, 2.21; 95% CI, 1.56 to 3.13; P < .001). CONCLUSIONS: Among surgical complexity, duration of anesthesia, and total volume of intraoperative intravenous fluids administered for routine orthognathic surgery, the duration of anesthesia has the strongest predictive value for patients requiring prolonged hospital stay for postoperative convalescence.

Morbidity and mortality associated with dental extraction before cardiac operation.

BACKGROUND: Dental extraction of abscessed or infected teeth before cardiac operation is often performed to decrease perioperative infection and late endocarditis. Literature to support dental extraction before cardiac operation is limited. The goal of this study was to evaluate the risk of major adverse outcomes in patients undergoing dental extraction before cardiovascular surgical procedures. METHODS: A retrospective review was performed to identify patients who underwent dental extraction before planned cardiac operation. Major adverse outcomes within 30 days after dental extraction or until time of cardiac operation were recorded and defined as death, acute coronary syndrome, stroke, renal failure requiring dialysis, and need for postoperative mechanical ventilation. RESULTS: Two hundred five patients underwent 208 dental extractions before 206 planned cardiac operations. Major adverse outcomes occurred in 16 of 205 patients (8%). Twelve patients (6%) died within 30 days after dental extraction, of which 6 (3%) occurred before cardiac operation, and 6 (3%) occurred after cardiac operation. CONCLUSIONS: Patients with planned dental extraction before cardiac operation are at risk for major adverse outcomes, including a 3% risk of death before cardiac operation and an 8% risk of a major adverse outcome. The prevalence of major adverse outcomes should advise physicians to evaluate individualized risk of anesthesia and surgical procedures in this patient population.

Auriculotemporal neuralgia secondary to TMJ synovial cyst: a rare presentation of a rare entity.

Synovial cysts of the temporomandibular joint are rare, and to our knowledge, only 14 cases have been reported. The most common presentation is local pain and swelling. We present a case of a synovial cyst presenting with neuralgia in the distribution of the auriculotemporal nerve, initially misdiagnosed as trigeminal neuralgia.