Dento-facial infections in children - A potential red flag for child neglect?

BACKGROUND: Healthcare professionals are often confronted with children presenting to the emergency department with dento-facial infections. These infections may be associated with dental neglect and as such could be a marker for general neglect. The aim of this retrospective study was to ascertain whether dento-facial infections can be used as an indicator for general neglect. METHOD: All children aged 16 years and under, who were admitted for surgical incision and drainage of dento-facial infection between January 2017 and January 2019 at King's College Hospital were examined retrospectively. All patients were discussed with the local safeguarding team/local authority to establish whether they were previously known to social services. RESULTS: This study showed that in our cohort, 48% of children admitted with dento-facial infection were already known to social services and one (2%) had been recently referred. The most commonly affected age group were 5-8-year-olds (50%) indicating that these children have an increased risk of neglect. An average of 5.6 teeth were extracted and four (10%) patients required extra-oral drainage. The average hospital stay was 2.26 days. CONCLUSION: Our retrospective study revealed that social services were already aware of 48% of patients under the age of 16, who were admitted to hospital with a dento-facial infection. This suggests a relationship between dental neglect and generalised neglect. Families of children presenting with dento-facial infection should be supported in accessing appropriate dental services for their children and clinicians should consider dento-facial infection a potential 'red flag' for generalised neglect.

Open versus percutaneous tracheostomy in COVID-19: a multicentre comparison and recommendation for future resource utilisation.

PURPOSE: The COVID-19 pandemic placed an unprecedented demand on critical care services for the provision of mechanical ventilation. Tracheostomy formation facilitates liberation from mechanical ventilation with advantages for both the patient and wider critical care resource, and can be performed using both percutaneous dilatational and surgical techniques. We compared outcomes in those patients undergoing percutaneous dilatational tracheostomy to those undergoing surgical tracheostomy and make recommendations for provision of tracheostomy services in any future surge. METHODS: Multicentre multidisciplinary retrospective observational cohort study including 201 patients with COVID-19 pneumonitis admitted to an ICU in one of five NHS Trusts within the South London Adult Critical Care Network who required mechanical ventilation and subsequent tracheostomy. RESULTS: Percutaneous dilatational tracheostomy was performed in 124 (62%) of patients, and surgical tracheostomy in 77 (38%) of patients. There was no difference between percutaneous dilatational tracheostomy and surgical tracheostomy in either the rate of peri-operative complications (16.9 vs. 22.1%, p = 0.46), median [IQR(range)] time to decannulation [19.0 (15.0-30.2 (5.0-65.0)] vs. 21.0 [15.5-36.0 (5.0-70.0) days] or mortality (13.7% vs. 15.6%, p = 0.84). Of the 172 patients that were alive at follow-up, two remained ventilated and 163 were decannulated. CONCLUSION: In patients with COVID-19 pneumonitis that require tracheostomy to facilitate weaning from mechanical ventilation, there was no difference in outcomes between those patients that had percutaneous dilatational tracheostomy compared with those that had surgical tracheostomy. Planning for future surges in COVID-19-related critical care demands should utilise all available resource and expertise.

Use of topical local anaesthetics for paediatric facial lacerations.

BACKGROUND: Closure of facial lacerations in young children can be difficult under local anaesthetic in an emergency department setting. Sedation or general anaesthetic are often required to close lacerations safely and to a good surgical standard. Our hospital introduced the use of local anaesthetic gel (LAT) following an audit, to reduce the need for paediatric admissions. In light of the current COVID-19 pandemic, this can be a valuable tool to help avoid admissions. OBJECTIVES: To ascertain the usefulness of LAT gel in reducing paediatric admissions. METHODS: Data was collected prospectively of all children presenting to the paediatric emergency department for input by the oral and maxillofacial team after the introduction of LAT gel. Data collected included age, aetiology, length and position of laceration, associated injuries and management. Use of LAT gel and other anaesthetics was recorded. FINDINGS: Over a 12 month period, 536 children attended the paediatric ED. Paediatric lacerations accounted for 45% of the reasons for attendance. LAT gel was used in management of 33% of patients with facial lacerations. The use of the gel was successful in 76% of occasions. Ninety children (16.8% of all attendances) were admitted to hospital during this time, of which 49 were paediatric lacerations. CONCLUSION: LAT gel is an effective adjunct to management of laceration in the paediatric population.

Penetrating trauma during a global pandemic: Changing patterns in interpersonal violence, self-harm and domestic violence in the Covid-19 outbreak.

INTRODUCTION: The restrictions imposed on social activity in response to the Covid-19 pandemic have had a profound impact globally. In the UK, the NHS was placed on a war-footing, with elective surgery, face-to-face outpatient clinics, and community care facilities all scaled back as a temporary measure to redistribute scarce resources. There has been concern during this period over increasing levels of violence in the domestic setting, as well as self-harm. METHODS: Data was collected on all patients presenting with traumatic penetrating injuries during the 'lockdown' period of 23rd March to 29th April 2020. Demographics and injury details were compared with the same period in the two preceding years. RESULTS: Overall trauma fell by 35% compared with the previous year. Over one in four penetrating injuries seen were a result of self-harm, which was significantly higher than in previous years (11% in 2019, 2% in 2018). There were two cases of injuries due to domestic violence, while a total of 4 cases of injury arose in separate violent domestic incidents. Self-harm commonly involved penetrating injury to the neck. DISCUSSION: Our centre has seen an increase in the proportion of penetrating injuries as a result of both self-harm and violence in the domestic setting. The number of penetrating neck injury cases, which can represent suicidal intent or a major presentation of psychiatric illness, is of particular concern. We must further investigate the effect of social restrictions on violent injury, and how home confinement may influence a changing demographic picture of victims.

Patients understanding of terminology commonly used during combined orthodontic-orthognathic treatment.

BACKGROUND: Communication between patients and clinicians plays an important role in improving quality of healthcare and clinical outcomes and ensuring that patients understand medical terminology used by their physicians is a core aspect of this. The aim of this study is to evaluate the degree of patient understanding with respect to commonly used terms in a joint orthodontic-maxillofacial clinic in the context of preparing for combined orthodontic/orthognathic treatment. METHODS: Patients were recruited to partake in a short two-part questionnaire. Demographic data collected included participants' age, sex, level of education, fluency of English and whether English was their first language. In the second part of the questionnaire, participants were asked to identify the correct definition of 11 commonly used terms from a series of multiple-choice answers. RESULTS: 51 patients participated in this study ranging between ages 15 to 52. 86% of patients selected English as their first language and 37% reported having a university education. The overall mean score for the questionnaire was 44%, with the best understood term being 'retainers' at 80% correct and 'decalcification' the worst understood at 14% correct. An association between level of education and understanding of specific terms was detected. CONCLUSION: This study highlights the overall sub-optimal patient understanding of medical terminology used by clinicians on a joint orthodontic-maxillofacial orthognathic clinic. The authors of this study recommend further consideration to the terminology currently used as well as adapting the mode and frequency of information delivery, serving to improve patients' understanding and retention of medical conversations.

Paediatric dental pain and infection during the COVID period.

BACKGROUND: During the coronavirus pandemic, paediatric patients will still likely present with dental pain and infection. In order to streamline care at King's College Hospital (KCH), Paediatric Dentistry and Oral and Maxillofacial Surgery (OMFS) have developed a collaborative working approach allowing patients to be treated effectively and to streamline patient care in the absence of easy access to general anaesthetic facilities. METHOD: Presenting complaints, treatment need and the treatment received were recorded for all paediatric patients presenting with dental pain and infection in the "lockdown" period (23rd March- 14th June) during "normal" working hours and "out of hours" to either paediatric dentistry or OMFS. RESULTS: 420 calls were triaged which converted to 67 patients seen face-to-face for oro-facial pain and infection. 41% of children were treated successfully under Local anaesthetic alone, only 13% required a general anaesthetic (GA) in the "lockdown" period. The vast majority of patients had antibiotics prescribed prior to attendance (80%). CONCLUSION: We have demonstrated the demographic, presenting complaints and treatment need of patients who presented to KCH during the lockdown period with dental pain and infection. The majority were able to be treated without needing for GA facilities. This paper highlights how a collaborative approach between paediatric dentistry and OMFS can help streamline patient care and is a model which can be adopted by other units in the event of further "lockdowns".

Demographics and management of paediatric dental-facial trauma in the 'lockdown' period: A UK perspective.

BACKGROUND: The United Kingdom entered 'lockdown' on the 23 March 2020 due to the COVID-19 pandemic. This resulted in school closures forcing children to remain at home. Dental-facial trauma was still likely to be common place due to falls and injuries exercising. The aim of this study was to explore the impact of the COVID-19 pandemic on clinical practice in a paediatric population in a tertiary care hospital and a linked Dental Institute. METHOD: A proforma was designed to capture the demographics, presenting complaints, type of dental-facial injury, treatment need and the treatment received for all paediatric patients presenting face to face with dental-facial trauma to King's College Hospital during the 'lockdown' period (23 March- 14 June 2020). RESULTS: Four hundred and twenty calls were triaged, converting to 102 patients seen face-to-face for dental-facial trauma. The remainder were able to be triaged 'virtually'. Injuries seen included 56 (54.9%) dentoalveolar injuries, 37 (36.2%) lacerations, five (4.9%) suspected facial fractures and four (3.9%) dog bites. Males and females were equally affected. The majority of incidents occurred in the home environment (n = 60, 58.8%), with the remainder (n = 42, 41.2%) occurring outside the home environment. The main causes of dental-facial trauma were falls (n = 47, 46.1%) and bicycles/scooters (n = 29, 28.4%). The most common type of dentoalveolar injury was lateral luxation (n = 15, 26.7%), followed by avulsion (n = 12, 21.4%). Only one child required treatment under general anaesthesia (GA). CONCLUSION: The demographic, presenting complaints and treatment needs of patients who presented during the lockdown period with dental-facial trauma were unusual. The overwhelming majority were able to be treated without the use of GA. The attendance protocol in a tertiary care setting and the use of 'teledentistry' ensured only the most severe trauma cases were seen. This highlights how more complex trauma can still occur during 'lockdown' and requires immediate management.

Penetrating head & neck trauma - Epidemiology and injury characteristics in terror-related violence, interpersonal violence and deliberate self-harm at a level 1 trauma centre.

INTRODUCTION: Penetrating trauma to the head and neck presents specific clinical challenges. Aetiologies include interpersonal violence, deliberate self-harm and terror-related violence. King's College Hospital is a Major Trauma Centre serving inner-city London boroughs with a high incidence of knife and gun crime. It also received victims of the terrorist attack at London Bridge in June 2017. METHODS: Data was collected prospectively on all patients presenting with penetrating trauma to the head and neck over a one-year period (August 2016-July 2017). RESULTS: Overall figures for penetrating trauma are the highest since comparable records began with 478 cases (2016/17) compared with 172 (2010/11). Most patients had injuries resulting from interpersonal violence (83%); a group consisting mostly in males (88%) under the age of 30 (69%). The sole fatality among all patients was a result of repeat deliberate self-harm. Terror-related violence victims were equally gender split and older; all patients in this group required surgical intervention and had longer lengths of stay (16.3 days) compared with interpersonal violence (6.3 days) and deliberate self-harm (3 days). CONCLUSION: Violent crime is increasing. Overall penetrating injury has more than doubled in 6 years. The injury characteristics observed are distinct depending on the assailants and motives. Head and neck trauma requires a multidisciplinary approach, with an understanding of the care needs of patients. Interpersonal violence is the most common aetiology and as such efforts to tackle rising violent crime must involve police and the community. In addition, terror-related violence is evolving in the United Kingdom and globally, and as such healthcare professionals must understand differences in aetiologies to promote optimal patient care.

Common maxillofacial terminology: do our patients understand what we say?

UNLABELLED: For a patient to make appropriate, informed decisions regarding their medical care, it is vital that the information given to them is complete and comprehensible. We have investigated patients' understanding of commonly used terms in an oral and maxillofacial clinic. To the authors' knowledge, this pertinent subject has not previously been explored for this specialty. METHOD: Patients were recruited for this questionnaire-based study in the oral and maxillofacial department out-patient clinics. The questionnaire includes multiple choice questions and 'free text' answers. RESULTS: All patients were invited to participate and we have shown the results of the 100 consecutive patients who agreed to take part. The 100 patients recruited ranged between the ages of 16 and 75. English was the first language for 76 participants. The term 'mandible' was correctly defined by 37 respondents. Sixty per cent of patients' think that a fracture is a 'crack' and less severe than a broken bone. CONCLUSION: Common maxillofacial jargon can easily be misunderstood by patients. It is essential that all clinicians appropriately modify their language during consultations in order to deliver information in a comprehensive manner, to educate patients on their condition and to ensure sensible decision making by patients.

The Application of Cone Beam Computed Tomography (CBCT) on the Diagnosis and Management of Maxillofacial Trauma.

The assessment and management of facial trauma in an acute setting is one of the core services provided by oral and maxillofacial units in the United Kingdom. Imaging is a pre-requisite for appropriate diagnosis and treatment planning, with a combination of plain radiographs and medical-grade CT being the mainstay. However, the emergence of cone beam CT in recent years has led to its wider applications, including facial trauma assessment. It can offer multi-planar reformats and three-dimensional reconstruction at a much lower radiation dose and financial cost than conventional CT. The purpose of this review is to appraise its potential indications in all anatomical areas of maxillofacial trauma and provide our experience at a level 1 trauma centre.

Changing patterns of penetrating neck injuries at a London-based level 1 major trauma centre: a five-year review.

Penetrating neck trauma is becoming a more frequently encountered presentation in UK emergency departments. Although largely attributable to violent crime, other aetiologies are on the rise. This study aimed to review changes in the pattern of penetrating neck injury (PNI) over a five-year period at our level 1 major trauma centre. Data were retrospectively collected on all patients presenting to the emergency department with PNIs between 2016 and 2021. The number of these injuries doubled between 2016 and 2021, accounting for 11% of all penetrating trauma in 2021. The majority of patients were male (87%). Violence remained the predominant aetiology but numbers of self-harm-related PNIs trebled between 2018 and 2021. PNIs are on the rise. These injuries remain complex to manage and require a multidisciplinary approach. Tackling violent crime remains essential in combating PNIs, but focus must also be placed on identifying and supporting individuals most at risk of deliberate self-harm from a deterioration in mental health.

An Algorithm for Jaw Pain among Divers.

Background: Temporomandibular disease (TMD) is commonly seen, and divers also experience pain in the temporomandibular joint (TMJ) or masticatory muscles. This article aims to provide a tool for diving physicians or medical professionals involved in diving medicine since jaw pain among divers is a pertinent subject and can be challenging to evaluate without some background in dentistry or maxillofacial surgery. Method: A basic algorithm was developed to provide a tool to differentiate jaw pains experienced by divers. Three brief case studies were developed, and five diving physicians were tasked with diagnosing the cases using the algorithm. Additionally, simple exercises and massage techniques that can benefit patients with TMD, particularly immediately after diving, are outlined. Results: All five diving physicians successfully diagnosed the cases using the algorithm. However, three of them were unable to diagnose the first case (disc luxation) without consulting the algorithm. Nevertheless, all physicians acknowledged the utility of the algorithm. Conclusions: Jaw pain in divers can stem from diverse causes, but effective treatment options exist. Our study findings provide valuable insights to assist diving physicians in making accurate diagnoses and guiding appropriate patient management, which may include referrals to specialists such as dentists, maxillofacial surgeons, or orthodontists.

Awareness of oral and maxillofacial surgery as a specialty and potential career pathway amongst UK medical undergraduates.

BACKGROUND AND PURPOSE OF THE STUDY: Although traditionally a "dentistry first, medicine second" training route, UK Oral and Maxillofacial surgery is increasingly populated with medicine-first trainees at ST3 level. Despite this, there is little evidence suggesting any increase in exposure at medical undergraduate level. We sought to evaluate the current level of awareness of OMFS as a medical specialty and potential career pathway amongst 'first-degree' medical undergraduates. METHOD: We distributed an on-line survey amongst 253 medical undergraduates divided between two UK universities. FINDINGS: A total of 72.3% of undergraduates received no exposure to OMFS in any form. Those with exposure had an improved understanding of the scope of the specialty. Regardless of previous exposure to the specialty, only 27.7% correctly identified the essential requirements for entry in OMFS specialty training. Nevertheless, a vast majority (76.7%) wanted more guidance on the possibility of pursuing a career in OMFS. CONCLUSIONS: Undergraduate exposure to OMFS in UK medical schools is limited. Even a small degree of exposure to OMFS improves understanding of the scope of the specialty. Although medical students do not fully understand the career pathway, they wish to explore OMFS as a career option. It is therefore important that UK undergraduate surgical curricula offer greater exposure to the specialty, the career pathway and the clinical opportunities it can provide.

Improving documentation of visual acuity in patients suffering facial fractures.

Failure to identify eye injuries associated with facial fractures can lead to life-altering morbidity. Oral and maxillofacial surgery teams receiving referrals of patients with these injuries have a vital role in ensuring that visual acuity (VA) is recorded at the time of presentation. We present a clinical audit of documentation of VA in 126 patients who sustained orbital floor and zygoma fractures. Our intervention involved a focussed teaching session for trainees responsible for taking such referrals. VA was appropriately documented in 16.5% before the session and 57.1% afterwards. This study shows that education of junior trainees gives rise to an increase in the proportion of patients where VA is properly documented. We suggest this teaching should occur routinely at junior doctor departmental inductions.

Orbital reconstruction: a systematic review and meta-analysis evaluating the role of patient-specific implants.

The purpose of this study is to execute an evidence-based review answering the following question (PICO): "Do patient-specific implants (PSI), manufactured or designed using computer-assisted technology, improve outcomes (orbital volume change, enophthalmos, diplopia, and operative duration) compared to conventional methods in orbital reconstruction following traumatic orbital injury in the adult patient population?" We performed a systematic review and meta-analysis in accordance with PRISMA guidelines. Inclusion criteria included any comparative paper whereby computer-assisted technology was used in the prefabrication or design process of implants for use in post-traumatic orbital reconstruction. Paediatric patient populations were excluded. Eight databases were systematically searched for relevant studies. Risk of bias was assessed through the NOS and RoB2 tools. Random-effects models were used to identify differences in outcomes between groups where possible. Analysis was performed using R 4.0.0. Eleven of 4784 identified studies were included, comprising 628 adult patients, with 302 and 326 patients in the patient-specific and conventional groups, respectively. Weighted mean difference between unaffected and post-operative orbital volume was 0.32 ml (SD 0.75) and 0.95 ml (SD 1.03) for patient-specific and conventional groups, respectively. Significant improvement was identified in post-operative orbital volume reconstitution with the use of PSI, compared to conventional implants, in 3 of the 5 reporting studies. Equally, post-operative enophthalmos trended towards lower severity in the patient-specific group, with 11.2% of patients affected in the patient-specific group and 19.2% in the conventional group, and operative duration was significantly reduced with the use of PSI in 3 of the 6 reporting studies. Despite a tendency to favour PSI, no statistically significant differences in key outcomes were identified on meta-analysis. Although there is some encouraging data to support improved outcomes with the use of patient-specific orbital implants in post-traumatic reconstruction, there is, at present, no statistically significant evidence to objectively support their use over conventional implants based on the currently available comparative studies. Based on the results of this study, the choice of implant used should, thus, be left to the discretion of the surgeon.

Isolated paediatric orbital fractures: a case series and review of management at a major trauma centre in the UK.

PURPOSE: Paediatric orbital fractures are rare. Existing literature demonstrates wide variation in estimates of incidence, aetiology, management protocols and outcomes. Despite this, it is generally acknowledged that orbital fractures with entrapment of the extraocular muscles constitute a surgical emergency due to the potential for persistent diplopia secondary to muscle ischaemia and necrosis. METHODS: This retrospective study was conducted to determine the characteristics and outcomes of management of orbital fractures amongst the paediatric population. It involved patients presenting to a major trauma unit in London between 2010 and 2020. RESULTS: Thirteen patients with isolated orbital fractures presented to our unit in this period. The average age was 13 years. Surprisingly the predominant aetiology was interpersonal violence. The most common fracture pattern involved the orbital floor and medial wall. One medial wall fracture case was missed in the emergency department. Eight patients required surgical intervention due to diplopia caused by muscular entrapment of extraocular muscles; the final patient had a large defect resulting in enophthalmos requiring a large titanium plate. A transconjuctival approach was preferred for surgical access and resorbable sheet was used in the remaining cases. Five patients had nausea, vomiting or bradycardia associated with the oculocardiac reflex. Surgical intervention occurred within 24-48 h of injury in 6 cases. Resolution of diplopia occurred in 7 patients within 6 months. CONCLUSION: Paediatric patients with orbital fractures should be assessed on the day of injury by a maxillofacial surgeon. Due to the risk of persistent diplopia, urgent surgical intervention in patients with entrapment of extraocular muscles should occur as soon as possible.

Changes in Body Mass Index in Children and Adolescents with Asthma during the COVID-19 Pandemic.

Background: Increased weight gain in children during the COVID-19 pandemic has been reported. Changes in weight in children with asthma during this period have not been well described. Methods: Retrospective review of children with asthma, 6-18 years of age, seen in 2019 and 2020. Mean monthly rates of change in body mass index (BMI) were compared between years. Demographic and asthma-related factors were examined. Results: Two hundred sixty-seven patients were enrolled. BMI increased by 0.128 ± 0.283 kg/m2/month during the pandemic year as compared with 0.084 ± 0.160 kg/m2/month during the previous year (P = 0.03). Patients with baseline overweight or obesity trended toward higher rates of BMI increase than those starting with normal weight, with the greatest BMI increase occurring in the severely obese. Conclusions: In this single-site study of children with asthma, there was a greater monthly rate of BMI gain during the early pandemic as compared with that observed in the previous year.

Academic Training in Oral and Maxillofacial Surgery - when and how to enter the pathway.

Entering into surgical academia can seem a daunting prospect for an oral and maxillofacial surgery (OMFS) trainee. However, the streamlining of academic training by the NIHR to create the integrated academic training (IAT) pathway has simplified academic training and more clearly defined academic positions and entry points for trainees. In this article we review the current NIHR IAT pathway and the various grades and entry points available to OMF surgeons, both pre- and post-doctoral. We highlight the unique challenges facing OMF trainees and provide advice and insight from both junior and senior OMFS academics. Finally, we focus on the planning and application for a doctoral research fellowship - discussing funding streams available to OMF surgeons.

Using the iBook in medical education and healthcare settings--the iBook as a reusable learning object; a report of the author's experience using iBooks Author software.

The recently launched iBooks 2 from Apple has created a new genre of 'interactive multimedia eBook'. This article aims to dscribe the benefit of the iBook in a medical education and healthcare setting. We discuss the attributes of an iBook as compared with the requirements of the conventional web-based Reusable Learning Object. The structure and user interface within an iBook is highlighted, and the iBook-creating software iBooks Author is discussed in detail. A report of personal experience developing and distributing an iBook for junior trainees in oral and maxillofacial surgery is provided, with discussion of the limitations of this approach and the need for further evidence-based studies.