American Association of Oral and Maxillofacial Surgeon's Position Paper on Oral Mucosal Dysplasia.

Oral potentially malignant disorders (OPMDs) of the oral mucosa include leukoplakia, erythroplakia, erythroleukoplakia, lichen planus, and oral lichenoid lesions, each with varying incidences of dysplastic disease at the time of presentation and each with observed incidences of malignant transformation over time. The primary goal of the management of dysplasia, therefore, includes their early detection and treatment prior to malignant transformation. The recognition and management of these OPMDs and an understanding of their potential progression to oral squamous cell carcinoma will reduce the morbidity and mortality associated with these lesions with expedient and properly executed treatment strategies that will have a positive effect on patient survival. It is the purpose of this position paper to discuss oral mucosal dysplasia in terms of its nomenclature, epidemiology, types, natural history, and treatment to acquaint clinicians regarding the timing of biopsy, type of biopsy, and follow-up of patients with these lesions of the oral mucosa. This position paper represents a synthesis of existing literature on this topic with the intention of closing gaps in our understanding of oral mucosal dysplasia while also stimulating new thinking to guide clinicians in the proper diagnosis and management of OPMDs. The fifth edition of the World Health Organization classification of head and neck tumors published in 2022 represents new information regarding this topic and a construct for this position paper.

Reducing transmission of COVID-19 using a continuous negative pressure operative field barrier during oral maxillofacial surgery.

Oral and maxillofacial surgery in patients with suspected or confirmed COVID-19, presents a high risk of exposure and cross contamination to the operative room personnel. We designed, simulated and implemented a continue negative pressure operative field barrier to provide an additional layer of protection, using standard equipment readily available in most operative rooms during oral and maxillofacial procedures.

Immediate Oral Rehabilitation Using Dental Implants After Marginal Mandibulectomy: A Case Report.

Mandibular reconstruction techniques are always a challenge to oral and maxillofacial (OMF) surgeons. Techniques and treatment plans that offer the patient OMF rehabilitation should always be available. Technological innovations have enabled more rapid, safer, and more secure treatment than in the past. This article describes a case using a different approach. The patient was treated with marginal mandibulectomy and immediate rehabilitation with osseointegrated implants; a hybrid prosthesis was fabricated a short time thereafter. This treatment plan demonstrated its utility and efficiency in this case. An approach with fewer surgeries and OMF rehabilitation needs be considered in all cases.

Prevention of Opioid-Induced Nausea and Vomiting During Treatment of Moderate to Severe Acute Pain: A Randomized Placebo-Controlled Trial Comparing CL-108 (Hydrocodone 7.5 mg/Acetaminophen 325 mg/Rapid-Release, Low-Dose Promethazine 12.5 mg) with Conventional Hydrocodone 7.5 mg/Acetaminophen 325 mg.

OBJECTIVES: To evaluate the prevention of opioid-induced nausea and vomiting (OINV) and the relief of moderate to severe acute pain by CL-108, a novel drug combining a low-dose antiemetic (rapid-release promethazine 12.5 mg) with hydrocodone 7.5 mg/acetaminophen 325 mg (HC/APAP) was used. METHODS: This was a multicenter, randomized, double-blind, placebo- and active-controlled multidose study. After surgical extraction of two or more impacted third molar teeth (including at least one mandibular impaction), 466 patients with moderate to severe pain (measured on a categorical pain intensity scale [PI-CAT]) were randomized to CL-108, HC/APAP, or placebo. Over the next 24 hours, patients used the PI-CAT to assess pain at regular intervals whereas nausea, vomiting, and other opioid-related side effects were also assessed prospectively. Study medications were taken every four to six hours as needed; supplemental rescue analgesic and antiemetic medications were permitted. Co-primary end points were the incidence of OINV and the time-weighted sum of pain intensity differences over 24 hours (SPID24). RESULTS: Relative to HC/APAP treatment alone, CL-108 treatment reduced OINV by 64% (P < 0.001). Treatment with CL-108 significantly reduced pain intensity compared with placebo (SPID24 = 16.2 vs 3.5, P < 0.001). There were no unexpected or serious adverse events. CONCLUSIONS: CL-108 is a safe and effective combination analgesic/antiemetic for the prevention of OINV during treatment of moderate to severe acute pain.

Does Pre-Emptive Administration of Intravenous Ibuprofen (Caldolor) or Intravenous Acetaminophen (Ofirmev) Reduce Postoperative Pain and Subsequent Narcotic Consumption After Third Molar Surgery?

PURPOSE: Pre-emptive analgesia is known to reduce postoperative pain after third molar removal. The purpose of this study was to compare postoperative pain in patients receiving either preoperative intravenous (IV) ibuprofen or preoperative IV acetaminophen for third molar surgery. PATIENTS AND METHODS: This study was a randomized, single-blinded clinical study conducted in patients undergoing surgical extraction of 2 or more impacted third molars under deep sedation. This study compared 2 interventions: 800 mg of IV ibuprofen (Caldolor; Cumberland Pharmaceuticals, Nashville, TN) and 1,000 mg of IV acetaminophen (Ofirmev; Mallinckrodt Pharmaceuticals, Staines-upon-Thames, United Kingdom). The primary outcome variable was postoperative pain measured on a visual analog scale at different time points. The secondary outcome variable was the amount of postoperative analgesic (narcotic and over-the-counter) medication taken in both groups. The Mann-Whitney U test was used to compare groups in terms of outcomes, the χ2 test was used to assess associations between nominal variables, and Spearman correlations were used to assess associations between continuous variables. Significance was set at P < .05. RESULTS: The study sample consisted of 58 patients (39 female and 19 male patients). A total of 41 patients (IV ibuprofen, n = 19; IV acetaminophen, n = 22) completed the study. Equal distributions of age, gender, and number of impacted teeth were noted between the groups. At 4 hours postoperatively, the pain level in the ibuprofen group was significantly lower than that in the acetaminophen group (P = .004). This trend continued at 24 hours (P = .019) and 48 hours (P = .017). The average amount of narcotic medication taken in the ibuprofen group (2.68 ± 2.26 doses) was lower than that in the acetaminophen group (7.32 ± 6.68 doses), and the result was statistically significant (P = .005). CONCLUSIONS: Pre-emptive analgesia with IV ibuprofen is more effective than IV acetaminophen in reducing postoperative pain and opioid use for third molar surgery.

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.

Nevoid Basal Cell Carcinoma Syndrome and the Keratocystic Odontogenic Tumor.

PURPOSE: To analyze the clinical and radiographic manifestations of nevoid basal cell carcinoma syndrome (NBCCS) with a particular emphasis on the presence, treatment, and outcomes of keratocystic odontogenic tumors (KOTs) in these patients. PATIENTS AND METHODS: The authors implemented a prospective case series and enrolled a sample of patients with KOTs and NBCCS. The primary study variables were the demographics, treatment, and outcomes of managing KOTs in this sample. Descriptive statistics were computed. RESULTS: The sample was composed of 16 patients (10 male and 6 female; mean age, 24 yr). These patients presented with 32 previously untreated KOTs. Fifteen patients with 31 KOTs consented to surgery that consisted of a total of 61 procedures during the study period. These procedures included 19 primary enucleation and curettage surgeries and 12 marsupialization procedures followed by secondary enucleation and curettage surgeries. During the course of clinical and radiographic follow-up examinations, 14 new primary and 5 persistent KOTs (refractory to enucleation and curettage surgeries) were diagnosed, of which 13 new primary KOTs and 5 persistent KOTs were treated. A total of 51 KOTs (32 primary, 14 new lesions that developed during follow-up, and 5 persistent lesions) were diagnosed, and 15 patients consented to operative treatment of 49 KOTs. Forty-eight enucleation and curettage surgeries were performed for 49 KOTs that showed effective treatment without persistence in 43 cases (90%) during a follow-up period from 2 to 20 years (mean, 7 yr). One resection was performed for a persistent KOT. The 5-year disease-free estimate after primary enucleation and curettage was 86% (95% confidence interval, 74.8-97.4). Other clinical and radiographic stigmata of the syndrome were diagnosed, including calcified falx cerebri, frontal bossing, hypertelorism, multiple basal cell carcinomas, and others. CONCLUSIONS: The results of this study identify the variable expressivity of this syndrome and the favorable outcomes of marsupialization and enucleation and curettage of syndromic KOTs.

A prospective randomized controlled trial of two different sedation sequences for third molar removal in adults.

PURPOSE: In oral and maxillofacial outpatient surgery, sedation techniques are an important component in patient management for a wide variety of surgical procedures. Fentanyl and midazolam are commonly used sedatives with different mechanisms of action and specific analgesic or amnestic properties. This study examined whether the order of their administration would affect a patient's pain perception or procedural vital signs. MATERIALS AND METHODS: After institutional review board approval and written informed consent, a prospective, randomized, parallel-group clinical trial was conducted in patients who planned to undergo removal of at least 2 third molars under intravenous moderate sedation. Patients were randomly assigned to 1 of 2 groups. The fentanyl-first group received fentanyl and then midazolam; the midazolam-first group received midazolam and then fentanyl. Recollection of the intraoperative pain score was assessed 24 hours after surgery using the Wong-Baker FACES pain scale. The Mann-Whitney U test was used to assess for the presence of a statistically significant difference between the 2 groups. Statistically significant differences in procedural vital sign fluctuations were examined using the t test. Patients' satisfaction with the procedure was assessed and intergroup comparisons were made. RESULTS: Sixty-six patients were enrolled, 1 of whom did not complete the study. Recollected procedural pain scores at 24 hours after surgery were not statistically different between groups. Median scores on the Wong-Baker FACES pain scale for the 2 groups were 2.0 (interquartile range, 3.1) for the fentanyl-first group and 1.5 (interquartile range, 2.5) for the midazolam-first group (P = .333). There was no statistical difference in the change in vital signs from baseline to 2 surgical end points in the 2 groups. In addition, patient satisfaction with the procedure did not statistically differ between the 2 groups. CONCLUSIONS: In this study, selective sequencing of midazolam or fentanyl during an intravenous moderate-sedation procedure did not result in a measurable difference of recollected procedural pain scores at 24 hours after third molar extraction. The choice of the sedation agents and the order of their administration should be tailored to the patient's needs, type of surgical procedure, and surgeon preference.