Is There Uniformity and Satisfaction Among Clinical Practice Models and Faculty Compensation Plans in US Dental School-Based Oral and Maxillofacial Surgery Departments?

PURPOSE: There is a lack of information regarding clinical practice models and faculty compensation plans used by dental school-based departments of oral and maxillofacial surgery (OMS) and their effectiveness. The purpose of this study was to examine 1) the level of uniformity in clinical practice models and faculty compensation plans for US dental school-based OMS departments and 2) the level of satisfaction expressed by faculty with their current compensation plan. MATERIALS AND METHODS: A survey was sent to the chairs of the 40 US dental school-based OMS departments asking them specific information regarding their current practice model, the faculty compensation plan, and their satisfaction with their current plan. RESULTS: Twenty-four of the 40 department chairs returned the survey, for a 60% response rate. The OMS practice was part of the dental school faculty practice in 50% of the departments and a separate entity in 33%. The most common faculty compensation plan consisted of an academic salary plus a faculty practice salary based on a collection-based incentive (38%), but in 25% it was based on production. Fifty-seven percent of the responding chairs stated they were not satisfied with their current practice and compensation plans. CONCLUSIONS: There is considerable variation in the practice models and compensation plans in US dental school-based OMS departments. More than half the department chairs expressed a general dissatisfaction with their current compensation plans. The survey data indicate a need for alternative models, and this report presents one such model.

Narcotic prescribing habits and other methods of pain control by oral and maxillofacial surgeons after impacted third molar removal.

PURPOSE: It has been suggested that a source of narcotics used for nonmedical purposes by young adults is the unused opioids prescribed for the management of pain after the removal of impacted third molars. The purpose of the present study was to determine whether oral and maxillofacial surgeons routinely prescribe larger amounts of a narcotic than would generally be needed for adequate postoperative pain control. A secondary goal was to determine whether they use methods other than analgesic drugs to minimize postoperative pain and thereby reduce the amount of narcotic that might be needed. PATIENTS AND METHODS: An 8-question survey was sent to 100 randomly selected oral and maxillofacial surgeon members of the American Association of Oral and Maxillofacial Surgeons in each of the 6 association districts. The questions asked were related to whether a narcotic was routinely prescribed for patients who have had impacted teeth removed, the most common drug used, and the dosage and number of tablets prescribed. The participants were also asked whether they had pretreated patients with a nonsteroidal anti-inflammatory drug or had prescribed one along with the narcotic, had injected a steroid, or had used a long-lasting local anesthetic postoperatively. RESULTS: Only 2 of the 384 respondents stated that they did not prescribe a narcotic for patients who had had impacted teeth removed. Hydrocodone (5 mg) was the most frequently prescribed narcotic. The number of tablets varied from 10 to 40, but the most common number was 20 tablets. However, 80 respondents (22%) prescribed more, with 40 prescribing 30 tablets. Also, 80% of the respondents injected their patients with a steroid, and 62% injected a long-lasting local anesthetic postoperatively. Only 34% pretreated their patients with a nonsteroidal anti-inflammatory drug, but 66% recommended such use postoperatively. CONCLUSIONS: Most oral and maxillofacial surgeons prescribe analgesic drugs of an appropriate type and dosage and use proper adjunctive pain control measures to supplement these drugs. However, our findings also indicated that more than 20% prescribe more tablets than would generally be necessary to control the postoperative pain after the removal of impacted third molars. This could be a source of drug diversion and nonmedical use by young adults and should be avoided.

Accuracy of predicting the duration of a surgical operation.

PURPOSE: The ability to predict how long a particular operation will take is important for maintaining operating room efficiency. The purpose of this study was to determine how accurate oral and maxillofacial surgeons (OMSs) can be in making this determination. MATERIALS AND METHODS: Three experienced OMSs predicted their operating times for various operations; these predictions were compared with the actual times. The cases were then grouped into those with accurate predictions and those with overestimated and underestimated times, and the operative reports were reviewed for possible operation trends or other contributing factors. RESULTS: In the 100 cases analyzed, the surgeons correctly estimated operating times 26% of the time, overestimated 42% of the time, and underestimated 32% of the time. In the 42 overestimated times, 10 cases involved multiple tooth extractions or removal of impacted third molars, and 8 cases involved orthognathic surgery. In the 32 underestimated cases, 7 involved orthognathic surgery and 8 involved the open reduction of fractures. The 26 accurately estimated cases involved 7 cases of multiple tooth extractions or impacted third molar removal and 5 cases of arthroscopic temporomandibular joint lysis and lavage. CONCLUSIONS: Although operating times need to be used for scheduling purposes, they can be highly unpredictable. Surgeons need to constantly analyze their predictions for confounding factors in order to improve their accuracy.

The financial burden of hospitalization associated with odontogenic infections.

PURPOSE: Although it is generally agreed that there are high costs involved in the management of acute odontogenic infections in hospitalized patients, there are sparse data on the actual amounts involved. The purpose of this study was to examine the costs and charges associated with the treatment of such patients in a university medical center hospital. PATIENTS AND METHODS: Hospital records from 2003 through 2010 were reviewed for patients admitted for management of acute odontogenic infections, and 327 patients were identified. The cost of their hospital care, doctors' fees, and hospital charges (amount billed) were then determined. RESULTS: An average of 40 patients was seen each year. The cost of their care ranged from $1,035 to $252,888 (average, $9,417). This did not include doctors' charges. The hospital charges averaged $28,841 per patient. Over the 8-year period, the hospital costs exceeded $3.3 million and the charges submitted were in excess of $10 million. CONCLUSIONS: The management of acute odontogenic infections in the hospital engenders considerable costs. Although it would appear that the charges compensate for these costs, that figure does not represent the amount actually collected, which is much less based on the economic status of the patient population generally being treated. Methods to lower the costs associated with hospitalization are proposed.

Reducing the burden of dental patients on the busy hospital emergency department.

PURPOSE: Studies have shown that there is a current trend for many patients with dental problems to seek care in a hospital emergency department (ED). This may contribute to an already overcrowded and overburdened situation. The purpose of this study was to determine the volume and characteristics of the patients seeking care in the ED of a large metropolitan level I trauma center. PATIENTS AND METHODS: Using ICD-9 diagnosis codes for dental complaints, the following ED data were collected for the years 2007 through 2009: the number of patients, the age of patients, the day and time the patients presented, the number of visits patients made to the ED for a dental-related complaint, and the insurance status of the patients. This information was then used to develop a pilot program to divert these patients from the ED to a special Urgent Dental Care Clinic located in the hospital Oral and Maxillofacial Surgery Clinic, and data on number of patients treated in the following year were compared with the number treated in the ED the previous year. RESULTS: There were 173,648 emergency department visits between 2007 and 2009. Of these, 4.3% were dental-related. The majority of the patients presented between 7 am and 6 pm on Monday through Thursday, with the highest percentage on Monday. The insurance status showed that 39.7% had Medicaid or Medicare, 52.7% were uninsured, and only 7.6% had private insurance. Sixty-seven percent had tooth-related ailments. The treatment in most cases was limited to a prescription for pain medicine and an antibiotic. In the year prior to initiation of the pilot program there were 2,618 patients with dentally related problems managed in the ED. This decreased more than 52% during the first year of the pilot program. Return to the ED for a subsequent dental problem was also reduced by more than 66%. CONCLUSION: A diversion plan for dental patients can be effective in reducing their impact on the busy ED.

Masseteric artery: anatomic location and relationship to the temporomandibular joint area.

PURPOSE: This study was performed to determine the precise location of the masseteric artery in relation to the temporomandibular joint region to reduce the risk of injury during surgery. MATERIALS AND METHODS: A careful dissection of 16 intact human cadaveric head specimens was carried out to determine the course of the masseteric artery. The location of the masseteric artery was then determined in relation to 3 points in the anterior-posterior plane between the mandibular condyle and the coronoid process: 1) the anterior-superior aspect of the condylar neck, 2) the most inferior aspect of the articular tubercle, and 3) the inferior aspect of the sigmoid notch. RESULTS: The mean distance of the masseteric artery to the most anterior-superior aspect of the condylar neck was 10.3 mm; to the most inferior aspect of the articular tubercle, 11.4 mm; and to the most inferior aspect of the sigmoid notch, 3 mm. CONCLUSIONS: These results show that there is considerable variability in the location of the masseteric artery. Although it is generally closest to the depth of the sigmoid notch, which can explain why this vessel can be easily damaged during intraoral vertical ramus osteotomies, in some instances it can also be close to either the neck of the condylar process or the coronoid process. The data provided in this study can serve as a guide for locating the vessel when operating in these areas.

Appointment keeping behavior of Medicaid vs non-Medicaid orthodontic patients.

INTRODUCTION: State Medicaid programs were established to care for the poor by eliminating financial barriers that otherwise prevent them from being treated in the mainstream health care system. The number of children eligible for Medicaid services is increasing, yet the number of Medicaid providers remains low. Health care providers cited failed appointments as a major problem with Medicaid patients and a great deterrent to participating. The purpose of this study was to determine whether a difference in appointment-keeping behavior exists between Medicaid and non-Medicaid orthodontic patients. METHODS: During a 12-month period, a tally of appointments was kept for all active patients (n = 707) at Virginia Commonwealth University's Department of Orthodontics. Patients were categorized as either Medicaid or non-Medicaid, and their appointment-keeping behavior was evaluated. RESULTS: A significant difference was found in the number of failed appointments between the groups. The Medicaid patients failed 247 (15.4%) of 1609 appointments, and the non-Medicaid patients failed 367 (8.3%) of 4438 appointments. Medicaid patients accounted for 26.6% of all appointments but were responsible for about 40% of all appointment failures. In addition, 104 (56.2%) of 185 Medicaid patients missed 1 appointment or more during the year, compared with 211 (40.4%) of 522 non-Medicaid patients. CONCLUSIONS: The findings from this study support the concern among dental practitioners and orthodontic specialists that Medicaid patients have a higher rate of appointment failures than non-Medicaid patients, although the frequency of missed appointments was substantially lower for orthodontic appointments than that reported for general dental appointments.

The temporalis muscle flap in reconstruction of intraoral defects: an appraisal of the technique.

PURPOSE: The purpose of this article is to review the experience of the authors in the use of the temporalis muscle flap for reconstruction of intraoral defects. PATIENTS AND METHODS: This is a retrospective review of the use of the temporalis muscle flap for reconstruction of different types of intraoral defects in 8 patients. All patients in this series previously wore obturators as a nonsurgical treatment of their defects. Criteria used to evaluate the results of this technique included flap necrosis, facial nerve deficit, limitation of mandibular range of motion, and cosmetic deformity from scarring of the incision line or from loss of muscle volume in the temporal fossa. The patients were also evaluated for their degree of satisfaction with their speech and mastication with the obturator preoperatively and with the flap postoperatively. This article also reviews the success rates and complications with use of the temporalis muscle flap reported in the English-language literature during the past 14 years. RESULTS: All 8 patients in this series had their defects successfully reconstructed, completely eliminating any further need for prosthetic obturation of the defect. There were no incidents of flap necrosis, facial nerve deficit, or long-term changes in mandibular range of motion. Slight temporal hollowing was seen in the first 3 patients. Results of the literature review also showed a high success rate and a low incidence of complications with use of this flap. CONCLUSIONS: The temporalis flap is a useful, reliable, and versatile option for reconstruction of moderate to large sized defects. The muscle can provide abundant tissue, with minimal to no functional morbidity or esthetic deformity in the donor site.

Management of mandibular angle fracture.

Fractures through the angle of the mandible are one of the most common facial fractures. The management of such fractures has been controversial, however. This controversy is related to the anatomic relations and complex biomechanical aspects of the mandibular angle. The debate has become even more heated since the evolution of rigid fixation and the ability to provide adequate stability of the fractured segments. This article provides an overview of the special anatomic and biomechanical features of the mandibular angle and their impact on the management of these fractures.