Surgical Safety Checklists Are Underutilized in Ambulatory Oral and Maxillofacial Surgery.

PURPOSE: The objective of this study was to determine attitudes toward and the prevalence of using a surgical safety checklist in ambulatory oral and maxillofacial surgery (OMS) practice. MATERIALS AND METHODS: The authors designed and implemented a cross-sectional study and enrolled a random sample of oral and maxillofacial surgeons. The predictor variable was years removed from residency. The primary outcome was the prevalence of surgical safety checklist usage in ambulatory OMS practice. The secondary outcome was to determine whether surgeons who do not currently use a checklist would be willing to do so if provided with one. Other demographic variables included age, gender, location of practice, type of practice, and number of ambulatory procedures performed per week. Appropriate uni- and bivariate statistics were computed and the level of significance set at .05; 95% confidence intervals also were calculated. RESULTS: The study sample was composed of 120 clinicians. Forty-two percent of respondents reported that they were not using a surgical safety checklist for ambulatory surgery. Ninety-three percent of those respondents not currently using a checklist reported they would consider implementing a surgical safety checklist in their practice if provided with one. In addition, 45.3% of surgeons performing more than 30 procedures a week reported not using a surgical safety checklist. Most respondents (67.9%) who had completed OMS training more than 20 years previously reported not using a checklist in their practice. CONCLUSION: According to this survey, most practicing oral and maxillofacial surgeons do not currently use surgical safety checklists. Although the response rate was only 12%, the survey does reflect a clear lack of use of checklists among practicing oral and maxillofacial surgeons despite its widespread acceptance in the medical community.

Evaluation of Staff Satisfaction After Implementation of a Surgical Safety Checklist in the Ambulatory of an Oral and Maxillofacial Surgery Department and its Impact on Patient Safety.

PURPOSE: Safety checklists in medicine have been shown to be effective in the prevention of complications and adverse events in patients undergoing surgery. Such checklists are not as common in dentistry. The aims of this study were to propose a safety checklist for the ambulatory treatment of patients undergoing oral and implant surgery and to assess its impact on patient safety and staff satisfaction. MATERIALS AND METHODS: After implementation of a surgical safety checklist in the ambulatory treatment of patients undergoing oral and implant surgeries, a questionnaire regarding staff satisfaction and safety-related parameters was randomly administered. Incidents, complications, and adverse events were documented. Outcomes with (n = 40 surgeries) and without (n = 40 surgeries) use of the checklist were analyzed and compared. RESULTS: Staff reported high satisfaction with the use of the checklist, which demonstrably improved team communication and lowered stress levels during surgery. There was a statistically significantly higher frequency of reported incidents without the use of the checklist (n = 43) than with the use of the checklist (n = 10; P = .000). Most incidents were reported in the context of pre- and post-procedural processes. CONCLUSIONS: Safety checklists help to improve work processes, optimize communication, and lower stress levels. Their use in clinical dental practice is recommended.

Senior Oral and Maxillofacial Surgery Resident Confidence in Performing Invasive Temporomandibular Joint Procedures.

PURPOSE: The purpose of this study was to evaluate the level of confidence that senior-level oral and maxillofacial surgery (OMS) residents have in the management of temporomandibular joint (TMJ) disorders, determine their exposure to various invasive TMJ procedures during training, and assess their confidence in performing those procedures on completion of residency. MATERIALS AND METHODS: A questionnaire was designed, and a link to a University of Illinois at Chicago Qualtrics Survey platform (Qualtrics, Provo, UT) was e-mailed to all program directors at Commission on Dental Accreditation-accredited OMS training programs in the United States. The program directors were asked to forward the 20-multiple-choice question anonymous survey to their senior-level residents for completion. The survey included the program's demographic characteristics, resident's confidence in assessing and managing patients with temporomandibular disorders (TMDs), resident's experience performing various invasive TMJ procedures, and whether the resident believed he or she had received sufficient education and clinical experience in the management of TMJ disorders. The data were collected and summarized by use of a standard spreadsheet analysis, as well as appropriate descriptive and analytical statistical tests. RESULTS: The response rate was 28.0%. Of the 56 respondents, 52 (92.9%) reported having received instruction in nonsurgical management of TMDs. All respondents confirmed that invasive TMJ procedures were performed in their program. The most commonly performed procedure was TMJ arthrocentesis (mean rating, 3.11), followed by open TMJ surgery (mean rating, 2.82). The least-performed invasive surgical procedure was autogenous total TMJ replacement surgery (mean rating, 1.39). Eighty percent of residents reported being comfortable managing the TMD patient. The only procedure with which the respondents were highly confident was TMJ arthrocentesis (mean rating, 3.89). CONCLUSIONS: This study suggests that confidence levels in the management of the TMD patient are related directly to the invasive TMJ procedure experience obtained during residency. This finding may have implications on the practice patterns of OMS surgeons as it relates to access to care for the TMD patient.

Cleft and Craniofacial Clinic Formats in the United States: National and Institutional Survey.

BACKGROUND: Craniofacial teams employ multidisciplinary clinics to optimize patient care. Different clinic formats exist among teams. Formats include providers rotating from room to room as separate specialties, patients rotating from room to room to either separate specialties or as 1 group, as well as providers rotating together as 1 group. Surveys were used to study family preferences between the different formats and to compare them with trends of national practices. METHODS: Families of the authors' team clinic patients were surveyed from November 2012 to February 2013, after a clinic format change from patients moving between rooms to see providers, to providers moving between rooms to see patients. This survey focused on patient satisfaction, clinic format preference, and their perception of efficiency. A second, national survey was distributed to 161 American craniofacial teams approved by the American Cleft Palate-Craniofacial Association to survey clinic formats, provider satisfaction, and experience with other formats. Institutional survey data were tabulated as percentages and further analyzed using the Mann-Whitney Test. The national survey data was then tabulated and compared with authors' institutional results. RESULTS: Thirty-nine of 54 (72.2%) families responded to the institutional survey. Providers moving between rooms were associated with greater patient satisfaction (mean 4.8 of 5, 5 being most satisfied) (0<0.0001), shorter perceived clinic time (76.9%), and an increased sense of comfort (84.6%). The difference in satisfaction rates was statistically significant (P <0.0001) between the primary clinic formats of providers rotating (mean of 4.8) and patients rotating (mean of 2.4).The national survey had 93 responses of 161 (57.7%). 54.9% of respondents have providers rotating between examination rooms, and 32.3% have patients moving between rooms. Other formats included the entire team moving as a group between rooms (10.8%) and specialties sitting together in 1 room while patients rotate (9.7%). Respondents were satisfied with current formats (mean 4.24 of 5, 5 being most satisfied). 22.2% had tried a different format previously. CONCLUSION: The most common American cleft and craniofacial clinic format is providers moving between rooms; however, all formats have high provider satisfaction. At our institution, patients prefer when providers move between rooms. Our study suggests that clinic formats do not need to be standardized, and the clinic format utilized should be tailored to the individual needs of the institution.

[Recent increase in simple extractions in OMF-surgeries in the Netherlands studied]. / Recente toename van reguliere extracties in mka-chirurgie onderzocht.

Tooth extraction is a treatment that can be carried out by general dental practitioners. It is suspected that the number of referrals to OMF-surgeons for simple tooth extractions has increased in the Netherlands in recent years. In a study, the health records of 2 groups of outpatients treated at the Oral and Maxillofacial Surgery department of a university medical centre between 1996 and 2014 were investigated. Patients who had undergone tooth extractions were included. The complexity of the tooth extractions was analyzed according to 4 criteria. The results of the study show a significant increase in simple tooth extractions by OMF surgeons in 2014 in comparison with 1996. The complexity of the total number of tooth extractions in 2014 was lower than in 1996. Reasons for these results could not be unambiguously determined. Possible significant aspects are the risk of per-operative complications, insufficient affinity of general dental practitioners with tooth extractions or financial considerations on the part of both the general dental practitioners and the patients.

Approaching 3D printing in oral and maxillofacial surgery - suggestions for structured clinical standards.

PURPOSE: With respect to the European Union 2017 amendment of the Medical Device Regulations (MDR), this overview article presents recommendations concerning medical 3D printing in oral and maxillofacial surgery (OMFS). METHODS: The MDR were screened for applicability of the rules to medical in-house 3D printing. Applicable regulations were summarized and compared to the status of medical use of 3D printing in OMFS in Germany. Recommendations were made for MDR concerning medical 3D printing. RESULTS: In-house printed models, surgical guides, and implants fall under the category of Class I-III, depending on their invasive and active properties. In-house medical 3D printing for custom-made medical devices is possible under certain prerogatives: (1) the product is not being used in another facility, (2) appropriate quality systems are applied, (3) the reason for omitting commercial products is documented, (4) information about its use is supplied to the responsible authority, (5) there is a publicly accessible declaration of origin, identification, and conformity to the MDR, (6) there are records of manufacturing site, process and performance data, (7) all products are produced according to the requirements proclaimed before, and (8) there is an evaluation of clinical use and correction of possible issues. CONCLUSION: Several aspects must be addressed for in house medical 3D printing, according to the MDR. Devising MDR related to medical 3D printing is a growing challenge. The implementation of recommendations in OMFS could help practitioners to overcome the challenges and become aware of the in-house production and application of 3D printed devices.

Chief resident case experience and autonomy are associated with resident confidence and future practice plans.

PURPOSE: To measure oral and maxillofacial surgery (OMS) chief resident case experience, including autonomy, and discover the role of this experience in developing resident confidence and determining the scope of practice on completion of training. MATERIALS AND METHODS: A cross-sectional study was conducted using an online questionnaire made available to residents near the completion of their final year of training in United States OMS training programs. Predictors were the case numbers and autonomy level. Outcomes were the anticipated frequency of practice, confidence to meet the standard of care, and changes in anticipated practice scope. Each was measured in 10 domains within the scope of OMS. RESULTS: Eighty-four residents (44%) completed the 116-item questionnaire. All respondents were "very confident" in their ability to meet the standard of care in mandibular trauma and dentoalveolar surgery. Autonomy was associated with the confidence to meet the standard of care in midface trauma, temporomandibular joint, orthognathic, cosmetic, pathology, reconstructive, and craniofacial surgery. Associations were noted between primary surgeon cases and confidence in midface trauma, temporomandibular joint, orthognathic, cosmetic, and craniofacial surgery. Case numbers were associated with an anticipated frequency of practice within the domains of midface trauma, temporomandibular joint, cosmetic, and pathology surgery. CONCLUSIONS: Results of this study suggest an association between a resident's surgical case experience (overall exposure and autonomy) and that resident's future plans for practice and confidence to meet the standard of care in this specialty. OMS training curricula should evolve to incorporate an evaluation of competence and an appropriate transfer of responsibility and experience to residents, thus maximizing confidence and future practice opportunities.

A baseline audit of referral and treatment delivered to patients in the intermediate minor oral surgery service in Croydon PCT.

INTRODUCTION: Patients attending for primary dental care may require oral surgery procedures beyond the capability of a generalist and thus need to be treated by a dentist with greater expertise. In the United Kingdom, it is increasingly accepted that such care may be provided in primary care settings by specialists or dentists with a special interest. In response to local pressures, an intermediate minor oral surgery (IMOS) service has been established in Croydon, south west London, to provide oral surgery treatment for non-urgent patients on referral. AIM: To audit the appropriateness and quality of oral surgery referrals after triage to an IMOS service in Croydon and to set standards for future audits on this topic. METHODS: An audit tool was developed in line with the local referral guidelines and agreed with local stakeholders. Information on 501 (10%) triaged referrals to IMOS practices over a 24-month period was obtained through the referral management centre. A 10% sample of referrals per month to each practice was calculated and IMOS providers randomly selected the relevant patient records. Using an agreed audit pro forma, information on the indications for referral, treatment provided, and dates relating to patient management, in addition to the age and sex of patients, was collected from the IMOS providers by one investigator. Descriptive analysis of the data was performed. RESULTS: Of the 501 patient records that were examined, 99% of patients were treated in IMOS practices, with only three (less than 1%) patients being referred on to hospital consultant services. The largest proportion (237; 40%) of referrals was for the extraction of teeth considered to have special difficulty, followed by lower third molars (154; 26%). Almost one-third (159; 32%) of patients were referred for more than one procedure. One in eight (72; 13%) teeth removed by the IMOS providers were recorded as a simple extraction without medical complications. CONCLUSIONS: In general, patients were referred appropriately to the primary care oral surgery service in Croydon, with only a minority recorded as receiving simple care that should not have required referral. The clinician-led triage process using a referral management system worked well in selecting appropriate patients for treatment by IMOS providers in primary care and reduced referrals to hospital. Suggested standards for future audits of IMOS referrals have been set.

[Histological investigations in ambulatory oral surgery practice]. / Szövettani vizsgálatok az ambuláns szájsebészeti gyakorlatban.

In the practice of oral surgery correspondence with the pathologist is required in order to identify the lesions in question by histologic examination. By current legal regulations the histological evaluation of removed tissues is mandatory. In the presentation the authors process the data obtained in their Department since 2008. Coincidence of the clinical and histological diagnosis is analysed statistically such is the occurrence of various types of oral mucosa lesions and cysts. In cases of presumed malignancy the biopsies were carried out in a department with adequate oncological background. In indications of autoimmun deseases mainly in cases of Sjögren's syndrome the Department has been requested to carry out minor salivary gland biopsies. Statistical analysis of the findings of the minor salivary gland biopsies will also be discussed. The histological diagnoses have been provided by Prof. Zsuzsanna Suba MD, DMD, PhD of the Semmelweis University, Department of Oral and Maxillofacial Surgery, Oral Pathology Unit. In order of prevalence the most common histologically verified lesions were: radicular cyst, fibromas and granulation tissue. In 84.5% of the cases the histological findings confirmed the clinical diagnoses. In 44,5% of the cases Sjögren's syndrome was verified by the minor salivary gland biopsy. Although in most cases the histological examination supported the clinical diagnoses, close cooperation of the oral surgeon and pathologist is essential.

[A clinical study of dental surgery in anticoagulated patients]. / Antikoaguláns kezelésben részesülo betegek szájsebészeti ellátásának klinikai vizsgálata.

It is a worldwide trend that oral surgeons do not stop patients' anticoagulant therapy, but they leave the INR in the therapeutic range (INR: 2.0-3.0). The reason is that stopping drugs carries a higher risk of embolism, and thrombosis. The purpose of the present study is to reproduce these international guidelines in a Hungarian setting. On the day of surgery a lab test is performed immediately before the operation. These tests include coagulation data. A control (INR < 1.89) and an experimental group (INR: 2.0-3.0) were formed. Clinical complications, especially bleeding and thromboembolic complications were monitored. Based on the data and types of surgery no significant differences were found between the two groups. In conclusion it can be stated that it would be advisable to implement international guidelines and recommendations because there is a higher risk for anticoagulated patients if their therapy is stopped as if their INR is left in the therapeutic range. Of course appropriate wound care and bleeding control are necessary.

[Loading, volumes, kinds and structure of work of doctors-dental-surgeons working in system of obligatory medical insurance].

The message concerns problems of calculation of loading of doctors-dental-surgeons, their structures of work. "The Korolevskaya dental polyclinic" is offered to carry out on example STPE the analysis of loading, volumes, kinds and structure of work of the doctors-dental-surgeons working in system OMI.

Antibacterial prophylaxis in dermatologic surgery: an evidence-based review.

Clean, non-contaminated skin surgery is associated with low rates of surgical site infection (SSI), bacterial endocarditis, and joint prosthesis infection. Hence, antibacterial prophylaxis, which may be associated with adverse effects, the emergence of multidrug-resistant pathogens, and anaphylaxis, is generally not recommended in dermatologic surgery. Some body sites and surgical reconstructive procedures are associated with higher infection rates, and guidelines for SSI antibacterial prophylaxis have been proposed for these cases. Large prospective, controlled trials are needed to ascertain the role of oral SSI prophylaxis for these surgical sites and procedures especially in patients with diabetes mellitus who are intrinsically at greater risk of SSI. Topical antibacterial ointment and sterile paraffin appear to make no difference to healing or the incidence of SSIs in clean wounds. Although further research is needed, preliminary studies have shown that intraincisional antibacterials, which may be associated with fewer adverse effects and a lower risk of multidrug-resistant bacteria, could potentially be helpful for SSI prophylaxis. Trials using honey- and silver-impregnated dressings have found no advantage in the healing of chronic wounds. However, several case studies, which need corroboration in larger studies, suggest that these dressings may be helpful in preventing and treating SSIs. Bacterial endocarditis and joint prosthesis infection prophylaxis are not routinely recommended in cutaneous surgery. The updated 2007 American Heart Association guidelines now advocate bacterial endocarditis prophylaxis for high-risk cardiac patients having surgery involving the oral mucosa or infected skin. The latest American Dental Association/American Academy of Orthopaedic Surgery guidelines recommend considering antibacterial prophylaxis for oral procedures where bleeding is anticipated and for surgery involving acute orofacial skin infections if the patient has had a total joint replacement within 2 years or is in a high-risk group and has had a joint replacement at any time.

[New guidelines on the prevention of infective endocarditis. Special aspects for dentists]. / Az infektív endocarditis megelozésének uj irányelvei es fogászati-szájsebészeti vonatkozásai.

Infective endocarditis (IE) is a disease with serious, even fatal complications, often requiring long-term and expensive treatment. Therefore, prophylaxis has emerging importance. Previous guidelines suggested the use of prophylactic treatment for a wide range of patients and procedures. The Working Group of the European Society of Cardiology accepted a new guideline on the prevention, diagnosis, and treatment of infective endocarditis in 2009. One of its major point is a radical decrease in the type of procedures requiring prophylaxis. These changes also affect dental and oral surgical procedures. It is important for dentists and oral surgeons to come to know the changes and to apply them in their everyday practice.

Root coverage esthetic score: a system to evaluate the esthetic outcome of the treatment of gingival recession through evaluation of clinical cases.

BACKGROUND: Generally, esthetic outcomes following root-coverage procedures are not assessed. This article proposes a score for evaluating the esthetic outcome following root-coverage surgery. METHODS: Thirty-one patients with Miller Class I and II recession defects treated with root-coverage procedures were evaluated. Esthetic outcomes were assessed using the root coverage esthetic score (RES) 6 months after surgery. This score evaluates five variables: level of the gingival margin, marginal tissue contour, soft tissue texture, mucogingival junction alignment, and gingival color. Because complete root coverage was the primary treatment goal, and the other variables were considered secondary, the value assigned for root coverage was 60% of the total score, whereas 40% was assigned to the other four variables. With regard to assessment of the final position of the gingival margin, 3 points were given for partial root coverage, and 6 points were given for complete root coverage; 0 points were assigned when the final position of the gingival margin was equal or apical to the previous recession. One point was assigned for each of the other four variables. Thus, 10 points was a perfect score. RESULTS: Of the 31 treated recession defects, 24 (77%) exhibited complete root coverage at 6 months. The mean amount of root coverage was 89.4% (range, 0% to 100%). The mean RES was 7.8. Five of 24 cases of complete root coverage achieved a perfect score (RES = 10). In one case, RES = 0. CONCLUSION: The RES system may be a useful tool to assess the esthetic outcome following root-coverage procedures.

Safe, efficient, and cost-effective orthognathic surgery in the outpatient setting.

There has been a dramatic decline in the number of orthognathic surgery cases over the past 15 to 20 years. This decrease is a result of several compounding factors including decreasing coverage by major medical insurance companies and increasing health care costs. The difficulty associated with making orthognathic surgery financially practical has turned the interest of many oral and maxillofacial surgeons away from orthognathic procedures. The combination of these factors has resulted in decreased availability of surgeons participating in the correction of dentofacial deformities and has forced orthodontists and patients, without surgical correction as an option, to settle for less-than-ideal treatment results. To reverse this trend and make surgery more affordable and available, surgeons must work to make surgical treatment more acceptable to patients. This can be accomplished in several ways. First, the oral and maxillofacial surgery profession must reinforce the importance and value of orthognathic surgery to insurance providers, patients, and referring clinicians, as well as to surgeons within our own specialty. Alternative methods for providing high-quality surgical services at a reasonable cost must be explored including providing options for cost-effective outpatient surgical care, making better arrangements for financial assistance, and exploring options to obtain coverage from third-party providers. Outpatient surgery in facilities that can substantially reduce cost can be an effective way of providing quality treatment that is affordable to patients. Efficient, safe, and effective outpatient orthognathic surgery will help patients benefit from this valuable service.

Has the time come for de-escalation in the management of oropharyngeal carcinoma?

Over the course of the last two decades, there has been a decrease in the incidence of head and neck cancers thanks to a decreasing prevalence of smoking. However, a new risk factor has been coming to the fore: human papillomavirus infection (HPV). HPV-positive oropharyngeal squamous cell carcinoma (HPV+OPC) is more sensitive to chemotherapy and radiotherapy, which translates to a much better prognosis with conventional treatment protocols than tumours that are HPV-negative. Traditional therapeutic interventions are associated with substantial morbidity and have a great impact on patient quality of life. The main focus is on identifying an ideal group of HPV-positive patients who could receive de-intensification treatment regimens aimed at avoiding the late toxicity of treatment. Various strategies are considered, such as reduction in radiotherapy dose following induction chemotherapy, radiotherapy alone, minimally invasive surgical techniques, and substituting platinum-based chemotherapy. The first generation of de-escalation randomised phase III trials have now been published. The following review summarizes the current knowledge and treatment of oropharyngeal carcinoma.

Antibiotic prophylaxis in dermatologic surgery: advisory statement 2008.

BACKGROUND: Antibiotic prophylaxis is an important component of dermatologic surgery, and recommendations in this area should reflect the updated 2007 guidelines of the American Heart Association, the American Dental Association with the American Academy of Orthopaedic Surgeons guidelines, and recent prospective studies on surgical site infection. OBJECTIVE: To provide an update on the indications for antibiotic prophylaxis in dermatologic surgery for the prevention of infective endocarditis, hematogenous total joint infection, and surgical site infection. METHODS: A literature review was performed, expert consensus was obtained, and updated recommendations were created, consistent with the most current authoritative guidelines from the American Heart Association and the American Dental Association with the American Academy of Orthopaedic Surgeons. RESULTS: For patients with high-risk cardiac conditions, and a defined group of patients with prosthetic joints at high risk for hematogenous total joint infection, prophylactic antibiotics are recommended when the surgical site is infected or when the procedure involves breach of the oral mucosa. For the prevention of surgical site infections, antibiotics may be indicated for procedures on the lower extremities or groin, for wedge excisions of the lip and ear, skin flaps on the nose, skin grafts, and for patients with extensive inflammatory skin disease. LIMITATIONS: These recommendations are not based on multiple, large-scale, prospective trials. CONCLUSIONS: There is a strong shift away from administration of prophylactic antibiotics in many dermatologic surgery settings, based on updated authoritative guidelines. These recommendations provide guidance to comply with the most current guidelines, modified to address dermatology-specific considerations. Managing physicians may utilize these guidelines while individualizing their approach based on all clinical considerations.