Are There Differences in Opioid Prescriptions to Urban and Rural Patients by Oral and Maxillofacial Surgeons in Massachusetts From 2011 to 2021?

PURPOSE: Oral-maxillofacial surgeons (OMSs) are frequent prescribers of opioid analgesics. It remains unclear if prescription patterns differ for urban versus rural patients, given potential differences in access to and delivery of care. This study aimed to characterize urban-rural differences in opioid analgesic prescriptions to patients in Massachusetts by OMSs from 2011 to 2021. METHODS: This retrospective cohort study used the Massachusetts Prescription Monitoring Program database to identify Schedule II and III opioid prescriptions by providers with specialty of oral and maxillofacial surgery from 2011 to 2021. The primary predictor variable was patient geography (urban/rural) and secondary predictor was year (2011-2021). The primary outcome variable was milligram morphine equivalent (MME) per prescription. Secondary outcome variables were days' supply per prescription and number of prescriptions received per patient. Descriptive and linear regression statistics were performed to analyze differences in prescriptions to urban and rural patients each year and throughout the study period. RESULTS: The study data, which includes OMS opioid prescriptions (n = 1,057,412) in Massachusetts from 2011 to 2021, ranged annually between 63,678 and 116,000 prescriptions to between 58,000 and 100,000 unique patients. The cohorts each year ranged between 48 and 56% female with mean ages between 37 and 44 years. There were no differences in the mean number of patients per provider in urban and rural populations in any year. The study sample had a large majority of urban patients (>98%). MME per prescription, days' supply per prescription, and prescriptions received per patient were all generally similar between urban and rural patients each year, with the largest MME per prescription difference in 2019 (87.3 for rural to 73.9 for urban patients, P < .01). From 2011 to 2021, all patients had a steady decrease in MME per prescription (ß = -6.64, 95% confidence interval: -6.81, -6.48; R2 = 0.39) and day's supply per prescription (ß = -0.1, 95% confidence interval: -0.1, -0.09; R2 = 0.37). CONCLUSION: In Massachusetts, there were similar opioid prescribing patterns by oral and maxillofacial surgeons to urban and rural patients from 2011 to 2021. There has also been a steady decrease in the duration and total dosage of opioid prescriptions to all patients. These results are consistent with multiple statewide policies over the last several years aimed at curbing opioid overprescribing.

Are There Identifiable Risk Factors Associated With Heterotopic Ossification of the Temporomandibular Joint?

PURPOSE: Heterotopic ossification (HO) is defined as bone where it does not belong and as the abnormal presence of calcifications within soft tissues or joints. The purpose of this study was to answer the following clinical question: Are there identifiable risk factors associated with HO in and around the temporomandibular joint (TMJ)? METHODS: We designed a retrospective review of patients seen at the Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, between January 1985 and December 2019 and diagnosed with HO involving the TMJ. Variables studied included demographic factors, medical history including hereditary conditions, and specific TMJ history including past interventions. The primary outcome variable was the diagnosis of HO based on radiographic findings using the classification system described by Turlington and Durr. Inclusion criterion was clinical or radiographic evidence of TMJ HO. RESULTS: A total of 67 patients met the inclusion criteria. There were 48 females and 19 males (2.5:1) with an average age of 44.1 ± 16.7 years (range, 5-76 years). Risk factors associated with TMJ HO included musculoskeletal disease, psychiatric illness, history of trauma or previous TMJ surgeries, and congenital conditions. Of these, a history of nonsurgical TMJ therapy (odds ratio [OR], 3.5; P < .00) was most closely associated with HO. This was followed by male sex (OR, 3.1; P = .001), other craniofacial or musculoskeletal surgeries (OR, 2.4; P = .004), TMJ surgeries (OR, 1.9; P = .012), and neurogenic injury (OR, 1.8; P = .018). The results also demonstrated that patients diagnosed with TMJ HO were medically complex, with 86.6% presenting with other systemic conditions. CONCLUSION: This study identifies several risk factors which differ from those reported in the orthopedic literature. The Turlington and Durr classification is only partially helpful in clinical decision-making and needs to include HO associated with TMJ alloplasts and autogenous bone grafts (eg, costochondral grafts).

Do rural oral and maxillofacial surgeons prescribe more postoperative opioids?

PURPOSE: This study assesses rural-urban differences in opioid prescription practices among oral and maxillofacial surgeons (OMSs) who treated Medicare beneficiaries in 2017. METHODS: This cross-sectional study examines the 2017 Medicare Provider Utilization and Payment Dataset. The primary predictor variable was provider Rural-Urban Commuting Area code (rural versus urban). The primary outcome variable was mean opioid claims per Medicare beneficiary. Additional outcomes include total opioid claims volume, average Medicare beneficiaries and opioid cost per provider, mean days' supply of opioids per opioid claim, and average percentage of Medicare Part D claims represented by opioid claims. Mann-Whitney U tests compared continuous variables. A least-squares regression identified correlates of opioid claims volume. RESULTS: Rural OMSs demonstrated a higher mean opioid claims per OMS and opioid cost per provider compared to urban surgeons. Urban OMSs prescribed a greater mean days' supply of opioids per opioid claim. A larger percentage of Medicare Part D claims were represented by opioid claims for rural OMSs compared to urban OMSs. There were no differences in mean opioid claims per Medicare beneficiary. Male provider gender, female Medicare beneficiary gender, total number of beneficiaries, and a higher hierarchical condition category score were correlated with increased opioid claims per Medicare beneficiary for urban providers only. CONCLUSION: Urban and rural OMSs prescribe a similar volume of opioids per Medicare beneficiary, with rural providers prescribing higher total volumes of opioids due to larger patient panels. This work indicates that rural and urban OMSs have similar opioid prescribing practices.

First Bite Syndrome - An Underrecognized and Underdiagnosed Pain Complication After Temporomandibular Joint Surgery.

PURPOSE: First bite syndrome (FBS) can develop after head and neck surgical procedures. The aim of this study is to identify patients diagnosed with FSB after temporomandibular joint (TMJ) surgery, including their pain characteristics and risk factors for FBS. METHODS: Using a retrospective study design, a cohort of 24 patients with confirmed diagnosis of FBS were identified from the oral and maxillofacial surgery and orofacial pain (OFP) practices at Massachusetts General Hospital and Research Patient Data Registry (RPDR) between 1975 and 2019. The inclusion criteria were facial pain that was triggered by taste stimulus only and followed by a refractory period until the next gustatory stimulus. RESULTS: Of the 24 patients identified, 19 had undergone TMJ surgery, 3 patients had idiopathic FBS, 1 had a parapharyngeal space tumor and 1 developed FBS after facial burns. In the surgical patients, the median duration of onset was 2.75 months post-surgery. Most patients reported pain in the parotid region. Pain was only triggered by a taste stimulus and subsided with subsequent bites of food. 2 patients underwent spontaneous resolution of their symptoms and 1 reported complete resolution with onabotulinum toxin A (BTX) injections. Anxiety and depression were the most common comorbid conditions. CONCLUSION: FBS is an underrecognized pain complication in TMJ surgery patients. A precise history and accurate description of the pain is necessary for correct diagnosis which is important for improved treatment outcomes.

Persistent Pain Following Proplast-Teflon Implants of the Temporomandibular Joint: A Case Report and 35-Year Management Perspective.

Over three decades ago, hundreds of predominantly young women with temporomandibular joint pain and other symptoms were implanted with a prosthetic device composed of Proplast-Teflon that subsequently caused considerable harm, with patients developing chronic pain, dysfunction, and disability. This perspective review presents such a patient who suffered for decades with severe pain despite extensive pharmacotherapy, injection therapy, multiple surgeries, and behavioral health interventions. The details of the origin and subsequent events regarding the use of Proplast-Teflon interpositional implants in the temporomandibular joint are described with resources from several different perspectives. The lessons learned demonstrate failures at the federal, professional, and individual level.

Neuropathic orofacial pain: Characterization of different patient groups using the ICOP first edition, in a tertiary level Orofacial Pain Clinic.

OBJECTIVE: To characterize patients with chronic neuropathic orofacial pain in accordance with the International Classification of Orofacial Pain (ICOP first edition) criteria. STUDY DESIGN: A retrospective chart review of 108 patients was conducted. The most common categories observed were trigeminal neuralgia (TN) (25.9%), burning mouth syndrome (BMS) (11.1%), persistent idiopathic facial pain (PIFP) (26.9%), and posttraumatic trigeminal neuropathic pain (PTTNP) (26.9%); 9.3% of patients could not be categorized. RESULTS: TN and BMS was more prevalent in the sixth decade, and PIFP and PTTN were more prevalent in the fifth decade. All categories showed female predilection. The pain in TN was predominantly episodic, described as "sharp shooting" and like an "electric shock," unilateral and affecting the V2 division, and with trigger zones in 50% of patients. Pain in BMS was predominantly constant and described as "burning," with the tongue being the most common site. Pain in PIFP and PTTNP was as follows: varied from constant to episodic; described as "burning," "sharp shooting," "throbbing," or "dull aching"; intraoral or extraoral; and mostly involving the V2 or V3 division. CONCLUSION: This study is the first to characterize patients with neuropathic orofacial pain using the new ICOP criteria. PIFP and PTTNP were most commonly misdiagnosed categories. Using diagnostic criteria will increase the understanding of this patient group.

Special Screening Resources: Strategies to Identify Substance Use Disorders, Including Opioid Misuse and Abuse.

The prescription drug crisis has affected all sectors of the population, and so it is inevitable that dentists will increasingly see at-risk patients or those with substance use disorders in the course of their professional activities. Recognizing these patients and the special needs that they may have is now part of the standard of care for the profession. Screening for substance misuse involves a thorough history and review of the patient's medical record and, as appropriate, reviewing prior records and use of available screening tools.

Five-Year Comparative Analysis of Medicare Opioid Prescription Volume Among Oral and Maxillofacial Surgeons.

PURPOSE: To examine the volume and variation in opioid prescribing practices among oral and maxillofacial surgeons (OMSs) serving Medicare beneficiaries from 2013 to 2017 and identify the practice-level features that correlate with the opioid prescription volume. MATERIALS AND METHODS: The present cross-sectional study included Medicare Provider Utilization and Payment Data from 2013 to 2017. Providers were included if they were labelled as OMSs. The primary outcome variable was the opioid claim volume. The predictor variables included provider and beneficiary gender, beneficiary age, and beneficiary hierarchical condition category (HCC). The secondary outcome variables included mean opioid prescriptions per beneficiary and opioid days' supply per claim. Descriptive statistics and regression analyses were computed at an α level of 0.05. RESULTS: The 5-year analysis cohort included 2071 distinct providers; 605,593 total opioid prescription claims were recorded for 516,217 Medicare beneficiaries, with an average supply of 3.54 days of opioids per patient. From 2013 to 2017, a significant increase had occurred in the number of mean opioid claims per provider (P < .001) and a significant decrease in both the mean opioid claims per beneficiary (P < .001) and the days' supply per opioid claim per beneficiary (P < .001). Male provider gender (P < .001), lower beneficiary age (P < .001), percentage of female beneficiaries seen by a provider (P < .001), and lower HCC risk score (P < .001) all correlated with an increased opioid claim volume. Finally, a significant difference was found in the opioid claim volume among OMSs between the states (P < .001) and between oral and maxillofacial surgery and other surgical subspecialties (P < .001). CONCLUSIONS: Although the total number of opioids prescribed by OMSs has increased over time, the prescribing practices have, on the aggregate, become more responsible. The extreme cases of opioid prescribing and variations in state-level opioid claim volumes warrant additional investigation.

Dr Guralnick's 'Secret' Mission.

Walter C. Guralnick, a major figure in Oral and Maxillofacial Surgery, educational innovator, master surgeon and mentor died, surrounded by family, on September 6, 2017 at Massachusetts General Hospital, the institution he loved and served for 65 years. Like others of his generation, Dr Guralnick served in the Armed Services in Europe during World War II. Little was known of his activities with the 7th General Hospital and of his contributions to the war effort. This paper brings together material from military, local and overseas archives to provide an insight into his life and work during those years.

A Retrospective Study of Patient Outcomes After Temporomandibular Joint Replacement With Alloplastic Total Joint Prosthesis at Massachusetts General Hospital.

PURPOSE: Disorders of the temporomandibular joint (TMJ) occur frequently, with a prevalence of 15 to 18%. Total joint replacement (TJR) surgery is indicated for severe joint damage associated with impaired function, pain, or occlusal change for which other treatments have been unsuccessful. The aim of this study was to assess changes in pain and range of motion (ROM), as well as postoperative complications and comorbidities, in patients receiving TJR surgery at Massachusetts General Hospital (MGH). PATIENTS AND METHODS: This study is a retrospective review that describes the clinical variables in patients after alloplastic TMJ reconstruction performed at MGH from 2000 to 2015. Clinical variables included primary diagnosis; number of previous surgical procedures; comorbidities; preoperative and postoperative pain; preoperative, intraoperative, and postoperative ROM; and complications. RESULTS: Data were obtained from 95 patients undergoing a total of 108 surgical procedures, with an average follow-up period of 4.48 ± 3.38 years. The most common primary indications for TJR were ankylosis (44%) and inflammatory disease (23%). The maximum interincisal opening improved by a mean of 7.7 ± 10.27 mm, and pain decreased by a mean of 1.5 ± 3.29 points on a visual analog scale. Transient facial nerve palsy (25%) was the most common postoperative complication; however, long-term complications were rare. The most frequent comorbidities were psychiatric disorders (56%) and gastrointestinal disease (46%). Psychiatric patients had similar preoperative pain scores (6.0 ± 2.90) but significantly higher postoperative pain scores (4.7 ± 2.58) compared with nonpsychiatric patients. Twenty-eight percent of patients had prior failed TMJ implant materials, specifically Proplast-Teflon (Vitek, Houston, TX). These patients were significantly older (50.4 ± 8.26 years) and had smaller preoperative ROM (21.7 ± 8.85 mm) and smaller postoperative ROM (28.3 ± 9.59 mm). CONCLUSIONS: Patients showed a statistically significant (P < .01) increase in ROM and reduction in pain. TJR is an effective treatment option in patients with limited mouth opening or severe pain.

Combined or Staged Temporomandibular Joint and Orthognathic Surgery for Patients with Internal Derangement and Dentofacial Deformities.

Patients with internal derangement of the temporomandibular joint and dentofacial deformities need appropriate evaluation for both conditions. Correct diagnosis of internal derangement is vital in determining the correct orthognathic surgery plan, and it is particularly important to differentiate between myofascial dysfunction and intra-articular joint problems. Depending on the stage of internal derangement, patients may need treatment for temporomandibular dysfunction symptomatically, staged, or concurrently with orthognathic surgery.

What Variables Are Associated With the Outcome of Arthroscopic Lysis and Lavage Surgery for Internal Derangement of the Temporomandibular Joint?

PURPOSE: Arthroscopic lysis and lavage surgery (AS) is an effective modality that can decrease pain and increase maximum interincisal opening (MIO) in patients with internal derangement (ID) of the temporomandibular joint (TMJ). However, some patients remain in pain or have limited mandibular range of motion despite AS. The purpose of this study was to determine the effectiveness, prevalence of adverse effects, and predictors of response to TMJ AS in patients with TMJ arthralgia and ID. MATERIALS AND METHODS: A retrospective cohort study was conducted using data of patients who had undergone AS by a single surgeon (D.A.K.) from September 2010 to April 2015 in the Department of Oral and Maxillofacial Surgery at Massachusetts General Hospital (Boston, MA). Variables, including demographic data, medical history, and clinical presentation, were extracted and analyzed. Criteria for surgical success were defined as a postoperative MIO of at least 35 mm and a postoperative pain level no higher than 3 on an 11-point Likert-type numeric verbal pain rating scale. Appropriate descriptive and analytic statistics were computed and significance was set at a P value less than .05. RESULTS: Of the 247 participants, 226 (91.5%) were women. The mean age of the sample was 38 ± 15.4 years. Successful surgical outcome was achieved in 62.3% of patients. Based on logistic regression analysis, higher initial mean pain score and concurrent use of benzodiazepines were the only variables that predicted an unsuccessful surgical outcome (P < .001; P = .005). Adverse effects were reported by 13.4% of patients, the most common being postoperative increase in pain (13.4%), temporary malocclusion (1.2%), and temporary paresthesia in the preauricular region (0.4%). CONCLUSION: The results from this study indicate that in patients with ID of the TMJ unresponsive to noninvasive treatments, high initial pain scores and concurrent use of benzodiazepines are correlated with an unsuccessful outcome after AS.

Effectiveness, Safety, and Predictors of Response to Botulinum Toxin Type A in Refractory Masticatory Myalgia: A Retrospective Study.

PURPOSE: Masticatory muscle pain disorders respond well to conservative therapy; however, in some patients the pain becomes refractory. Botulinum toxin type A (BoT-A) therapy has been shown to be an effective modality in the management of refractory headache disorders. Conversely, there are conflicting reports in the literature regarding the efficacy, safety, and predictors of therapeutic response to BoT-A therapy for management of refractory masticatory muscle pain. MATERIALS AND METHODS: We performed a retrospective chart review of patients who underwent at least 2 injection cycles of 100 U of BoT-A for refractory masticatory myalgia in the Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, between May 2012 and June 2016. Information regarding demographic, diagnostic, and therapeutic characteristics was extracted and analyzed. The χ2 test was used for analysis between independent and dependent variables. Forward step-wise-type logistic regression analysis was conducted to determine the predictors of outcome. RESULTS: Among 116 participants, 30.6% reported significant relief in pain for a mean period of 10.1 weeks. A total of 16.4% of participants reported at least 1 adverse effect. The effectiveness of the BoT-A therapy was found to be statistically associated with the presence of muscle hypertrophy (P = .004), range of motion (P = .02), concurrent use of opioid analgesics (P = .003), and local anesthetic trigger-point injections (P = .003). Logistic regression analyses suggested that the presence of muscle hypertrophy and occurrence of adverse effects were predictors of positive outcome. On the contrary, concurrent use of opioid analgesics was found to be a predictor for no or minimal relief. CONCLUSIONS: BoT-A therapy provides significant relief for approximately one third of patients with refractory masticatory muscle pain. Therapy is associated with a mild risk of adverse effects. The presence of muscle hypertrophy, occurrence of an adverse effect, and concurrent use of opioid analgesics were found to be predictors of outcome response.

Relapsing Polychondritis Concomitant With Synovial Chondromatosis of the Temporomandibular Joint.

Relapsing polychondritis (RP) is a rare, multisystem autoimmune disease characterized by inflammation, structural damage, and impaired function of cartilaginous tissues throughout the body. In the craniofacial region, this rare disease has been reported to affect structures of the ear and nose; however, reports of temporomandibular joint (TMJ) involvement are scarce. A second uncommon disorder of cartilage is synovial chondromatosis (SC), a progressive and proliferative disorder of the synovial membrane associated with the formation of variably sized cartilaginous and calcified loose bodies, often causing dysfunction of the joints and enlargement of the joint capsule. It commonly affects the larger joints; TMJ involvement is uncommon. We present the case of a 45-year-old woman with previously diagnosed RP in whom right TMJ pathology subsequently developed, undergoing arthroscopy and biopsy followed by arthroplasty, which was proved to be SC, likely due to her autoimmune disease. To our knowledge, this is the first case describing concomitant SC of the TMJ presumably from pre-existing RP.

Periarticular Cysts of the Temporomandibular Joint Are More Frequently Synovial Than Ganglion.

PURPOSE: Differentiating between ganglion and synovial cysts by standard histology is difficult, leading to inaccurate statements on frequency for each of these periarticular lesions. The purpose of this study was to use immunohistochemical (IHC) analysis to 1) calculate the accuracy of the histologic diagnoses, 2) determine the frequency of ganglion and synovial cysts of the temporomandibular joint (TMJ), and 3) compare the frequency of these lesions in the TMJ compared with the extracranial skeleton in patients treated at Massachusetts General Hospital (MGH). MATERIALS AND METHODS: This is a retrospective cohort study of all patients undergoing treatment of TMJ cysts at MGH from 2001 through 2013. IHC analysis of tissue samples for each patient was completed and compared with the original histologic diagnoses. Categorical variables, including age, gender, and sidedness, were recorded. A natural language search of the MGH Department of Pathology database determined the frequency of extracranial periarticular cysts during the same period. RESULTS: Thirteen patients met the inclusion criteria. Eleven cysts were synovial and 2 were ganglion based on histology. IHC analysis identified 2 false-positive synovial cyst diagnoses, resulting in 100% sensitivity and 50% specificity for the original histologic assessment and a percentage error of 22%. Of the periarticular TMJ lesions, 69% were synovial cysts and 31% were ganglion cysts. The frequency of TMJ versus extracranial ganglion cysts was 0.24%, and the frequency of TMJ versus extracranial synovial cysts was 0.60% based on 3,176 extracranial cysts (1,506 synovial; 1,670 ganglion). CONCLUSION: This study represents the largest single-institution experience with periarticular cysts of the TMJ, and contrary to previous reports, TMJ cysts appear to be more frequently synovial than ganglion. IHC can be used to overcome the relatively poor specificity of histologic diagnosis of synovial cysts.

Pseudogout in the temporomandibular joint with imaging, arthroscopic, operative, and pathologic findings. Report of an unusual case.

The authors present a case of a 60-year-old woman with a destructive painful condition in the right temporomandibular joint (TMJ) that proved to be calcium pyrophosphate crystal deposits at subsequent biopsy examination. The patient presented with the chief complaints of pain and limitation that had not resolved with splint therapy, medications, and habit control. Magnetic resonance imaging studies showed internal derangement without reduction. Right TMJ arthroscopy with manipulation of the jaw under anesthesia showed unique findings of fronds of synovial tissue in the posterior joint space and areas of white matter. Because there was no long-term improvement in her clinical symptoms, she subsequently underwent arthroplasty of the right joint, with the white material clearly seen at surgery, and the biopsy examination confirmed the clinical and arthroscopic impression of pseudogout. The presentation, diagnosis, pathology, and treatment of pseudogout of the TMJ are discussed.