Microvascular reconstruction of medication related osteonecrosis of the head and neck.

BACKGROUND: Medication related osteonecrosis of the jaw (MRONJ) requiring free flap (FF) reconstruction is uncommon with limited reported findings. METHODS: Multicenter, retrospective case series of 49 consecutive adult patients presenting with advanced MRONJ requiring FF reconstruction from 2010 to 2022. Perioperative complications and outcomes were analyzed. RESULTS: Eighty-two percent (n = 40) of cases were of the mandible and 18% (n = 9) were of the maxilla. The mean follow-up was 15 months (±19.6). The majority of FF survived (96%, n = 47). FF reconstructions of the maxilla were more likely to require postoperative debridement (56%, 95% CI [27, 81%] vs. 15%, 95% CI [7, 25%], p = 0.008) or develop intraoral bone exposure (56%, 95% CI [27, 81%] vs. 18%, 95% CI [9, 27%], p = 0.02). Most patients (71%, n = 35) received preoperative antibiotics which was associated with a higher rate of FF survival (100% vs. 86%, 95% CI [60, 96%], p = 0.02) and fewer complications. CONCLUSIONS: Patients undergoing FF reconstruction for MRONJ do well with high rates of FF success. MRONJ of the maxilla have a higher rate of some complications. Preoperative antibiotics correlated with higher FF survival and fewer postoperative complications.

Impact of depth of invasion on local recurrence in R0 resected node-negative oral tongue squamous cell carcinoma.

BACKGROUND: This study evaluates the impact of depth of invasion (DOI) on local recurrence (LR) in node-negative oral tongue squamous cell carcinoma (SCC). METHODS: Fifty-one patients were retrospectively reviewed from an institutional database. Patients were evaluated for local control (LC). Cox-proportional hazards modeling was used to calculate hazard ratios. RESULTS: There were 84.3% T1/2 and 15.7% T3/4 classification tumors. The 3-year overall survival rate was 97.9%. Local failure rate was 5.7% with a 3-year LC of 93.6%. On Univariate analysis, increased hazard of LR was noted with each unit increase in DOI (HR 1.40, 95% CI 1.07-1.83, p = 0.014). Age, sex, T classification, margins ≥5 mm, lymphovascular invasion (LVI) and perineural invasion (PNI), and adjuvant treatment were not associated with LR. On Multivariate analysis, adjusting for age and adjuvant treatment, results for DOI remained significant (aHR 1.46, 95% CI 1.08-1.98, p = 0.013). CONCLUSION: On evaluation of our institutional dataset increasing DOI was associated with increased hazard of local recurrence with oral tongue SCC.

Oral cancer patients achieve comparable survival at high safety-net burden hospitals.

PURPOSE: To evaluate the impact of hospital safety-net burden and social demographics on the overall survival of patients with oral cavity squamous cell carcinoma. MATERIALS AND METHODS: We identified 48,176 oral cancer patients diagnosed between the years 2004 to 2015 from the National Cancer Database and categorized treatment facilities as no, low, or high safety-net burden hospitals based on the percentage of uninsured or Medicaid patients treated. Using the Kaplan Meier method and multivariate analysis, we examined the effect of hospital safety-net burden, sociodemographic variables, and clinical factors on overall survival. RESULTS: Of the 1269 treatment facilities assessed, the median percentage of uninsured/Medicaid patients treated was 0% at no, 11.6% at low, and 23.5% at high safety-net burden hospitals and median survival was 68.6, 74.8, and 55.0 months, respectively (p < 0.0001). High safety-net burden hospitals treated more non-white populations (15.4%), lower median household income (<$30,000) (23.2%), and advanced stage cancers (AJCC III/IV) (54.6%). Patients treated at low (aHR = 0.97; 95% CI = 0.91-1.04, p = 0.405) and high (aHR = 1.05; 95% CI = 0.98-1.13, p = 0.175) safety-net burden hospitals did not experience worse survival outcomes compared to patients treated at no safety-net burden hospitals. CONCLUSION: High safety-net burden hospitals treated more oral cancer patients of lower socioeconomic status and advanced disease. Multivariate analysis showed high safety-net burden hospitals achieved comparable patient survival to lower burden hospitals.

Dental Practice Patterns for Oral Care in Medical Oncology Patients-a Survey-Based Assessment of Massachusetts Dentists.

Oral complications associated with cancer therapy lead to a significant deterioration of oral health and overall quality of life. The primary aim of this study was to assess dental practice patterns followed by dentists for oral care of medical oncology patients and to identify potential barriers to recommended care. A questionnaire-based survey was developed using the Qualtrics online platform. It was electronically distributed to all dentists within the Massachusetts Dental Society (MDS). Descriptive statistics were automatically computed by Qualtrics. A total of 363 responses (10.7%) were received. Dentists reported minimal correspondence from the oncology team during referrals. Most dentists communicate treatment recommendations to the oncology team with regard to extractions (74.6%), restorations (66.7%), periodontal health (68.8%), and other urgent needs (73.5%). Potential obstacles to providing care included insufficient time for dental care before start of therapy (61%), lack of patient education on oral complications associated with therapy (56%), and lack of dental insurance (31%). Only 50% of the dentists felt adequately trained to treat oncology patients, and 46% of dentists infrequently followed the recommendations set by the National Institute of Dental and Craniofacial research (NIDCR). The findings of this study indicate significant variability in the referral patterns and practice protocols for medically necessary oral care in oncology patients. The major barriers to following established guidelines for care may be attributed to the lack of correspondence between provider teams, inadequate training of professionals, and financial or insurance factors associated with increased cost of supportive care.

Long-Term Opioid Use in Post-Surgical Management of Patients With Head and Neck Cancer.

OBJECTIVE: This study aims to identify clinical and socioeconomic factors associated with long-term, post-surgical opioid use in the head and neck cancer population. METHODS: A single center retrospective study was conducted including patients diagnosed with head and neck cancer between January 1, 2014 and July 1, 2019 who underwent primary surgical management. The primary outcome measure was continued opioid use 6 months after treatment completion. Both demographic and cancer-related variables were recorded to determine what factors were associated with prolonged opioid use. Univariate analysis was performed using chi-squared test for categorical variables and 2-sample t-test for continuous variables. Multivariate analysis was performed using logistic regression. RESULTS: A total of 359 patients received primary surgical management. Forty-five patients (12.53%) continued to take opioids 6 months after treatment completion. Using univariate analysis, patients less than 65 years of age (P = .0126), adjuvant chemoradiation (n = 25, P < .001), and overall length of hospital stay (8.60 ± 8.58 days, P = .0274) were significantly associated with long term opioid use. Multivariate logistic regression showed that adjuvant chemoradiation (OR = 3.446, 95% CI [1.742, 6.820], P = .0004) and overall length of hospital stay (OR = 0.949, 95% CI [0.903, 0.997], P = .0373) to be significantly associated with opioid use 6 months after head and neck cancer treatment. CONCLUSION: Long-term postoperative opioid use in head and neck cancer patients is significantly associated with adjuvant chemoradiation, and patients with longer length of hospital stay. Therefore, future research should focus on interventions to better manage opioid use during the acute treatment period to decrease long-term use.

Geographic Barriers Affect Follow-Up Care in Head and Neck Cancer.

OBJECTIVES/HYPOTHESIS: Follow-up care in head and neck cancers (HNC) is critical in managing patient health. However, social determinants of health (SDOH) can create difficulties in maintaining follow-up care. The study goal is to explore how SDOH impacts maintenance of HNC follow-up care appointments. METHODS: A systematic retrospective chart review of 877 HNC patients diagnosed in the past 10 years a safety-net tertiary care hospital with systems to help reduce care disparities. Cohort groups were identified and compared against protocols for follow-up. Data were analyzed using analysis of variance, chi-square tests, Fisher's exact tests, two-sample t-tests, and simple linear regression. RESULTS: The average length of follow-up time in months and average total number of follow-ups over 5 years were 32.96 (34.60) and 9.24 (7.87), respectively. There was no significant difference in follow-up care between United States (US) versus non-US born and English versus non-English speaking patients. Race/ethnicity, county median household income, insurance status, and county educational attainment were not associated with differences in follow-up. However, living a greater distance from the hospital was associated with lower follow-up length and less frequency in follow-up (P < .0001). CONCLUSION: While income, primary language, country of birth, race/ethnicity, insurance status, and markers of educational attainment do not appear to impact HNC follow-up at our safety-net, tertiary care institution, and distance from hospital remains an important contributor to disparities in care. This study shows that many barriers to care can be addressed in a model that addresses SDOH, but there are barriers that still require additional systems and resources. Laryngoscope, 132:1022-1028, 2022.

Social determinants of health and treatment decisions in head and neck cancer.

BACKGROUND: This study compares select social determinants of health (SDOH) with treatment modality selection and treatment completion in head and neck cancer (HNC) patients, to better understand disparities in health outcomes. METHODS: A retrospective cohort study of HNC (n = 1428) patients was conducted. Demographic and disease-specific variables were recorded, including treatment modality selection and completion. Data were analyzed using two-sample t tests, chi-square, and Fisher's exact tests. RESULTS: Primary language was significantly associated with treatment choice, where non-English speakers were less likely to choose treatment as recommended by the Tumor Board. Lower mean distance from the hospital (37.38 [48.31] vs. 16.92 [19.10], p < 0.0001) and a county-based higher mean percentage of bachelor degree or higher education (42.16 [8.82] vs. 44.95 [6.19], p < 0.0003) were associated with treatment selection. CONCLUSION: Language, distance from the hospital, and education affected treatment selection in this study and may be useful in understanding how to counsel patients on treatment selection for HNC.

Relationship of grit and resilience to dental students' academic success.

OBJECTIVES: This study assesses the levels of grit (the perseverance and passion for long-term goals), and resilience (the ability to bounce back or recover from stress), reported by U.S. dental students, and its possible association with academic achievements. METHODS: An anonymous 27 question cross-sectional online survey with sections on demographics, grit, resilience, and academic achievement was e-mailed to all dental students in the U.S. The Short Grit and Brief Resilience scales were used. Scores for both scales ranged from 1 to 5, and were grouped into low, moderate, and high tertiles based on distribution. Dental school grade point average (GPA), and class rank were used to measure academic achievement, and were similarly grouped. Odds ratios (ORs) and 95% confidence intervals (CIs) were obtained from multinomial logistic regression models assessing the relationship of grit and resilience to the outcomes adjusting for gender, dental school year, race, geographic origin, and a variable combining education and income. RESULTS: Of the 3292 (17%) respondents, 58% were female. Hispanics reported significantly higher grit and resilience scores while Asian students reported the lowest. 18% of Hispanics were ranked in the top 20 percentile versus 37% of whites. CONCLUSION: Results indicate that dental students with high grit (high vs. low scores: OR [95% CI]: 2.06 [1.57-2.72]) and resilience (high vs. low scores: 1.36 [1.04-1.76]) achieved higher GPA and better class ranks. Therefore, it is crucial for students wanting to achieve academic success to consider the value that these non-cognitive characteristics might have on their overall progress.

Head and Neck Cancer Complications in the Geriatric Population Based on Hospital Case Volume.

OBJECTIVE: To determine whether surgical case volume is a predictive factor of surgical outcomes when managing geriatric patients with head andneck cancer. METHODS: A cross-sectional study design was used. Data were obtainedfrom the Vizient Database, which included a total of 93 academicinstitutions. Men and women aged between 65 and 100 years undergoing head and neck cancer surgery during 2009 and 2012,excluding cases of thyroid cancer and skin cancer of the head and neck(n = 4544) were included in the study. Hospital case volume was definedas low (≤21 cases/year), moderate (22-49 cases/year), or high (≥50 cases/year). The frequency of comorbidities and complications wasmeasured by hospital case volume using a χ2 test. Significancewas determined with an α level of .05. RESULTS: The largest number of head and neck cancer cases involving comorbidities (90.54%) and the highest rate of overall complications(27.50%) occurred in moderate case volume institutions compared to athe complication rate of 22.89% in low volume hospitals and 21.50% in highvolume hospitals (P < .0001). The most common comorbidities across all3 hospital case volumes included hypertension, metastatic cancer,and chronic pulmonary disease and the most common complicationsincluded hemorrhage/hematoma and postoperative pulmonarycompromise. CONCLUSION: With more geriatric patients requiring surgery for head andneck cancer, it would be beneficial to manage the more complex cases at high volume centers and to develop multidisciplinary teams to optimizecase management and minimize complications.

A survey assessing the early effects of COVID-19 pandemic on oral and maxillofacial surgery training programs.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has specific implications for oral and maxillofacial surgeons because of an increased risk of exposure to the virus during surgical procedures involving the aerodigestive tract. The objective of this survey was to evaluate how the COVID-19 pandemic affected oral and maxillofacial surgery (OMFS) training programs during the early phase of the pandemic. STUDY DESIGN: During the period April 3 to May 6, 2020, a cross-sectional survey was sent to the program directors of 95 of the 101 accredited OMFS training programs in the United States. The 35-question survey, designed by using Qualtrics software, aimed to elicit information about the impact of the COVID-19 pandemic on OMFS residency programs and the resulting specific modifications made to clinical care, PPE, and resident training/wellness. RESULTS: The survey response rate from OMFS program directors was 35% (33 of 95), with most responses from the states with a high incidence of COVID-19. All OMFS programs (100%) implemented guidelines to suspend elective and nonurgent surgical procedures and limited ambulatory clinic visits by third week of March, with the average date being March 16, 2020 (date range March 8-23). The programs used telemedicine (40%) and modified in-person visit (51%) protocols for dental and maxillofacial emergency triage to minimize the risk of exposure of HCP to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Shortage of personal protective equipment (PPE) was experienced by 51% of the programs. Almost two-thirds (63%) of the respondents recommended the use of a filtered respirator (i.e., N95 respirator) with full-face shield and stated that it was their preferred PPE, whereas 21% recommended the use of powered air-purifying respirators (PAPRs) during OMFS procedures. Only (73%) of the programs had resources for resident wellness and stress reduction. Virtual didactic training sessions conducted on digital platforms, most commonly Zoom, formed a major part of education for all programs. CONCLUSIONS: All programs promptly responded to the pandemic by making appropriate changes, including suspending elective surgery and limiting patient care to emergent and urgent services. OMFS training programs should give more consideration to providing residents with adequate stress reduction resources to maintain their well-being and training and to minimize exposure risk during an evolving global epidemic.

Risk assessment of osteoradionecrosis associated with periodontitis using 18F-FDG PET/CT.

PURPOSE: Osteoradionecrosis (ORN) is a serious complication after radiotherapy (RT), even in the era of intensity modulated radiation therapy (IMRT). The purpose of this study was to evaluate whether 18F-FDG PET/CT can predict ORN associated with periodontal disease in patients with oropharyngeal or oral cavity squamous cell carcinoma (OP/OC SCC) undergoing RT. METHODS: One hundred and five OP/OC SCC patients treated with RT who underwent pretreatment 18F-FDG PET/CT between October 2007 and June 2016 were retrospectively reviewed. A post-treatment diagnosis of ORN was made clinically based on presence of exposed irradiated mandibular bone that failed to heal after a period of three months without persistent or recurrent tumor. The maximum standardized uptake value (SUVmax) of periodontal regions identified on PET/CT was measured for all patients. Image-based staging of periodontitis was also performed using American Academy of Periodontology staging system on CT. RESULTS: Among 105 patients, 14 (13.3 %) developed ORN. The SUVmax of the periodontal region in patients with ORN (3.35 ±â€¯1.23) was significantly higher than patients without ORN (1.92 ±â€¯0.66) (P <  .01). The corresponding CT stage of periodontitis in patients with ORN was significantly higher (2.71±0.47) than patients without ORN (1.80±0.73) (P <  .01). ROC analysis revealed the cut-off values of developing ORN were 2.1 in SUVmax, and II in CT stage of periodontitis. The corresponding AUC was 0.86 and 0.82, respectively. CONCLUSIONS: Pretreatment 18F-FDG PET/CT identification of periodontitis may be helpful to predict the future development of ORN in patients with OP/OC SCC undergoing RT.

Deep learning analysis using FDG-PET to predict treatment outcome in patients with oral cavity squamous cell carcinoma.

OBJECTIVE: To assess the utility of deep learning analysis using 18F-fluorodeoxyglucose (FDG) uptake by positron emission tomography (PET/CT) to predict disease-free survival (DFS) in patients with oral cavity squamous cell carcinoma (OCSCC). METHODS: One hundred thirteen patients with OCSCC who received pretreatment FDG-PET/CT were included. They were divided into training (83 patients) and test (30 patients) sets. The diagnosis of treatment control/failure and the DFS rate were obtained from patients' medical records. In deep learning analyses, three planes of axial, coronal, and sagittal FDG-PET images were assessed by ResNet-101 architecture. In the training set, image analysis was performed for the diagnostic model creation. The test data set was subsequently analyzed for confirmation of diagnostic accuracy. T-stage, clinical stage, and conventional FDG-PET parameters (the maximum and mean standardized uptake value (SUVmax and SUVmean), heterogeneity index, metabolic tumor volume (MTV), and total lesion glycolysis (TLG) were also assessed with determining the optimal cutoff from training dataset and then validated their diagnostic ability from test dataset. RESULTS: In dividing into patients with treatment control and failure, the highest diagnostic accuracy of 0.8 was obtained using deep learning classification, with a sensitivity of 0.8, specificity of 0.8, positive predictive value of 0.89, and negative predictive value of 0.67. In the Kaplan-Meier analysis, the DFS rate was significantly different only with the analysis of deep learning-based classification (p < .01). CONCLUSIONS: Deep learning-based diagnosis with FDG-PET images may predict treatment outcome in patients with OCSCC. KEY POINTS: • Deep learning-based diagnosis of FDG-PET images showed the highest diagnostic accuracy to predict the treatment outcome in patients with oral cavity squamous cell carcinoma. • Deep learning-based diagnosis was shown to differentiate patients between good and poor disease-free survival more clearly than conventional T-stage, clinical stage, and conventional FDG-PET-based parameters.

Determining the optimal osteotomy distance with the fibula free flap in mandibular reconstruction.

OBJECTIVE: Fibula free tissue transfer is a common and reliable method for mandibular reconstruction. Functional outcomes from this procedure are dependent on the successful union of the osseous segments postoperatively. This study was conducted to define the maximum gap-size criteria for osseous union to occur at osteotomy sites in fibula free flap reconstruction of the mandible. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary care academic center. SUBJECTS AND METHODS: A retrospective chart review of computed tomography and medical records was conducted on patients who underwent fibula free flap surgery and had imaging of the mandible at <3 months and >6 months after surgery. Distances between osteotomies were measured and evaluated for interval healing. Secondary data included subject age, sex, smoking status, diabetes, number of osteotomies, complications, and adjuvant therapy. RESULTS: Thirty-eight osteotomy sites were analyzed from thirteen subjects and a total of 190 measurements were made. The mean gap size at the first scan that demonstrated union by the second scan interval was 1.31 mm and mean gap size demonstrating non-union was 2.55 mm (p < 0.01). Complication rate, number of osetotomies, adjuvant therapy, or medical co-morbidities did not significantly affect rates of union. CONCLUSIONS: In this study, osseous union was achieved with a mean osteotomy gap size of 1.31 mm. The data suggests that distances between ossesous segments >2 .55mm have a higher risk of non-union. We believe the information from this study will help augment current and future techniques in the field of mandible reconstruction.

Quality improvement in tracheostomy care: A multidisciplinary approach to standardizing tracheostomy care to reduce complications.

PURPOSE: Develop a model for quality improvement in tracheostomy care and decrease tracheostomy-related complications. METHODS: This study was a prospective quality improvement project at an academic tertiary care hospital. A multidisciplinary team was assembled to create institutional guidelines for clinical care during the pre-operative, intra-operative, and post-operative periods. Baseline data was compiled by retrospective chart review of 160 patients, and prospective tracking of select points over 8 months in 73 patients allowed for analysis of complications and clinical parameters. RESULTS: Implementation of a quality improvement team was successful in creating guidelines, setting baseline parameters, and tracking data with run charts. Comparison of pre- and post-guideline data showed a trend toward decreased rate of major complications from 4.38% to 2.74% (p = 0.096). Variables including time to tracheotomy for prolonged intubation, surgical technique, day of first tracheostomy tube change, and specialty performing surgery did not show increased risk of complications. There were increased tracheostomy-related complications in cold months (p = 0.04). CONCLUSIONS: An interdisciplinary quality improvement team can improve tracheostomy care by identifying system factors, standardizing care among specialties, and providing continuous monitoring of select data points.

Using CT texture analysis to differentiate cystic and cystic-appearing odontogenic lesions.

PURPOSE: Cystic and cystic-appearing odontogenic lesions of the jaw may appear similar on CT imaging. Accurate diagnosis is often difficult although the relationship of the lesion to the tooth root or crown may offer a clue to the etiology. The purpose of this study was to evaluate CT texture analysis as an aid in differentiating cystic and cystic-appearing odontogenic lesions of the jaw. METHODS: This was an IRB-approved retrospective study including 42 pathology-proven dentigerous cysts, 37 odontogenic keratocysts, and 19 ameloblastomas. Each lesion was manually segmented on axial CT images, and textural features were analyzed using an in-house-developed Matlab-based texture analysis program that extracted 47 texture features from each segmented volume. Statistical analysis was performed comparing all pairs of the three types of lesions. RESULTS: Pairwise analysis revealed that nine histogram features, one GLCM feature, three GLRL features, two Laws features, four GLGM features and two Chi-square features showed significant differences between dentigerous cysts and odontogenic keratocysts. Four histogram features and one Chi-square feature showed significant differences between odontogenic keratocysts and ameloblastomas. Two histogram features showed significant differences between dentigerous cysts and ameloblastomas. CONCLUSIONS: CT texture analysis may be useful as a noninvasive method to obtain additional quantitative information to differentiate cystic and cystic-appearing odontogenic lesions of the jaw.

Recategorization of tumor stage in patients with node-negative oral tongue cancer: Impact of the eighth edition American Joint Committee staging system.

BACKGROUND: To evaluate recategorization of pT1-3N0 oral tongue cancer, from seventh to eighth editions of the American Joint Committee on Cancer (AJCC) staging classification, and impact on overall survival (OS). METHODS: Using the National Cancer Database, 1277 patients were categorized using tumor size and depth of invasion with seventh and eighth AJCC staging systems and evaluated for OS. RESULTS: Tumor-category was unchanged in 82.9% and upstaged in 17.1% patients with eighth AJCC. The 3-year OS was 85.3%, 76.6%, and 77.0% with seventh AJCC compared to 87.1%, 75.1%, and 81% with eighth AJCC, for patients with pT1N0, pT2N0, and pT3N0 disease, respectively. Improved discrimination of pT1N0 vs pT2N0 for OS on multivariate analysis was seen for eighth AJCC (hazard ratio [HR] = 1.43, 95% confidence interval [CI]: 1.03-1.98, P = .03) but not for patients with pT3N0, with seventh AJCC (HR = 1.02, 95% CI:0.53-1.98, P = .95), and eighth AJCC (HR = 0.86, 95% CI: 0.52-1.42, P = .55). CONCLUSION: Eighth edition AJCC staging leads to improved discrimination of OS between pT1N0 and pT2N0 but not for patients with pT3N0.

Calcifying Epithelial Odontogenic (Pindborg) Tumor in a Child: A Case Report and Literature Review.

Calcifying epithelial odontogenic tumor (CEOT) is a rare neoplasm, which accounts for < 1% of all odontogenic tumors. CEOT occurs more frequently in adults with a peak incidence in the 5th decade of life and is extremely rare in the pediatric population. We present a case of a 13-year-old girl who was found to have a mandibular CEOT. We summarize the radiological features, pathological findings, clinical management and literature review focusing on this entity in children.