Arthrocentesis versus occlusal coverage splints in the management of disc displacement without reduction: a systematic review and meta-analysis.

Disc displacement without reduction (DDwoR) can cause pain and limitations in mouth opening, with a significant impact on function. The optimal management strategy for DDwoR is unclear. Treatments include conservative management such as mandibular manipulation, occlusal splints, and patient education/self-management, as well as arthrocentesis, which is a minimally invasive procedure. The aim of this systematic review and meta-analysis was to ascertain whether there is a role for arthrocentesis in the management of DDwoR. Studies analysing the outcomes pain and maximum mouth opening (MMO) in patients with DDwoR treated by arthrocentesis or occlusal coverage devices were eligible for inclusion. Following a database search, six studies with a total of 343 participants were found to be eligible for analysis (three prospective observational studies, one retrospective observational study, one non-randomized single-blind clinical trial, and one unblinded randomized clinical trial). When compared to occlusal coverage splints, arthrocentesis demonstrated a slight improvement in pain, although this was statistically non-significant (standardized mean difference (SMD) -0.50, 95% confidence interval (CI) -1.04 to 0.05, P = 0.07; I2 = 81%), and a significant improvement in MMO (SMD 0.79 mm, 95% CI 0.24-1.35 mm, P = 0.005; I2 = 79%). However, due to the significant heterogeneity between studies and the high risk of bias, along with the paucity of double-blind randomized controlled clinical trials, definitive conclusions cannot be drawn for this clinical question.

Antibiotic prophylaxis in alloplastic temporomandibular joint replacement surgery: A multi-national survey of temporomandibular joint surgeons.

Temporomandibular disorders include a wide spectrum of extra-articular and intra-articular conditions affecting the temporomandibular joint (TMJ). In salvage cases involving intra-articular end-stage disease, alloplastic temporomandibular joint replacement (TMJR) is a management option which can be utilised to rehabilitate a disabled joint's function and form. Whilst post-TMJR infection is rare, it is one of the most serious complications. The principles governing TMJR surgery antibiotic prophylaxis have been based on those established in orthopaedic surgery literature. Antibiotic resistance due to antibiotic over-use is a significant concern, therefore antibiotic stewardship has been developed to deal with this world-wide public health concern. The TMJ's anatomical proximity to the external auditory canal and oral cavity creates the potential for bacterial contamination. The aim of this study was to explore the views of 39 sub-specialist TMJ surgeons across nine nations usual approach to antibiotic prophylaxis and their management of TMJR infection. To accomplish this, an international survey was developed and conducted using Google Forms. The results demonstrated that 97.4% of the respondents employ prophylactic antibiotics at TMJR surgery, 83.8% on discharge. Variability in antibiotic choice with additional antimicrobial perioperative practices were also reported. Opinions on the management of a TMJR infection also varied. This survey establishes there is an agreement on the use of antibiotic prophylaxis, However the variability in choice, timing, course, duration of antibiotic use as well as the management of a postoperative TMJR infection demonstrates the need for further study leading to development of standardised antibiotic prophylaxis and infection management protocols for TMJR surgery.

Predictors and risk factors for admission to critical care in cervicofacial infections: a Maxillofacial Trainee Research Collaborative (MTReC) study.

Cervicofacial infections carry significant morbidity. Patients present on a broad spectrum of severity, with some requiring outpatient management and others admission to higher level care. Recognition of risk factors is helpful in decision making regarding the need for admission to higher level care. Prospective data were captured on 1002 patients in 25 centres across 17 regions of the United Kingdom (UK) by the Maxillofacial Trainee Research Collaborative (MTReC). Patients admitted to critical care were compared with those who received ward-level care. Multivariate and receiver operating characteristic curve analyses were used to identify predictors for critical care admission. Our results show that the best predictor for critical care admission is the presence of three or more features of airway compromise (AUC 0.779), followed by C-reactive protein (CRP) >100 mg/L (OR 2.70; 95% CI 1.59 to 4.58; p < 0.005), submandibular space involvement (OR 3.82; 95% CI 1.870 to 7.81; p = 0.003), white cell count (WCC) >12 × 109/ dl (1.05; 95% CI 1.01 to 1.10; p = 0.03), and positive systemic inflammatory response syndrome criteria (OR 2.78; CI 1.35 to 5.80; p = 0.006). Admission to critical care is multifactorial, however, the presence of three or more features of airway compromise is the best predictor. Awareness of this alongside other key clinical findings in cervicofacial infections may allow for the early recognition of patients who may require escalation to critical care.

Emergency versus semi-elective management of mandible fractures: a Maxillofacial Trainee Research Collaborative (MTReC) study.

INTRODUCTION: Recent evidence suggests that acute emergency management of mandible fractures does not improve surgical outcomes yet is associated with increased financial burden. Current NHS policy advocating for increased adoption of day-case and semi-elective surgical procedures to reduce bed strain must be balanced with providing timely, effective treatment. Our research aims to determine patient groups currently managed via semi-elective admission and whether this can be extended to other groups to provide safe and effective management of mandible fractures. METHODS: A multi-national trainee-led audit of mandibular fractures across 49 units was completed by the Maxillofacial Trainee Research Collaborative (MTReC). Each unit prospectively collected data on fractures on admission and at follow-up. Data collected included patient demographics, behaviour, health, injury, timing to intervention and surgical complications. RESULTS: Data were collected on 947 mandibular fractures. Of the surgically managed patients, 649 (90%) were managed via acute emergency admission at the time of presentation, while 68 (10%) were managed semi-electively. Patient demographics, injury pattern and mechanism appeared to significantly affect timing of management, whereas patient behaviour, health status, timing of injury and presentation did not. Semi-elective management was associated with a significantly shorter inpatient duration (0.9 versus 1.9 days, p=0.000) with no differences in readmission, antibiotic usage or surgical complications (p=1.000, RR 1.030). CONCLUSION: Our study demonstrates the efficacy of planned admissions and semi-elective management of mandibular fractures. Simple mandibular fractures in compliant patients are suitable for semi-elective treatment. Holistic patient assessment and tailored surgical planning is crucial in determining admission modality to effectively manage mandibular trauma.

Risk factors associated with short-term complications in mandibular fractures: the MANTRA study-a Maxillofacial Trainee Research Collaborative (MTReC).

INTRODUCTION: Complications following mandibular fractures occur in 9-23% of patients. Identifying those at risk is key to prevention. Previous studies highlighted smoking, age and time from injury to presentation as risk factors but rarely recorded other possible confounders. In this paper, we use a collaborative snapshot audit to document novel risk factors and confirm established risks for complications following the treatment of mandibular fractures. METHODS: The audit was carried out by 122 OMFS trainees across the UK and Ireland (49 centres) over 6 months, coordinated by the Maxillofacial Surgery Trainees Research Collaborative. Variables recorded included basic demography, medical and social history, injury mechanism and type, management and 30-day outcome. RESULTS: Nine hundred and forty-seven (947) patients with fractured mandibles were recorded. Surgical management was carried out in 76.3%. Complications at 30 days occurred 65 (9%) of those who were managed surgically. Risk factors for complications included male sex, increasing age, any medical history, increasing number of cigarettes smoked per week, increasing alcohol use per week, worse oral hygiene and increased time from injury to presentation. DISCUSSION: We have used a large prospective snapshot audit to confirm established risk factors and identify novel risk factors. We demonstrate that time from injury to presentation is confounded by other indicators of poor health behaviour. These results are important in designing trial protocols for management of mandibular fractures and in targeting health interventions to patients at highest risk of complications.

Does anticoagulation improve outcomes of microvascular free flap reconstruction following head and neck surgery: a systematic review and meta-analysis.

The commonest cause of microvascular free flap failure is thrombosis at the anastomosis. Pharmacological antithrombotic therapies have been used to mitigate this risk, but they carry the risk of bleeding and haematoma formation. To justify any intervention, it is necessary to evaluate the benefits and balance of risks. This meta-analysis aims to quantify the value of systemic anticoagulation during head and neck free tissue reconstruction. We performed a systematic review on the impact of additional prophylactic antithrombotic therapy on head and neck (H&N) free tissue transfer (on top and above the use of low molecular weight heparin to prevent deep vein thrombosis). We carried a PRISMA-guided literature review, following registration with PROSPERO. All studies analysing the possible impact of prophylactic anticoagulants on free flap surgery in the head and neck were eligible. The primary outcome was perioperative free flap complications (perioperative thrombosis, partial or total free flap failure, thrombo-embolic events, or re-exploration of anastomosis). Secondary outcomes included haematoma formation or bleeding complications requiring further intervention. We identified eight eligible studies out of 454. These included 3531 free flaps for H&N reconstruction. None of the assessed interventions demonstrated a statistically significant improvement in free flap outcomes. Accumulative analysis of all anti-coagulated groups demonstrated an increased relative risk of free flap complications [RR 1.54 (0.73-3.23)] compared to control albeit not statistically significant (p = 0.25). Pooled analysis from the included studies showed that the prophylactic use of therapeutic doses of anticoagulants significantly (p = 0.003) increased the risk of haematoma and bleeding requiring intervention [RR 2.98 (1.47-6.07)], without reducing the risk of free flap failure. Additional anticoagulation does not reduce the incidence of free flap thrombosis and failure. Unfractionated heparin (UFH) consistently increased the risk of free flap complications. The use of additional anticoagulation as 'prophylaxis' in the perioperative setting, increases the risk of haematoma and bleeding.

Antibiotic practices in non-condylar mandibular fractures: a Maxillofacial Trainee Research Collaborative (MTReC) UK-wide survey.

Non-condylar mandibular fractures are consdered 'open' fractures and as such are thought to require prophylactic antibiotics. There is no overall consensus on the optimal regimen or choice of antibiotic in the preoperative and postoperative periods due to a lack of high-quality evidence. We therefore set out to ascertain the current UK-wide practice of antibiotic prescribing for non-condylar mandibular fractures. We used a web-based online survey (Google Forms) that was disseminated via email and social media platforms to oral and maxillofacial surgery (OMFS) consultants and trainees of all grades. The questions focused on usual antibiotic practices and typical clinical management of non-condylar mandibular fractures. We gathered information on preoperative antibiotics, and on perioperative and postoperative periods. We collected data from 50 different UK OMFS units representing a broad snapshot of national practice. The majority of responders were speciality trainees (36%) followed by dental core trainees (34%). A total of 45/50 centres routinely admitted patients, and preoperative intravenous antibiotics were commenced on admission by 77/89 respondents, intravenous being the chosen route in all cases. In the preoperative period 81% prescribe co-amoxiclav. In 91% of cases, open reduction and internal fixation (ORIF) was on general emergency (CEPOD) operating lists, whilst dedicated OMFS trauma lists accounted for 9%. With respect to timing, 49% aimed to carry out ORIF within 24 hours from the time of admission, 44% aimed for surgery within 24 - 48 hours, and 6% aimed for surgery on a semielective basis (48 hours or more). Postoperative antibiotics were prescribed routinely by 88% of responders. Preoperative intravenous prophylactic antibiotics are commonplace in non-condylar mandibular fractures. This UK-wide survey demonstrated significant variability in antibiotic prescribing practices, especially in the postoperative period. Most units still rely on CEPOD emergency theatres to provide the capacity for ORIF in this patient group.

Use of antibiotics in traumatic mandibular fractures: a systematic review and meta-analysis.

The treatment of traumatic mandibular fractures constitutes a significant part of the oral and maxillofacial trauma service's workload. There are potential variations in how they are managed. Patients are often admitted and given intravenous antibiotics prior to their definitive treatment. The evidence behind this is inconclusive. We performed a systematic review as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance/ PROSPERO Registered (CRD:42020201398) on the use of antibiotics in the management of mandibular fractures. We identified studies using a search algorithm within the OVID Gateway (including MEDLINE, PubMed, and Cochrane Collaborative). Studies analysing the possible impact of prophylactic antibiotics on traumatic mandibular fractures were eligible. The primary outcome was surgical site infection requiring any treatment beyond the normal postoperative protocol. Secondary outcomes included any complication requiring further intervention. From the 16 studies identified (3,285 patients), seven were randomised controlled clinical trials (RCTs) and nine were retrospective observational studies. We have identified significant between-study variation in choice of antibiotic regimen (timing, dosage, duration) and in reporting both primary and secondary outcomes. There was significant between-study heterogeneity (p = 0.02, I2 = 69%) and none of the assessed interventions was found to be superior. The evidence behind the use of prophylactic antibiotics in mandibular fractures is weak. A properly designed and powered RCT is needed, in order to standardise practice for the benefit of patients and healthcare systems.

Management of oral and maxillofacial trauma during the first wave of the COVID-19 pandemic in the United Kingdom.

We assess the effect of coronavirus disease 2019 (COVID-19) on UK oral and maxillofacial (OMF) trauma services and patient treatment during the first wave of the pandemic. From 1 April 2020 until 31 July 2020, OMF surgery units in the UK were invited to prospectively record all patients presenting with OMF trauma. Information included clinical presentation, mechanism of injury, how it was managed, and whether or not treatment included surgery. Participants were also asked to compare the patient's care with the treatment that would normally have been given before the crisis. Twenty-nine units across the UK contributed with 2,229 entries. The most common aetiology was mechanical fall (39%). The most common injuries were soft tissue wounds (52%) and, for hard tissues, mandibular fractures (13%). Of 876 facial fractures, 79 patients' treatment differed from what would have been normal pre-COVID, and 33 had their treatment deferred. Therefore the care of 112 (14%) patients was at variance with normal practice because of COVID restrictions. The pattern of OMFS injuries changed during the first COVID-19 lockdown. For the majority, best practice and delivery of quality trauma care continued despite the on-going operational challenges, and only a small proportion of patients had changes to their treatment. The lessons learnt from the first wave, combined with adequate resources and preoperative testing of patients, should allow those facial injuries in the second wave to receive best-practice care.

Management of odontogenic cervicofacial infections presenting to oral and maxillofacial units during the first wave of the COVID-19 pandemic in the United Kingdom.

On 25 March 2020, the Chief Dental Officer issued national guidance restricting the provision of all routine, non-urgent dental services in response to the spread of COVID-19. We analysed odontogenic cervicofacial infections (CFI) presenting to oral and maxillofacial surgery (OMFS) departments during the first wave of COVID-19 in the United Kingdom. From 1 April 2020 until 31 July 2020 a database was used to prospectively collect records for all patients with CFI who presented to oral and maxillofacial teams. Information gathered included clinical presentation, location/origin of infection, and how this was managed. The OMFS units were asked to compare the patient's care with the treatment that would usually have been given prior to the crisis. A total of 32 OMFS units recorded 1381 cases of CFI in the UK. Most of the infections were referred via the emergency department (74%). Lower first or second molars were the most common origin, contributing 40% of CFI. Collaborators reported that patients' treatments were modified as a response to COVID in 20% of cases, the most frequently cited reason being the application of COVID-19 hospital policy (85%). The impact of the first wave of COVID modified the management of a significant number of patients presenting with CFI, and there was a proactive move to avoid general anaesthetics where possible. Some patients who presented to secondary care were given no treatment, suggesting they could have been managed in primary dental care if this had been available. We recommend that OMFS units and urgent dental care centres (UDCCs) build strong communication links not only to provide the best possible patient care, but to minimise COVID exposure and the strain on emergency departments during the pandemic.

Clinical features and presentation of cervicofacial infection: a Maxillofacial Trainee Research Collaborative (MTReC) study.

Cervicofacial infection (CFI) is a common presentation to the Oral and Maxillofacial (OMFS) department and accounts for significant emergency activity. The current study aims to understand the aetiology, management, and clinical features of patients hospitalised with CFI. Our study included all patients admitted for management of CFI from May to October 2017 at 25 OMFS units across 17 UK regions. Data were collected prospectively and included age, comorbidities, prior treatment received, markers of sepsis, and presenting clinical features. One thousand and two (1002) admissions were recorded; 546 (54.5%) were male. Median (range) age was 34 (1-94) years. The most common presenting complaints were trismus (46%) and dysphagia (27%). Airway compromise was present in 1.7% of cases. Odontogenic infection accounted for 822/1002 (82%) admissions. Of those with an infection of odontogenic origin, 453/822 (55.1%) had received previous treatment. Two-thirds of those who had received treatment were managed by antibiotics alone (300/453, 66.2%). Patients met criteria for sepsis in 437/1002 (43.6%) of CFI, and in 374/822 (45.5%) of odontogenic infections. This is the largest study worldwide of patients requiring inpatient management for CFI. Infection due to odontogenic origin is the most frequent reason for admission and nearly half do not seek treatment before presentation. Patients with CFI often present late in their disease and frequently meet criteria for sepsis, requiring timely and aggressive treatment to ensure optimum outcomes. Trismus is an emerging dominant feature with all the implications related to the anaesthetic management of these patients. Knowledge of these factors has implications for the referrer, triage, the emergency department, the anaesthetic team, and members of the OMFS team.

Impacts of lockdown during the SARS-CoV-2 pandemic on patients presenting with cervicofacial infection of odontogenic origin: a comparative study.

The SARS-CoV-2 pandemic caused unprecedented disruption to primary and secondary healthcare services. Our aim was to explore whether the pandemic had had any impact on patients presenting with cervicofacial infections (CFI) of odontogenic origin to secondary care and management. Comparative analysis was carried out evaluating prospective and retrospective consecutively admitted patients with a diagnosis of CFI of odontogenic origin in the COVID-19 lockdown period from 15 March to 15 June 2020 and pre-COVID-19 during the same period of the previous year. Data included patients' demographics, comorbidities, systemic inflammatory response syndrome (SIRS) status on admission, clinical features, prior treatment in primary care, source of referral, SARS-COV-2 antigen status, treatment received in secondary care, intraoperative findings, and whether escalation of the level of care was required. Across both cohorts there were one hundred and twenty-five (125) patients admitted with CFI of odontogenic origin, with a 33% reduction (n=75 (2019) vs n=50 (2020)) in number of patients admitted during COVID-19 lockdown. There was no difference between the cohorts in terms of age (p=0.192), gender (p=0.609) or major comorbidities (p=0.654). Proportionally more patients in the COVID-19 group presented with SIRS (p=0.004). This group of patients persisted with symptoms for longer before presenting to secondary care (p=0.003), more delay from hospital admission to surgical intervention (p<0.005) and had longer hospital stays (p=0.001). More patients required extraoral surgical drainage during COVID-19 (p=0.056). This study suggests that the COVID-19 lockdown has had adverse effects on the presentation of CFI of odontogenic origin and its management within a Regional Acute Maxillofacial Service. Commissioners and clinicians should endeavour to plan for adequate primary and secondary care provision during any future local lockdowns to ensure that patient care is optimised.

Systematic review of the role of corticosteroids in cervicofacial infections.

The role of corticosteroids in the management of cervicofacial infections continues to cause controversy. Systemic anti-inflammatory and immunomodulatory effects that reduce swelling and improve symptoms in the head and neck may make these agents an effective addition to the antibiotics used and to surgical management, although this same effect may dull the physiological response to infection, and allow infections to progress. We have systematically reviewed the evidence for the use of corticosteroids in common cervicofacial infections following the PRISMA guidelines. MeSH terms included "head", "neck", "infection", and "glucocorticoid". In total, 31 papers were identified. Eight reported the use of corticosteroids for peritonsillar abscess (PTA), 10 for pharyngitis, four for deep neck space infection (DNSI), four for periorbital cellulitis, and five for supraglottitis. Whilst there is an established evidence base for their use in the treatment of PTA and pharyngitis, other indications need further study, and we highlight the potential pitfalls. The evidence suggests that the use of adjunctive, short-term, high-dose corticosteroids in cervicofacial infections may be safe and effective.

Management of cervicofacial infections: a survey of current practice in maxillofacial units in the UK.

Cervicofacial infections are common emergency presentations to maxillofacial departments in the UK, there is no consensus about their management and, in particular, the role of corticosteroids is not clear. Our aim was to find out the current practice of UK maxillofacial surgeons in managing these infections using a multicentre questionnaire study. The questionnaire was designed, piloted, and revised before distribution, and questions were asked to assess preoperative, operative, and postoperative management. It was distributed to maxillofacial surgeons throughout the UK through the Maxillofacial Research Trainee Collaborative (MTReC) network, and at the 2016 British Association of Oral and Maxillofacial Surgeons (BAOMS) Junior Trainees Group conference. A total of 350 questionnaires were distributed to 17 maxillofacial units. Eighty-six questionnaires were distributed at the BAOMS Junior Trainee conference. An overall response rate of 92% (n=324) was achieved. The results showed that there were important differences in reported practice between and within maxillofacial units in the UK in managing these infections. The antibiotic regimens and use of steroids varied widely. Twenty-three per cent of respondents had to wait over 24hours for access to emergency theatres. However, these results provide no hard evidence for or against the use of corticosteroids in cervicofacial infections.

Interventions for the prevention of dry socket: an evidence-based update.

This paper reviews the latest evidence for local and systemic interventions for the prevention of alveolar osteitis (dry socket). Dry socket is a painful and common post-operative complication following exodontia. Any interventions for the prevention of dry socket could reduce both its incidence and help avoid this painful complication. Prophylactic measures proposed in the literature are discussed. Furthermore, this article discusses both the clinical and histological stages of a normal healing socket.

Drug interactions in general dental practice--considerations for the dental practitioner.

The aim of this article is to explore the diverse and complex nature of pharmacological drug-drug interactions in the general dental practice setting. Using published NHS statistics, this article will highlight medications for common medical conditions that could interact with frequently prescribed drugs by the general dental practitioner.