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.

American Association of Oral and Maxillofacial Surgeons' Anesthesia and Third Molar Extraction Benchmark Study: Rationale, Methods, and Initial Findings.

PURPOSE: Benchmark statistics are used in quality assurance/quality improvement processes. The purposes of the present report are to 1) review the rationale for a new specialty-specific benchmark study, 2) summarize the methods to create a practice-based research collaborative (P-BRC) designed for collecting data to create benchmarks, and 3) describe the characteristics of the P-BRC surgeon participants. MATERIALS AND METHODS: The study was designed as a prospective cohort study. We created a P-BRC composed of randomly selected American Association of Oral and Maxillofacial Surgeons (AAOMS) members in private practice in the United States, who agreed to enroll patients scheduled to receive anesthesia of any type in the office-based ambulatory setting. The study variables included clinician demographics and their P-BRC status, grouped as 1) invited, active participants, 2) invited, inactive participants, and 3) uninvited AAOMS members. The P-BRC participants collected data for dozens of variables from their patients related to anesthesia. If the procedure was third molar (M3) surgery, additional M3 procedure-specific data were collected. Data analyses were composed of computing descriptive and bivariate statistics. Preliminary sample size estimates suggested that the P-BRC should include 300 surgeons to produce estimates with a ±5% error. RESULTS: During the 1-year study interval, 642 surgeons (11.8%) were invited to join the P-BRC from a population of 5,455 eligible AAOMS members. The 124 active participants in the P-BRC contributed 6,344 subjects to the anesthesia data set and 2,978 subjects who had had 9,207 M3s removed to the M3 data set. The active participants in the P-BRC were younger and more likely to be board-certified than were the inactive participants (P < .05). Details of the anesthesia and M3 variables will follow in future reports. CONCLUSIONS: Despite vigorous efforts, we did not achieve our stated goal of creating a P-BRC composed of a random sample of 300 AAOMS members. With the current P-BRC sample, variables with very high (>93%) or very low (<7%) frequency estimates will produce estimates with the desired range of ±5% error. The P-BRC includes a sample of self-selected, not random, participants and is well-characterized in terms of age, gender, board-certification status, academic degrees, and geographic distribution.

Anesthesia Complications of Diazepam Use for Adolescents Receiving Extraction of Third Molars.

PURPOSE: To evaluate the safety of midazolam and diazepam for adolescents during third molar extraction and whether any differences in perioperative complications exist when using the 2 benzodiazepines alone or in combination. MATERIALS AND METHODS: A prospective study was performed in adolescents (<21 yr old) who underwent at least 1 third molar extraction by an oral and maxillofacial surgeon in the ambulatory setting from January 2001 through December 2010 using the Oral and Maxillofacial Surgery Outcomes System. The primary predictor variable was type of benzodiazepine used, divided into the total number of patients who received diazepam with or without midazolam. The outcome of interest was adverse complications resulting from anesthesia. Multivariable logistic regression was applied to measure the association between benzodiazepine type and adverse complications. RESULTS: Patients in the diazepam group (n = 4,213) and in the combination group (n = 426) had a complication rate of 1.4%, whereas those in the midazolam group (n = 13,451) had a complication rate of 1.0% (P = .027). Multiple logistic regression analysis showed a 50% increased odds of adverse complications in patients receiving diazepam (adjusted odds ratio = 1.50; 95% confidence interval, 1.05 to 2.16; P = .027). CONCLUSIONS: Adolescent patients who received intravenous diazepam during third molar procedures had an increased odds of anesthesia-related complications compared with those given midazolam.

Complications of Moderate Sedation Versus Deep Sedation/General Anesthesia for Adolescent Patients Undergoing Third Molar Extraction.

PURPOSE: To examine the complications resulting from moderate sedation versus deep sedation/general anesthesia for adolescent patients undergoing third molar extraction and determine whether any differences in complication risks exist between the 2 levels of sedation. MATERIALS AND METHODS: We performed a prospective study of the Oral and Maxillofacial Surgery Outcomes System from January 2001 to December 2010. The primary predictor variable was the level of sedation, divided into 2 groups: moderate sedation versus deep sedation/general anesthesia. The primary outcome was the incidence of adverse complications resulting from the sedation level. Differences in the cohort characteristics were analyzed using the independent samples t test, χ(2) test, and analysis of variance, as appropriate. Multivariable logistic regression was used to measure the effect the level of sedation had on the adverse complication rate. RESULTS: Patients in the moderate sedation group had a complication rate of 0.5%, and patients in the deep sedation/general anesthesia group had a complication rate of 0.9%. Compared with moderate sedation, deep sedation/general anesthesia did not pose a significantly increased risk of adverse anesthesia complications (adjusted odds ratio 1.63, 95% confidence interval 0.95 to 2.81; P = .077). CONCLUSIONS: The results of our study have shown that the risk of adverse anesthesia complications is not increased when choosing between moderate and deep sedation/general anesthesia for adolescent patients undergoing third molar extraction.

What Factors Influence Community Oral and Maxillofacial Surgeons' Choice to Use Capnography in the Office-Based Ambulatory Anesthesia Setting?

PURPOSE: The American Association of Oral and Maxillofacial Surgeons Board of Trustees mandated monitoring using capnography during moderate sedation (MS) and deep sedation or general anesthesia (DS/GA) delivered in the office setting effective January 1, 2014. The purpose of this study was to estimate the frequency of capnography use and to identify variables associated with a clinician's choice to use capnography before the mandate. MATERIALS AND METHODS: To address the research purpose, the authors designed a prospective cohort study and enrolled 2 samples: 1) American private practicing oral and maxillofacial surgeons (OMSs) and 2) all eligible patients for whom these OMSs delivered MS or DS/GA. The predictor variables were categorized as surgeon or patient demographics, anesthesia risk factors, procedure-related variables, and anesthetic medications. The outcome variable was capnography use during MS or DS/GA. Descriptive, bivariate, and forward stepwise multiple logistic regression statistics were computed to evaluate the association between the predictor variables and capnography use, with statistical significance set at a P value less than or equal to .05. RESULTS: The surgeon sample was composed of 95 OMSs and 13.7% reported using capnography. The patient sample included 3,495 patients with a mean age of 30.6 years (standard deviation, 17.8 yr), 43.5% were men, and 5.6% were monitored using capnography. Based on bivariate analyses, 17 variables were associated with capnography use. Forward stepwise regression modeling identified 9 variables statistically associated with capnography use. These variables were patient's age, Mallampati airway score, alcohol consumption, board certification, sevoflurane use, number of monitoring methods, electrocardiogram use, precordial stethoscope use, and number of personnel in operating suite. CONCLUSIONS: Although this study might be of historical interest at this time, the results offer insight into OMSs' practice patterns before the mandatory requirement to use capnography. As more OMSs comply with the capnography mandate, their practice patterns involving variables found to statistically correlate with capnography use might become more similar to those of early adopters of this technology.

Comparison of methohexital and propofol use in ambulatory procedures in oral and maxillofacial surgery.

PURPOSE: Short-acting anesthetic agents, such as propofol and methohexital, are commonly used for ambulatory procedures in the practices of oral and maxillofacial surgeons (OMS). This study compares the safety and anesthetic outcomes of propofol and methohexital. In addition, the study compares the safety and outcomes of these agents when administered either by an OMS who simultaneously provides anesthesia and performs the procedure (anesthetist/surgeon), or by a non-OMS provider of anesthesia (anesthesiologist or certified registered nurse anesthetist; CRNA) whose sole obligation is to provide anesthesia. MATERIALS AND METHODS: This is a prospective study of anesthesia techniques used in an office-based ambulatory setting by OMS throughout the United States, in which either propofol or methohexital was used for sedation/anesthesia. The study variables included demographic information, anesthetic agent, adverse outcomes related to anesthesia, operative procedure, and provider of anesthesia. These variables were compared with the patient group that received a benzodiazepine/narcotics regimen for sedation (control group). Bivariate (contingency tables) and multivariate (logistic regression) analyses were conducted. P < or = .05 was considered statistically significant. RESULTS: The study included 47,710 patients who met the inclusion criteria: 26,147 (54.8%) patients were in the propofol group, 15,859 (33.2%) were in the methohexital group, and 5,704 (12.0%) were in the benzodiazepine group. Among all study patients, 333 (0.7%) had an adverse event. The most common complication was nausea and vomiting without aspiration. Of the patients in the propofol group, methohexital group, or benzodiazepine group, 0.4%, 1.1%, and 0.8% had an adverse event, respectively. The higher number of complications among patients in the methohexital group compared with patients in the other 2 groups was statistically significant. Of 26,147 patients in the propofol group, 23,799 (91.0%) received anesthesia from an anesthetist/surgeon (OMS), and 2,368 (9.1%) from an anesthesiologist or nurse anesthetist (non-OMS). A total of 109 patients (0.4%) had an adverse event. The majority of patients who received anesthesia from a non-OMS were in the propofol group (2,368 of 2,404 patients; 98.5%). There was no statistically significant difference in the occurrence of adverse outcomes when comparing patients in the propofol group who received anesthesia from an OMS with those who received anesthesia from a non-OMS (P = .24, bivariate analysis; P = .33, multivariate analysis). CONCLUSIONS: There is a statistically significant increase in adverse events related to methohexital compared with propofol or benzodiazepine/narcotics for anesthesia. Propofol appears to have the lowest risk for adverse events. There is no statistically significant difference in the number of adverse outcomes between the administration of propofol for ambulatory surgery by OMS as an anesthetist/surgeon and anesthesiologist/nurse anesthetist. It remains critical that our specialty maintains the highest standards, to provide safe anesthesia and to reduce adverse anesthetic events.

Employment of male and female graduates of US veterinary medical colleges, 2001.

Among graduates who received employment offers, 89.5% of males and 84.1% of females accepted an offer. Mean starting salary was $39,120 for females and $40,052 for males.

Office-based ambulatory anesthesia: Factors that influence patient satisfaction or dissatisfaction with deep sedation/general anesthesia.

PURPOSE: The purpose of this report was to analyze data collected in an outcomes study in an attempt to identify factors that may be significant predictors of either patient satisfaction or dissatisfaction with deep sedation/general anesthesia (DS/GA) administered in an office-based setting. MATERIALS AND METHODS: To address the research purpose, we used a prospective cohort study design and sample of patients undergoing procedures in the office-based ambulatory setting of oral and maxillofacial surgeons practicing in the United States who received local anesthesia (LA), conscious sedation (CS), or DS/GA. The predictor variables were categorized as demographic, anesthetic technique, adverse events, and patient-oriented outcomes (satisfaction/dissatisfaction). Appropriate descriptive and exact P values were completed as indicated. Statistical significance was set at P < .05. Multivariate analyses were performed to support the interpretation of univariate findings. RESULTS: The sample was composed of 34,191 patients, of whom 71.9% patients received DS/GA. There were 20,455 patient satisfaction forms completed, of which 14,912 forms were from patients undergoing DS/GA. Of patients who received DS/GA, 95.8% were extremely or moderately satisfied, 3.1% were neutral, and 1.1% moderately or extremely dissatisfied. Increased age and memory of postoperative instructions were identified as factors, which predicted satisfaction. The addition of nitrous oxide to some regimens also appeared to increase satisfaction. Young age, anxiety, pain, vomiting, and being awake during the procedure were predictors of dissatisfaction. CONCLUSIONS: The findings of this study indicate that patients are overwhelmingly satisfied with DS/GA provided in an office-based ambulatory setting. Items identified as significant predictors of dissatisfaction (anxiety, pain, vomiting, being awake) generally confirm preexistent suppositions. Surprisingly, patient age (<10 years old) and memory of postoperative instructions appear to have relevance to dissatisfaction as well. Lack of specific regimens and controls prevents confirmation that nitrous oxide improves patient satisfaction rates. Although statistically significant, the variations, which resulted in a higher or lower satisfaction rate, are of questionable clinical significance in many cases.

The American Association of Oral and Maxillofacial Surgeons Age-Related Third Molar Study.

PURPOSE: The purpose of this investigation was to assess the frequency of complications of third molar surgery, both intraoperatively and postoperatively, specifically for patients 25 years of age or older. MATERIALS AND METHODS: This prospective study evaluated 3,760 patients, 25 years of age or older, who were to undergo third molar surgery by oral and maxillofacial surgeons practicing in the United States. The predictor variables were categorized as demographic (age, gender), American Society of Anesthesiologists classification, chronic conditions and medical risk factors, and preoperative description of third molars (present or absent, type of impaction, abnormalities or association with pathology). Outcome variables were intraoperative and postoperative complications, as well as quality of life issues (days of work missed or normal activity curtailed). Frequencies for data collected were tabulated. RESULTS: The sample was provided by 63 surgeons, and was composed of 3,760 patients with 9,845 third molars who were 25 years of age or older, of which 8,333 third molars were removed. Alveolar osteitis was the most frequently encountered postoperative problem (0.2% to 12.7%). Postoperative inferior alveolar nerve anesthesia/paresthesia occurred with a frequency of 1.1% to 1.7%, while lingual nerve anesthesia/paresthesia was calculated as 0.3%. All other complications also occurred with a frequency of less than 1%. CONCLUSION: The findings of this study indicate that third molar surgery in patients 25 years of age or older is associated with minimal morbidity, a low incidence of postoperative complications, and minimal impact on the patients quality of life.