Impact of COVID-19 on emergency oral health care in New Jersey.

BACKGROUND: The COVID-19 pandemic led to reduced services of private dental practices. The public emergency clinic of Rutgers School of Dental Medicine (RSDM) (Newark, NJ) faced changing demands during various periods of the pandemic. METHODS: Records of patients visiting the emergency clinic at RSDM during 3 distinct periods (prelockdown, lockdown, teledentistry) from January 10, 2020, through June 30, 2020, were retrospectively reviewed. Qualitative and quantitative attributes pertaining to patient encounters were reviewed and analyzed. RESULTS: A total of 1,799 records were included in this study. Patient visits increased during the early lockdown but were reduced after the implementation of teledentistry. Trends were noted in patient volume, reasons for visits, treatment needs, symptoms, diagnostic methodology, prescription use, and final disposition of patients. CONCLUSIONS: The lockdown affected emergency dental clinic services at RSDM. Teledentistry visits played a key role in screening patients and in facilitating the delivery of oral health care and timely follow-ups to patients who needed urgent in-person emergency visits. PRACTICAL IMPLICATIONS: Data gathered will lead to a better understanding of patients seen in the emergency clinic and can help with long-term planning for both institutional and smaller outpatient clinics during public health emergencies.

Temporomandibular Disorders: Surgical Implications and Management.

Temporomandibular disorders are a group of conditions that interfere with the daily lives of patients. Pain and limited function are primary concerns, and general dentists are usually the primary clinicians to be made aware of this issue. Evaluation and diagnosis is the key to determining a management plan. Minimally invasive surgical treatment includes arthrocentesis and arthroscopy, which can reduce inflammatory mediators, thereby reducing pain and increasing joint function. Open joint surgery for internal derangements focuses on instrumentation to remove and reshape the diseased condyle and disc as arthroplasty. Patients with severely limited function are candidates for total joint replacement.

Outcomes of Direct Lingual Nerve Repair After an Injury: A Systematic Review.

PURPOSE: The purpose of this study was to conduct a systematic review with meta-analysis to investigate the outcomes of direct lingual nerve repair after injury. MATERIALS AND METHODS: The studies in this review were compiled by using PubMed/Medline and ScienceDirect, which were searched by a single reviewer (M.K.) from their inception until March 10, 2020. Two independent reviewers (M.K. and V.B.Z.) who were blinded to each other's assessments reviewed full-text articles to assess for study inclusion. Outcomes were dichotomized as either functional sensory recovery (FSR) or no FSR. Clinical testing must have been assessed at a minimum of 6 months postoperatively. FSR was defined as grade S3, S3+, or S4 on the British Medical Research Council scale of neurosensory function. Studies were only eligible if they provided the number of patients treated with conduits or time from injury to repair and the associated rates of FSR with each intervention. RESULTS: The initial search using the key terms yielded 4,921 results, which was then eventually filtered down to 6 articles after multiple levels of appraisal. Five articles were retrospective cohort studies and 1 was a randomized controlled study. Four of the 6 studies reported an FSR of grade S3 or higher in 85% or more of the patients. Conduit use was not associated with a significantly greater likelihood of achieving FSR (pooled risk ratio = 1.10; 95% confidence interval, 0.96 to 1.27; P = .17). Repair within 6 months was associated with significantly improved likelihood of achieving FSR (pooled risk ratio = 0.84; 95% confidence interval, 0.71 to 0.99; P = .04). CONCLUSIONS: The use of conduits during repair was not associated with clinically significant increased FSR. Early repair was associated with a beneficial effect on FSR; however, heterogeneity was an issue with the studies. There is a lack of strong evidence owing to the nature of studies analyzed and the need for further research is required.

Management of the Hypertensive Patient in Dental Practice.

More than 1 billion people worldwide have hypertension. Since the guidelines for classification and treatment of hypertension were updated in 2017 by American College of Cardiology/American Heart Association, it is now estimated that nearly half of the US adult population has hypertension. Hypertension may not show any sign or symptom apart from an elevated blood pressure reading until signs and symptoms of complications occur. Hence, dentists can play a unique role in identifying undiagnosed patients or those with uncontrolled blood pressure levels. This article is intended to provide dental clinicians essential information about hypertension and how the new guidelines affect the classification and treatment of the disease, and it discusses the management of patients with hypertension in the dental office.

Use of Virtual Surgical Planning as an Adjunct for Enucleation of Multiple Recurrent Odontogenic Keratocysts: Case Report.

This case report describes an interesting use of virtual surgical planning to fabricate tooth-borne cutting guides to assist in localization and enucleation of multiple recurrent odontogenic keratocysts close to the inferior alveolar nerve. The 3-dimensional models generated and cutting guides increased the accuracy and precision of the procedure and decreased surgical time and potential patient morbidity.

Lingual Nerve Microsurgery Outcomes Using 2 Different Conduits: A Retrospective Cohort Study.

PURPOSE: This study compared a type 1 collagen conduit (NeuraGen) with a porcine small intestinal submucosa conduit (AxoGuard) when used in lingual nerve microsurgery and any differences in achieving functional sensory recovery (FSR). PATIENTS AND METHODS: All patients who underwent lingual nerve microsurgery performed by 1 surgeon (V.B.Z.) from 2007 to 2014 had their surgical information obtained by a retrospective review of hospital records and office charts after institutional review board approval. Those patients whose surgery included the use of a nerve conduit were included in the study. Subjective neurosensory recovery was determined by neurosensory testing, including responses to hot, cold, wisp, brush, and pinprick. Objective recovery was determined by testing 2-point discrimination and fine touch threshold with von Frey fibers. The objective findings were correlated to a Medical Research Council System score, with grades S3, S3+, and S4 indicating FSR. RESULTS: The conduits were compared using a Student t test with a 2-tailed hypothesis. The von Frey fiber test had a preoperative mean of 6.29 (standard deviation [SD], 0.95), which improved to 3.97 (SD, 0.67) for the NeuraGen and 4.17 (SD, 0.56) for the AxoGuard. Two-point discrimination improved from a mean higher than 19.42 to 9.32 mm (SD, 2.96 mm) for the NeuraGen and 9.67 mm (SD, 2.13 mm) for the AxoGuard. The mean FSR was S3+. CONCLUSIONS: There were no meaningful differences in outcomes between the 2 conduits studied, and all patients achieved FSR according to the Medical Research Council Scale.

Management of endodontic injuries to the inferior alveolar nerve.

OBJECTIVE: Functional sensory recovery from microsurgical intervention for inferior alveolar nerve (IAN) injuries resulting from endodontic treatment were evaluated using a retrospective chart review. Other variables assessed included time from injury to surgery as well as other factors which improved functional neurosensory recovery (FSR). METHOD AND MATERIALS: This case series of seven patients evaluated the outcome of IAN microsurgery following endodontic-related nerve injuries. All patients were referred, evaluated, and operated on by the primary investigator (VBZ). Surgical intervention consisted of external and/or internal neurolysis with irrigation of the mandibular canal and decompression of the affected IAN as well as allogeneic nerve graft in one patient. Preoperative and postoperative sensory levels were recorded and FSR was assessed using the Medical Research Council scale. RESULTS: Seven subjects with a mean age of 35.57 years (range 22 to 55 years old) opted to undergo trigeminal nerve microsurgery for management of their IAN injury resulting from endodontic treatment of mandibular molar teeth. Six women and one man were included in this population. The majority of subjects presented with an initial chief complaint of dysesthesia and hypoesthesia. The mean interval between nerve injury and surgical treatment was 15 weeks (range 1 to 40 weeks). All patients had preoperative sensory level of S0, S1, or S2+, and achieved FSR following surgery. Two patients had postoperative sensory level of S3, four patients had a postoperative sensory level of S3+, and one had a postoperative sensory level of S4 (complete recovery). CONCLUSIONS: The results of this study suggest that trigeminal nerve microsurgery for the surgical treatment of endodontic injuries to the IAN can improve neurosensory function. Surgical intervention in this study was beneficial to alleviate neurosensory deficits and symptoms for those injuries to the IAN caused by endodontic treatment.

Use of Fibrin Glue as an Adjunct in the Repair of Lingual Nerve Injury: Case Report.

This report describes a case of lingual nerve injury repair using a novel technique in which Tisseel fibrin glue was used to stabilize an Axoguard nerve conduit placed around the site of primary neurorrhaphy to decrease the number of sutures required for stabilization. Five months postoperatively, the patient subjectively had increased sensation and improved taste in the left lingual nerve distribution. At neurosensory examination, the patient exhibited functional neurosensory recovery (S3+ on the Medical Research Council Scale).

Application of Maxillomandibular Fixation for Management of Traumatic Macroglossia: A Case Report.

We present a case of a 14-year-old adolescent boy who has oral cavity after gunshot wound to the tongue presenting with hemorrhage from the tongue requiring coil embolization of the right lingual artery. The patient subsequently developed macroglossia, which was managed with maxillomandibular fixation for a period of 3 weeks with complete resolution of glossal edema.

Trigeminal Nerve Injuries: Avoidance and Management of Iatrogenic Injury.

Iatrogenic injury to the trigeminal nerve can remain a source of concern and litigation even for the most experienced oral and maxillofacial surgeons. This article provides the most up-to-date evidence-based recommendations for identification, prevention, and management of these injuries to help clinicians provide the highest level of patient care.

Is there a role for a collagen conduit and anti-inflammatory agent in the management of partial peripheral nerve injuries?

PURPOSE: The purpose of this study was to investigate the effect of a collagen conduit and an anti-inflammatory agent in the treatment of acute partial sciatic nerve injuries in a rat chronic constrictive injury (CCI) model. MATERIALS AND METHODS: Adult male Sprague-Dawley rats were divided into 5 groups: group 1 (nerve damage with no treatment), group 2 (nerve damage and collagen tube), group 3 (nerve damage and collagen tube treated with anti-inflammatory agent), group 4 (sham surgery), and group 5 (naive rat). Each group consisted of 10 study animals. The nerve injury model used was the CCI model. Behavioral responses to thermal and mechanical stimuli were tested at 3, 7, and 14 days after surgery. Transverse sections of nerve tissue were harvested at day 14 and evaluated by standard error of mean (SEM). RESULTS: Tactile allodynia measurements showed initial increases in the threshold at day 3, followed by a significant decrease at day 7, and consistently remained lower than baseline by day 14. Heat allodynia measurements at day 3 showed a statistically significant decrease in threshold compared with the CCI group. However, at days 7 and 14, the threshold was not statistically different from the CCI group threshold. Groups with and without anti-inflammatory agents at day 7 showed a statistically significant decrease in threshold to both heat and tactile allodynia from day 3, indicating that groups with collagen and anti-inflammatory treatment had significant decreases in both heat and tactile allodynia. A similar relationship was observed at day 14. Transverse sections of nerve tissue evaluated by SEM of nerve tissue revealed a broad distribution of axons in group 1, with the greatest interaxonal distance in cross sections. Group 2 displayed less interaxonal distance compared with group 1, and group 3 had the least interaxonal distance. CONCLUSIONS: This study demonstrated a statistically significant decrease in pain secondary to the application of a collagen conduit and anti-inflammatory agent. Behavioral testing and SEM data also support the finding of a decrease in edema in the presence of a collagen conduit, with the greatest decrease being in the presence of both collagen conduit and anti-inflammatory agent.

Dental student perceptions of oral and maxillofacial surgery as a specialty.

PURPOSE: The specialty of oral and maxillofacial surgery (OMS) encompasses the diagnosis and surgical management of a variety of pathologic, functional, and esthetic conditions of the oral and maxillofacial region. Despite the specialty's prominent role in the field of dentistry, a lack of complete understanding still remains among dental and medical health professionals as to the exact scope and expertise of the oral and maxillofacial surgeon. The present study aimed to analyze a population of dental students' perceptions of OMS as a specialty with respect to treatment rendered, referral patterns, and a general opinion of the specialty as a whole. MATERIALS AND METHODS: A survey consisting of 10 multiple-choice questions was compiled and distributed to dental students through an on-line polling service (SurveyMonkey). A total of 5 dental student classes at a single dental school were polled using school-based electronic mail, including the graduating seniors. All answers were kept confidential, and no individual students were identified. The students were not able to retake the survey once completed. The final tallies of the survey results were compiled and submitted for statistical analysis. RESULTS: Statistically significant associations between the year of dental education and student perceptions of OMS were determined. As dental students progress through their undergraduate studies, their perceptions change with regard to the referral of dental implants. Periodontists were found to have statistically significantly greater rates of referral than oral and maxillofacial surgeons from dental students in the fourth year and recent graduates compared with younger dental students from the first, second, and third years for placement of dental implants. Statistically insignificant in terms of a changing dental student perception was the finding that third molar removal was within the domain of the oral and maxillofacial surgeon, as well as the management of cleft lip and palate deformities and mandibular fracture repair. Almost all the dental classes believed that the specialty of OMS was both medical and dental in nature and that it is a very important dental specialty. CONCLUSIONS: Dental student perceptions of OMS change throughout their undergraduate training. The reasons for such a change are multivariate and might include factors such as the amount of didactic training and clinical exposure. It is vital to both recognize and address this change at an undergraduate level of training in an effort to increase educated referrals to a surgeon who might provide the best treatment options for the patient. A stronger understanding of the dental students' perception of OMS provides an opportunity for the oral and maxillofacial academic faculty to better educate students and, ultimately, strengthen our specialty.

Training satisfaction versus dissatisfaction among chief residents in oral and maxillofacial surgery--a pilot survey.

PURPOSE: To survey chief residents in accredited oral and maxillofacial surgery (OMS) training programs to assess their satisfaction with their surgical training and analyze their career plans after residency. MATERIALS AND METHODS: A 19-question anonymous survey was electronically mailed to 212 individuals identified as graduating chief residents in accredited OMS training programs. RESULTS: Ninety-four individuals (44%) completed the survey. Of these 85 were men (90.4%) and 9 were women (9.6%). Average age was 32 years. Forty-seven respondents (50%) completed the 4-year traditional OMS programs, 37 respondents (39.4%) completed the 6-year MD integrated programs, 9 respondents (9.6%) completed the 4-year MD option programs, and 1 listed "other" as a program type. Fifty-two individuals (55.3%) planned a full-time private practice career, 5 (5.3%) planned a full-time academic career, 3 (3.2%) planned a military career, 27 (28.7%) planned a combined private practice and academic career, and 7 (7.4%) planned to complete a fellowship after residency. Seventy-nine of all respondents (84%) were satisfied with their OMS training program, whereas 15 (16%) were not. CONCLUSION: Most participants of this survey were satisfied with their training program and OMS as a career. However, it is important to note that less than half (44%) of chief residents who received this survey completed it. This short survey is a pilot survey; a more involved evaluation of OMS resident satisfaction is planned, further assessing satisfaction and burnout during residency.

Interval between injury and lingual nerve repair as a prognostic factor for success using type I collagen conduit.

PURPOSE: The purpose of the present study was to investigate the role of a type I collagen nerve conduit in the repair of lingual nerve injuries compared with those lingual nerve repairs performed without a collagen membrane and to identify the prognostic factors for functional sensory recovery (FSR). MATERIALS AND METHODS: This was a retrospective cohort study evaluating a sample derived from the population of patients who had undergone lingual nerve microsurgery from March 17, 2000, to February 23, 2010 by the same surgeon (V.B.Z.) with complete records available, including follow-up assessments. The primary outcome variable was the interval to successful FSR according to the British Medical Research Council criteria for FSR. The predictor variables were categorized into demographic, surgical, and clinical sensory testing. Appropriate descriptive statistics and univariate and multivariate Cox proportional hazards survival statistics were computed in analyzing the patient age at lingual nerve injury repair (in years), gender, timing of surgical intervention, mechanism of injury, specific surgical procedures, and application of a type I collagen conduit. RESULTS: The study cohort included 41 patients with 42 lingual nerve injuries who underwent surgical repair. Their mean age was 28.3 ± 8.3 years (range 13 to 44), with 88% females (n = 32). In the multivariate model, the injury to surgery interval per 1-month increase (hazard ratio 1.23, 95% confidence interval 1.02 to 1.48, P = .029) and injury to surgery interval of 9 months or longer (hazard ratio 4.67, 95% confidence interval 1.04 to 20.87, P = .04) remained significantly associated statistically with successful FSR. CONCLUSIONS: The results of the present study have demonstrated that the injury to surgery interval is the most significant prognostic factor in the repair of lingual nerve injuries. The use of the collagen membrane demonstrated a greater level of FSR compared with those treated without the use of the membrane. However, the results from the collagen conduit were not statistically significant.

Survey of residents who have participated in humanitarian medical missions.

PURPOSE: To survey physicians who participated in humanitarian missions as residents to assess the value of this experience on residency training and future career choices. MATERIALS AND METHODS: An anonymous 26-question survey was electronically mailed to 45 individuals identified as having participated in a cleft lip/palate mission during residency. The survey was created and distributed, and the data were collected using the online survey engine Survey Monkey. RESULTS: Thirty-nine individuals (86.7%) completed the survey. Of these, 27 were men (69.2%) and 12 were women (30.8%). Thirty-two (82.1%) were oral and maxillofacial surgeons, 4 (10.3) were plastic and reconstructive surgeons, 1 (2.6%) was an otolaryngologist, and 2 (5.1%) were pediatric dentists. Twenty-five respondents (64.1%) stated that, before their first mission, they had not operated on a primary cleft lip; 21 (53.8%) noted that they had not operated on a primary cleft palate before their first mission. Thirty-six (92.3%) noted that their mission experience improved their ability to repair facial clefts. Thirty-seven (94.9%) believed their mission experience improved their overall surgical skill. All respondents (n = 39, 100%) believed their mission experience improved their overall ability to evaluate patients with cleft. Thirty-six (92.3%) believed their experience in humanitarian missions made them more culturally sensitive/competent health care providers. Thirty-eight respondents (97.4%) believed these missions made them more socially aware of the differences in access/availability of health care globally. Thirty-eight (97.4%) believed that participation in a humanitarian mission was a high point of their residency. Thirty-seven (94.9%) planned to participate in humanitarian medical missions during their career after residency. CONCLUSION: All respondents believed that participation in a humanitarian mission during residency was a positive part of their training. In addition, these missions allowed the residents to develop as surgeons and improve their awareness of global health care and cultural competence. Given these important educational aspects, participation in a humanitarian mission should be considered a required part of residency training.

Comparison of current perception threshold electrical testing to clinical sensory testing for lingual nerve injuries.

PURPOSE: We performed a retrospective study of lingual nerve injury assessment comparing the techniques of current perception threshold testing versus clinical sensory testing. PATIENTS AND METHODS: We designed and implemented a cross-sectional study and enrolled a patient sample with lingual nerve injuries presenting for treatment to the principal investigator. The predictor variables were clinical sensory testing modalities (ie, temperature, nocioception, vibration, 2-point discrimination, brush stroke, and von Frey monofilament perception). The primary outcome variable was the electrical current perception thresholds of the tongue dorsum (neurometer measurements at 5, 250, and 2,000 Hz). Comparisons were established with the ipsilateral affected and contralateral unaffected lingual nerve distributions. The associations between the clinical sensory testing and current perception threshold measurements were assessed using correlation coefficients, with the level of statistical significance set at P < .05. RESULTS: A total of 40 patients (13 males and 27 females) were included in the present study. The average age of these patients was 34 years (range 13 to 66). Significant correlations were observed between the electrical stimulation thresholds at 2,000 Hz and the 2-point discrimination, reaction to brushing, reaction to vibration, and von Frey fiber thresholds, between the electrical stimulation thresholds at 250 Hz to the nociceptive and thermal thresholds, and between the electrical stimulation thresholds at 5 Hz to thermal stimuli. CONCLUSIONS: The significant correlations observed in the present study indicate that current perception threshold can be a complementary or alternative tool in the assessment and evaluation of lingual nerve injuries.

Safety of deep sedation in an urban oral and maxillofacial surgery training program.

PURPOSE: To study the safety of deep sedation in an urban-based oral maxillofacial surgery training program. MATERIALS AND METHODS: Charts of patients undergoing an intravenous sedation from January 2005 through December 2009 were reviewed. Data recorded included age, gender, type of procedures performed, and intravenous medications. Patients were divided in 2 groups depending on whether they received a general anesthetic agent (propofol or ketamine) or not. Anesthesia complications and failures were recorded and categorized. RESULTS: In total, 1,167 intravenous sedations were recorded. Eight patients developed adverse reactions, 3 of which required further evaluation in the emergency department. In addition, 7 intravenous sedations needed to be aborted because of patient agitation and combativeness. No deaths or long-term morbidities were reported. CONCLUSIONS: The safety of deep sedation in an urban-based oral maxillofacial training program is similar to office-based anesthesia. Sedations failures may be attributed to paradoxical benzodiazepine reactions.