Measuring Adherence to Antibiotic Use Guidelines in Managing Mandible Fractures.

PURPOSE: Due to variability in practice patterns when managing patients with facial fractures, the Surgical Infection Society's Therapeutics and Guidelines Committee (SIS) released guidelines in June 2020 concerning antibiotic use in the treatment of patients with facial fractures. The purpose of this study was to measure adherence to SIS guidelines among patients treated for isolated mandibular fractures and to identify factors associated with deviation from SIS guidelines. MATERIALS AND METHODS: The authors designed and implemented a retrospective cohort study and enrolled a sample derived from the population of patients treated for isolated mandibular fractures at Harborview Medical Center (Seattle, WA) and University of Washington Medical Center-Montlake (Seattle, WA) from June 2020 through October 2021. The primary outcome variable was adherence to SIS antibiotic guidelines (yes or no). Covariates were grouped into the following categories: demographic (age, gender), treatment (operative treatment, primary service, transfer status), and risk factor (Charlson Comorbidity Index, tobacco use, alcohol use, drug use other than marijuana, mandibular injury severity score). Descriptive and bivariate statistics were computed to measure the association between adherence and the study variables. The level of statistical significance was set at a P-value ≤.05. RESULTS: The study sample was composed of 114 patients with a mean age of 41.8 ± 19.0 years and 72% were males. The frequency of adherence to SIS antibiotic protocol was 91.2%. Variables associated with deviation from SIS antibiotic protocol were operative treatment (P-value = .03 - relative risk (RR) not calculable), current drug use other than marijuana (RR = 4.1; 95% confidence interval, 1.3-12.8; P-value = .01), and transfer from an outside facility (RR = 4.1; 95% confidence interval, 1.3-12.8; P-value = .01). CONCLUSIONS: The findings of this study suggest that the SIS antibiotic guidelines in the management of isolated mandible fractures were translated well into practice at our institution as evidenced by the high level of compliance (>90%). To improve adherence, additional research is indicated to better understand how factors such as treatment choice, drug exposure, and transfer status adversely affect adherence to guidelines.

What Is the Effect of COVID-19-Related Social Distancing on Oral and Maxillofacial Trauma?

PURPOSE: The purpose of this study was to understand the impact of social distancing policies enacted during the COVID-19 pandemic on the epidemiology of oral and maxillofacial fractures at an urban, Level I trauma center in the United States. MATERIALS AND METHODS: The investigators designed a retrospective cohort study and enrolled a sample of 883 subjects who presented for evaluation of oral and maxillofacial fractures (OMF) between March 1 and June 30 in the years 2018 through 2020. The primary predictor variable was the evaluation of OMF during a period with social distancing policies (2020 - experimental group) or without social distancing policies in place (2018 or 2019 - control group). The primary outcome variables were the facial fracture diagnosis, the abbreviated injury scale (AIS), injury severity score (ISS), and the mechanism of injury. Appropriate univariate and bivariate statistics were computed, and the level of significance was set at P < .05 for all tests. RESULTS: The number of subjects presenting with OMF was lower during the period of social distancing (n = 235 in 2020) than during the periods without (2018: n = 330; 2019: n = 318). During the period of social distancing, there were more individuals who presented secondary to assault, whereas fewer individuals presented secondary to falls (P = .05). On average, those who presented in 2020 had more severe oral and maxillofacial injuries (mean AIS = 3.2 ± 1.2 in 2020 vs 3.0 ± 1.1 in 2019 and 3.0 ± 1.1 in 2018. P = .03) and more overall injuries (mean ISS = 20.7 ± 13.1 in 2020 vs 19.2 ± 12.5 in 2019; 17.8 ± 12.8 in 2018. P = .03). CONCLUSIONS: The investigators found that during the period of social distancing through the COVID-19 pandemic, the number of OMF cases decreased but that the severity of oral and maxillofacial and overall injuries was higher.

Is Distance Between Home and Treatment Site a Risk Factor for Complications After Treating Mandibular Fractures?

PURPOSE: Our level I trauma center provides care over a large geographic area including Alaska, Washington, Idaho, Montana, and Wyoming, with many patients traveling hundreds of miles to receive care. Distance to a treatment site is documented to be an independent risk factor for complications after multisystem trauma, but it is unclear if it is a risk factor for isolated mandibular fractures. The study purpose was to measure the association between distance to treatment site and risk for postoperative complications after treatment of isolated mandibular fractures. MATERIALS AND METHODS: The investigators designed and implemented a retrospective cohort study and enrolled a sample derived from patients treated for isolated mandibular fractures at Harborview Medical Center by the oral and maxillofacial surgery service between June 2012 and December 2016. The primary predictor variable was distance (miles) between the patient's residence and site of treatment (Harborview Medical Center). The primary outcome variable was postoperative complication (yes or no), subcategorized as major and minor. Secondary outcome variables were time to treatment between injury and operative treatment (days) and length of hospital stay (LOS) (days). Descriptive, bivariate, and multiple logistic regression statistics were computed to measure the association between distance to treatment site and postoperative complications, time to treatment, and LOS. The level of statistical significance was set at P ≤ .05. RESULTS: The study sample was composed of 403 subjects with a mean age of 32.6 ± 14.3 years and 80% were men. The average distance from the patient's residence to treatment site was 44.8 ± 128.6 miles (range, 0 to 1,440 miles; median, 20.4 miles). Major complications occurred in 11.6% of patients. The average distance between patients with and without postoperative complications was not significantly different (42.3 ± 55.8 miles vs 45.5 ± 141.7 miles; P = .8). Increasing distance was significantly associated with longer LOS (r = 0.16; P < .001) but not time to treatment (r = .04; P = .4). CONCLUSIONS: In contrast to other studies regarding multisystem trauma, complications after treating isolated mandible fractures were not associated with increasing distance to treatment site. Increasing distance may be associated with longer LOS but not time to treatment.

Are Oral and Maxillofacial Surgeons Prescribing Fewer Opioids and More Non-Narcotic Analgesics for Postoperative Pain After Third Molar Removal?

PURPOSE: In response to the national opioid epidemic crisis, the purpose of this study was to measure changes in opioid and non-narcotic analgesia (NNA) prescribing practices over time after third molar (M3) removal. MATERIALS AND METHODS: A retrospective double cohort study was utilized enrolling 2 samples of patients who had M3s removed during 2 different 3-month intervals. The primary predictor variable was prescribing practice, divided into cohorts: 1) previous prescribing practice (PPP) occurring early during the evolving opioid epidemic (2014); and 2) current prescribing practice (CPP) (2018). The outcome measures were morphine milligram equivalents (MMEs), NNA prescriptions, and refill MMEs for inadequate pain control (IPC). Other variables were age, gender, payor, provider, anesthesia, procedure, and number of M3s removed. Descriptive, bivariate, and multiple linear and logistic regression models were computed. RESULTS: The sample included 330 subjects with a mean age of 23.1 ± 8.1 years; 42.4% were male. Of the 330 subjects, 147 were in the PPP cohort (44.5%) and 183 in CPP cohort (55.5%). Mean MMEs were 130.1 ± 42.4 and 68.5 ± 32.0 in the PPP and CPP cohorts, respectively (P ≤ .001). An adjusted linear regression model showed differences in MMEs prescribed persisted (P ≤ .001). The frequency of postoperative NNA prescriptions written increased from 2.7 to 71.6% (P ≤ .001). An adjusted logistic regression model also revealed that NNA prescriptions had significantly increased (odds ratio, 242.00; P ≤ .001). No difference was found in the frequency of refills for IPC (P = .13) or mean refill MME prescriptions between the cohorts (P = .48). CONCLUSIONS: Within our academic practice, fewer opioids and more NNAs are being prescribed for postoperative pain after M3 removal without an increase in IPC. Increased awareness through prescribing regulations, non-narcotic research findings, and organizational guidelines could have contributed to these changes.

Is the Mandible Injury Severity Score a Valid Measure of Mandibular Injury Severity?

PURPOSE: Developing a valid method for assessing mandibular injury severity could permit standardized comparisons of treatment-specific outcomes between and among various mandibular fracture studies. The study purpose was to assess the validity of the Mandible Injury Severity Score (MISS) developed by Shetty et al (J Oral Maxillofac Surg 65:663, 2007) by measuring the association between the MISS and postoperative complications, operative time, and length of hospital stay (LOS) after operative treatment of isolated mandibular fractures. MATERIALS AND METHODS: The authors designed and implemented a retrospective cohort study and enrolled a sample derived from patients treated for isolated mandibular fractures at Harborview Medical Center (Seattle, WA) by the oral and maxillofacial surgery service from June 2012 through December 2016. The primary predictor variable was the MISS. The primary outcome variable was postoperative complication (yes or no). Secondary outcome variables were operative time and LOS. Descriptive, bivariate, and multiple logistic regression statistics were computed to measure the association between the MISS and postoperative complications. The level of statistical significance was set at a P value less than or equal to .05. RESULTS: The study sample was composed of 415 patients with a mean age of 32.7 ± 14.3 years and 80% were men. The average MISS was 13.4 ± 3.5 (range, 6 to 25). The postoperative complication rate was 21%. The average MISS was significantly higher in patients with postoperative complications than in patients without complications (16.3 ± 3.3 vs 12.6 ± 3.1; P < .001). In the adjusted model, postoperative complications were significantly associated with an increasing MISS (odds ratio [OR] = 1.4; 95% confidence interval [CI], 1.3-1.6; P < .001) and open treatment (OR = 7.6; 95% CI, 1.6-35.6; P = .01). The MISS was positively correlated with operative time (r = 0.529; P < .001) and LOS (r = 0.114; P = .02). CONCLUSION: The results of this study suggest that the MISS may be a valid measurement of mandibular injury severity as evidenced by the positive correlation between the MISS and postoperative complications, duration of operation, and LOS.

Do Postoperative Antibiotics Decrease the Frequency of Inflammatory Complications Following Third Molar Removal?

PURPOSE: The purpose of this study was to answer the following clinical question: among patients who have their third molars (M3s) removed, do those who receive only postoperative antibiotics compared with those who receive no perioperative antibiotics have a lower frequency of postoperative inflammatory complications? MATERIALS AND METHODS: The authors designed and implemented a prospective cohort study and enrolled a sample of patients who had at least 1 M3 removed in an ambulatory private practice setting from June 2011 through May 2012 by oral and maxillofacial surgeons participating in a practice-based research collaborative. The predictor variable was postoperative antibiotic use categorized as postoperative antibiotics alone or no antibiotics. The primary outcome variable was the presence or absence of an inflammatory complication (ie, alveolar osteitis or surgical site infection) after M3 removal. Descriptive, bivariate, and multiple logistic regression statistics (adjusted for clustering within surgical practices) were computed to measure the association between postoperative antibiotic use alone and inflammatory complications after M3 removal, with statistical significance set at a P value less than or equal to .05. RESULTS: The study sample was composed of 1,877 patients having 5,631 M3s removed, of which 61% received postoperative antibiotics only. The overall inflammatory complication frequencies in the groups receiving postoperative antibiotic only and no antibiotic were 4.3 and 7.5%, respectively (P = .003). After adjusting for differences between the 2 study groups and clustering of patients within surgical practices, postoperative antibiotic use was associated with a 40% decreased risk of developing postoperative inflammatory complications (P = .04) with marginal statistical significance. CONCLUSIONS: The results of this study suggest that postoperative antibiotic therapy is associated with a statistically meaningful decreased risk of inflammatory complications after M3 removal compared with no antibiotic therapy.

Do Antibiotics Decrease the Risk of Inflammatory Complications After Third Molar Removal in Community Practices?

PURPOSE: The role of antibiotic use in third molar (M3) surgery is controversial. The purpose of this study was to measure the association between antibiotic use and postoperative inflammatory complications after M3 surgery in the community office-based ambulatory private practice setting. MATERIALS AND METHODS: The authors designed and implemented a prospective cohort study and enrolled a sample composed of patients who had at least one M3 removed in a private practice setting by oral and maxillofacial surgeons participating in a practice-based research collaborative from June 2011 through May 2012. The predictor variable was antibiotic use of any type, categorized as yes or no. The primary outcome variable was the presence or absence of an inflammatory complication, specifically surgical site infection (SSI) or alveolar osteitis (AO), after M3 removal. Descriptive, bivariate, and multiple logistic regression statistics were computed to measure the association between antibiotic use and inflammatory complications after M3 removal, with statistical significance set at a P value less than or equal to .05. RESULTS: The study sample was composed of 2,954 patients. Three fourths (75.2%) of the sample received antibiotics in some form. The overall inflammatory complication (AO or SSI) frequencies in the antibiotic and nonantibiotic groups were 5.0 and 7.5%, respectively (P = .012). After adjusting for differences between the two groups, statistical significance between the groups persisted. CONCLUSIONS: The results of this study suggest that antibiotic therapy, regardless of type, dose, frequency, or pattern of delivery, is associated with a decreased risk of inflammatory complications after M3 removal.

Management of Panfacial Trauma: Sequencing and Pitfalls.

Panfacial trauma refers to high-energy mechanism injuries involving two or more areas of the craniofacial skeleton, the frontal bone, the midface, and the occlusal unit. These can be distracting injuries in an unstable patient and, as in any trauma, Advanced Trauma Life Support (ATLS) protocols should be followed. The airway should be secured, bleeding controlled, and sequential examinations should take place to avoid overlooking injuries. When indicated, neurosurgery and ophthalmology should be consulted as preservation of brain, vision, and hearing function should be prioritized. Once the patient is stabilized, reconstruction aims to reduce panfacial fractures, restore the horizontal and vertical facial buttresses, and resuspend the soft tissue to avoid the appearance of premature aging. Lost or comminuted bone can be replaced with bone grafts, although adequate reduction should be ensured prior to any grafting. Operative sequencing can be performed from top-down and outside-in or from bottom-up and inside-out depending on patient presentation. All protocols can successfully manage panfacial injuries, and the emphasis should be placed on a systematic approach that works from known areas to unknown areas.

Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling: A report from the American Dental Association.

BACKGROUND: An expert panel convened by the American Dental Association Council on Scientific Affairs and the Center for Evidence-Based Dentistry conducted a systematic review and formulated clinical recommendations for the urgent management of symptomatic irreversible pulpitis with or without symptomatic apical periodontitis, pulp necrosis and symptomatic apical periodontitis, or pulp necrosis and localized acute apical abscess using antibiotics, either alone or as adjuncts to definitive, conservative dental treatment (DCDT) in immunocompetent adults. TYPES OF STUDIES REVIEWED: The authors conducted a search of the literature in MEDLINE, Embase, the Cochrane Library, and the Cumulative Index to Nursing and Allied Health Literature to retrieve evidence on benefits and harms associated with antibiotic use. The authors used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty in the evidence and the Evidence-to-Decision framework. RESULTS: The panel formulated 5 clinical recommendations and 2 good practice statements, each specific to the target conditions, for settings in which DCDT is and is not immediately available. With likely negligible benefits and potentially large harms, the panel recommended against using antibiotics in most clinical scenarios, irrespective of DCDT availability. They recommended antibiotics in patients with systemic involvement (for example, malaise or fever) due to the dental conditions or when the risk of experiencing progression to systemic involvement is high. CONCLUSION AND PRACTICAL IMPLICATIONS: Evidence suggests that antibiotics for the target conditions may provide negligible benefits and probably contribute to large harms. The expert panel suggests that antibiotics for target conditions be used only when systemic involvement is present and that immediate DCDT should be prioritized in all cases.

Antibiotics for the urgent management of symptomatic irreversible pulpitis, symptomatic apical periodontitis, and localized acute apical abscess: Systematic review and meta-analysis-a report of the American Dental Association.

BACKGROUND: Patients with pulpal and periapical conditions often seek treatment for pain, intraoral swelling, or both. Even when definitive, conservative dental treatment (DCDT) is an option, antibiotics are often prescribed. The purpose of this review was to summarize available evidence regarding the effect of antibiotics, either alone or as adjuncts to DCDT, to treat immunocompetent adults with pulpal and periapical conditions, as well as additional population-level harms associated with antibiotic use. TYPE OF STUDIES REVIEWED: The authors updated 2 preexisting systematic reviews to identify newly published randomized controlled trials. They also searched for systematic reviews to inform additional harm outcomes. They conducted searches in MEDLINE, Embase, the Cochrane Library, and the Cumulative Index to Nursing and Allied Health Literature. Pairs of reviewers independently conducted study selection, data extraction, and assessment of risk of bias and certainty in the evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. RESULTS: The authors found no new trials via the update of the preexisting reviews. Ultimately, 3 trials and 8 additional reports proved eligible for this review. Trial estimates for all outcomes suggested both a benefit and harm over 7 days (very low to low certainty evidence). The magnitude of additional harms related to antibiotic use for any condition were potentially large (very low to moderate certainty evidence). CONCLUSIONS AND PRACTICAL IMPLICATIONS: Evidence for antibiotics, either alone or as adjuncts to DCDT, showed both a benefit and a harm for outcomes of pain and intraoral swelling and a large potential magnitude of effect in regard to additional harm outcomes. The impact of dental antibiotic prescribing requires further research.