Does systemic steroid use affect the length of hospital stay for head and neck infections?

OBJECTIVE: The purpose of this study was to conduct a systematic review to perform a meta-analysis to investigate the outcomes of head and neck infections treated with systemic steroids. STUDY DESIGN: The protocol was registered to the International Prospective Register of Systematic Reviews on August 24, 2020. The studies were compiled using PubMed/Medline with a single reviewer from their inception until August 17, 2020. The studies were uploaded onto Convidence.org, and a repeat search was conducted and uploaded on August 17, 2021. Two independent reviewers (J.S. and S.H.) blinded to each other's assessments reviewed the title and/or abstract for inclusion. After a first pass, full-text reviews of the articles were assessed (J.S. and K.F.) for study inclusion. Data were extracted from the steroid (test) and nonsteroid (control) cohorts. RESULTS: The initial search of key terms yielded 2,711 studies. Titles and abstracts were reviewed, and only cohort and/or cross-sectional studies with the relevant study groups and the relevant outcomes were retrieved for the filtration system. The 2 reviewers reviewed 188 full-text studies, and 3 studies met the inclusion criteria. Although all 3 studies included the mean length of stay for the treatment and a control group, only 2 studies included the confidence interval, and only 1 included P values. Overall, the studies presented insufficient data to pool outcomes and ran a statistical analysis for meta-analysis. CONCLUSIONS: Steroid use reduced the length of stay in 2 studies and increased the length of stay in another larger study. Given the lack of data to perform a meta-analysis, more studies need to be conducted, with a prospective randomized control trial design being essential for guiding evidence-based practice regarding the use of steroids in head and neck infections.

Opioid-Prescribing Patterns in Connecticut and New Jersey Following Third Molar Extractions.

OBJECTIVE: In recent years, opioid misuse has resulted in much scrutiny on providers' prescribing habits. The purpose of this study was to analyze prescribing habits in the context of third molar extractions as a model for promoting better postsurgical pain management. METHODS: This was a cross-sectional survey of oral maxillofacial surgeons in Connecticut and New Jersey. A total of 291 practitioners were contacted to complete an online survey using Qualtrics Research Services to determine prescribing habits following third molar extractions. RESULTS: The most common approach for postoperative analgesia was nonsteroidal anti-inflammatory drugs (NSAIDs) and an opioid/acetaminophen (APAP) combination as 2 separate prescriptions, reported by 36% of participants. The combination of hydrocodone/APAP was the most common opioid formulation, and an average of 10.93 ± 4.51 opioid pills were prescribed with a maximum of 20 pills reported. Most providers (79%) consistently provided patients with opioid information. Only 22% reported always checking opioid-monitoring programs; however, providers were more likely to check if prescribing more than ∼11 opioid pills (P = .0228). Most reported using dexamethasone (82%) and bupivacaine (56%) intraoperatively, while ketorolac was less common (15%). No association was found between the quantity of opioids prescribed and the use of intraoperative ketorolac, steroids, or bupivacaine (P > .05). CONCLUSION: There remains to be a universal standard for using opioids for postoperative pain management in dentistry. Providers should be mindful when prescribing opioids and consider using NSAIDs and APAP for baseline pain plus a separate opioid prescription for breakthrough pain. Additional focus on minimizing the quantity of opioids prescribed and self-reflecting on prescribing and practice habits to further reduce opioid-related complications is warranted.

Are we training oral and maxillofacial surgeons in minimally invasive cosmetic procedures?

OBJECTIVE: Oral and maxillofacial surgeons (OMS) are well trained in facial anatomy, but exposure to cosmetic procedures in residencies is inconsistent due to several factors, including the patient population, technique, and cost. The primary objective of the present study was to identify an association with exposure to treatment modality in residency with likelihood to perform these procedures in practice. STUDY DESIGN: This was a cross-sectional survey distributed to practicing OMS in the United States. Links to the online survey were distributed using communications from local, state, and regional OMS surgery societies. Information was gathered on clinical practice and training during and after residency. The study outcome was whether the respondent performed injectables (dermal fillers or neuromodulators) in their practice. RESULTS: A total of 150 responses were included in the study sample, and no responses were excluded. Only 42.7% of respondents reported performing injectables. Just 37% of respondents stated they had had an opportunity to perform these procedures as a resident, suggesting that 5.7% did not perform injectables until they started practice. Dual-degree training, additional fellowship training, and practical and didactic continuing education training were all associated with higher likelihoods of having an injectable practice. Injectable exposure in residency did not significantly affect the prevalence of having an injectable practice. CONCLUSIONS: OMS who performed injectables were more likely to seek additional forms of training outside of residency. Educators should reevaluate the way that they are approaching cosmetics procedures in residency.

The Liability of Performing Orthognathic Surgery.

Study Design: This is a retrospective case series using the Thomson Reuters Westlaw Edge database, an online subscription-based database of over 40,000 state and federal records. Objective: There is growing academic interest in the medical malpractice literature. The primary objective of this study was to examine medical malpractice in orthognathic procedures in order to characterize factors that determine legal responsibility and help make the craniomaxillofacial (CMF) surgeon more comfortable when treating this patient population. Methods: The database was queried for medical malpractice cases involving orthognathic surgery from 1985-2021. The characteristics of each lawsuit were identified, and descriptive statistics were reported. Results: A total of 42 CMF malpractice cases were available for review, and total of 15 cases were included in the final sample. Verdict decisions and settlements occurred between 1991 and 2012. Of the 15 cases, the highest concentration of cases occurred in California (6) and Pennsylvania (2). 53% of cases were ruled in favor of the defendant, 7% of cases were settled, 27% of cases were ruled in favor of the plaintiff against the surgeon, and 13% were ruled in favor of the plaintiff against the hospital with the surgeon being found not liable. The minimum award of damages was $29,999 and the maximum was $550,000. Conclusion: Litigation experience can be very time consuming and troublesome for medical practitioners. The risk of litigation and complications might be a prohibiting factor as to why CMF surgeons may not be preforming orthognathic surgery. The best defense against a malpractice case is to avoid one altogether. Learning from past mistakes is one way of ensuring that goal.

Outcomes of Clinical Trials on Osteonecrosis of the Jaw.

OBJECTIVE: The purpose of this study was to provide a cross-sectional view of all registered clinical trials enrolling patients with osteonecrosis of the jaw (ONJ). The primary aim was to report predictors of trial completion and publication of results. MATERIALS AND METHODS: This is a cross-sectional study of ONJ trials registered with ClinicalTrials.gov. For each included entry, trial characteristics and endpoints were recorded. Predictors were enrollment size, etiology, study type, intervention type, sponsor, funding, study locations, number of centers, and specialty of the principal investigator. Outcomes were trial status, publication on PubMed, journal of publication, and length of time between endpoints. Associations between predictors and outcomes were evaluated using chi-square tests and t-tests. RESULTS: The final sample included 26 trials. Overall, 50% of trials were completed and 69% of completed trials were published. Three out of four terminated trials were suspended due to lack of funding. The median enrollment for completed trials was 149 participants with a mean length of five years. All trials included medication-related osteonecrosis of the jaw (MRONJ) patients and 26% also included osteoradionecrosis of the jaw (ORNJ) patients. The majority of trials were observational (65%), conducted internationally (62%), and involved multiple centers (54%). Published trials had a mean time of 5.9 years between trial start and publication, which was comparable to trial length (p=0.90) and appeared in either dental (44%) or cancer (56%) journals. Completion and publication rates were not significantly increased by industry sponsorship/funding, larger enrollment sizes, or multi-center involvement. Oral and maxillofacial surgery was the most represented dental specialty of principal investigators (56%). CONCLUSIONS: The majority of completed ONJ trials had their results published in a timely manner. Evidence-based investigation of ONJ is a multi-disciplinary and international effort. Among all specialists, oral and maxillofacial surgeons led the most ONJ trials.

Factors Affecting Outcomes of Craniofacial Clinical Trials.

PURPOSE: This study aims to provide a cross-sectional view of craniofacial trials and to identify factors associated with completion, publication, and trial longevity. MATERIALS AND METHODS: This is a cross-sectional study of cleft and craniofacial clinical trials registered with ClinicalTrials.gov between September 1999 and April 2020. Predictor variables included funding source, trial design, trial location, number of recruitment sites, and investigator specialty.Study outcomes were completion status, publication status, and trial duration. Univariate comparisons and multivariate regression models were calculated for each outcome. RESULTS: The final sample included 179 clinical trials pertaining to craniofacial care. Nearly all trials were single-center (86.5%), and roughly half of trials were interventional (57.0%) or conducted in the United States (40.5%). No single specialty predominated, although plastic surgery (13.4%) was the most common investigator specialty. The completion rate was 82.7%, the publication rate was 40.8%, and the mean trial duration was 39.1 months. Interventional design (odds ratio = 0.30, P = 0.02) and United States location (odds ratio = 0.15, P < 0.01) were each independently associated with lower odds of trial completion. Trial longevity was independently associated with the National Institute of Health-funding (P < 0.01) and multicenter design (P < 0.01). CONCLUSIONS: Craniofacial trials are multidisciplinary and have a high rate of completion. Although most existing trials were conducted at only a single-center, multicenter efforts significantly increased trial longevity without compromising completion and publication rates. Given the diverse array of conditions and lines of inquiry that compose craniofacial care, it is reassuring that collaboration did not negatively affect trial outcomes.

Is Weekend Presentation Associated With Odontogenic Infection Severity?

PURPOSE: Many dental infections that otherwise could be treated in-office are directly referred to emergency departments (ED) outside of normal business hours. This study sought to determine if odontogenic infections presenting to EDs were less severe on the weekends. MATERIALS AND METHODS: This was a retrospective cohort study of the 2014 Nationwide Emergency Department Sample. All patients with the primary diagnosis of an oral soft tissue infection were included in the study sample. The primary study predictor was day of presentation. The study outcome was inpatient admission from the ED. A multivariate regression model was created for ED admission rate to identify independent predictors. RESULTS: A total of 6,560 records were included in the final sample. Overall, 34.8% of encounters occurred on the weekend, and these patients were more likely to have private insurance and reside in higher income locations. The unadjusted ED admission rate (9.4 vs 13.4%, P < .01) was lower for patients evaluated on the weekend. The multiple regression model confirmed that weekend presentation was associated with a significantly lower odds of admission (OR = 0.69, P < .01). CONCLUSIONS: Weekend odontogenic infections were less severe than those presenting on the weekdays. Off-hour dental emergencies remain a potential source of ED waste and should be scrutinized in any reforms seeking to reduce unnecessary emergency room encounters.

COVID-19 Pandemic and its Impact on Dentistry: A Cross-sectional Survey of Practicing Dentists.

AIM AND OBJECTIVE: The purpose of this study was to evaluate the economic impact and the dental practice changes associated with the coronavirus disease-2019 (COVID-19). MATERIALS AND METHODS: This was a cross-sectional survey conducted at the peak of the COVID-19 pandemic (May 2020). The study sample was derived from the Columbia University College of Dental Medicine Alumni network, which included the graduating classes between 1975 and 2015. Active dental practitioners were surveyed regarding changes to their current operations and protective safety measures through a 22 closed-ended questionnaire-based survey. RESULTS: The response rate was 17%. Nearly 70.92% of respondents laid off at least one staff member during the COVID-19 pandemic, 51.80% expressed fear of permanent closure, and 79.43% applied for a small business administration loan. There were no significant associations between the amount of time in practice and the need to lay off staff members, the fear of going out of business, or the rates of application for the small business administration loan. Many practitioners bought at least one device geared toward reducing COVID-19 transmission, such as ultraviolet (UV) lights (26.21%), extraoral suctions (37.31%), and high-efficiency particulate air (HEPA) air filters (54.55%). CONCLUSION: At the peak of the pandemic, the majority of dental providers had to reduce staff and seek financial assistance. Concurrently, many of these practices also invested in new safety equipment with the intention of reducing viral transmission. CLINICAL SIGNIFICANCE: External mouth suctions, commercial air purifiers, and air exchange devices might be useful in the private practice setting. However, financially strained practitioners should recognize that these devices have not currently been proven to be effective against the COVID-19 virus. How to cite this article: Cimilluca JJ, Lee KC, Halepas S et al. COVID-19 Pandemic and its Impact on Dentistry: A Cross-sectional Survey of Practicing Dentists. J Contemp Dent Pract 2021;22(5):473-478.

The Past Decade in Courts, What Oral-Maxillofacial Surgery Should Know About Facial Cosmetic Surgery.

PURPOSE: The primary objective of this study was to examine medical malpractice in facial cosmetic surgery procedures to characterize factors that determine legal liability and help make the oral-maxillofacial surgeon (OMS) more comfortable with treating this patient population. METHODS: The Thomson Reuters Westlaw Edge is a subscription-based legal database that contains decisional law and other data from a variety of state and federal court records. The database was queried for medical malpractice cases involving facial surgical cosmetic procedures from 2010 to 2020. RESULTS: A total of 763 malpractice cases were identified through the search. After removing duplicates, 758 malpractice cases were hand reviewed based on inclusion/exclusion criteria. A total of 55 cases met criteria for inclusion. Verdict decisions and settlements occurred in the years of 2010 to 2019. Of those 55 cases, the highest concentration of cases occurred in New York (14), California (10) and Pennsylvania (6). Seventy-four percent of the verdicts were in favor of the defendant, 4% of cases settled and 22% of cases were decided in favor of the plaintiff. The minimum award of damages was $8,597.71 with the maximum of $4,150,000.00 (mean: $72,1915.69 ± $1,131,245.94). The provider's primary specialty was most often plastic and reconstructive surgery (84%), followed by ophthalmology (7%), dermatology (3%) and ENT (4%). CONCLUSION: While it is comforting to know that 74% of malpractice cases in the last decade were found in favor of the surgeon, it is important to realize how devastating the litigation experience can be for a medical practitioner. The best defense to a malpractice case is to avoid one altogether. Learning from past mistakes is one way of ensuring that goal.

Oral manifestations of COVID-2019-related multisystem inflammatory syndrome in children: a review of 47 pediatric patients.

BACKGROUND: Although much is still unknown about the full effects of COVID-19, literature from the early stages of the COVID-19 pandemic (spring and summer 2020) supports a postviral immunologic reaction resulting in a multisystem inflammatory syndrome in children (MIS-C). The purpose of this study was to report the rates of documented oral and oropharyngeal manifestations among these patients and to determine the association of these findings with other MIS-C symptoms. METHODS: The authors conducted a retrospective review of pediatric patients with COVID-19 who were admitted to the Morgan Stanley Children's Hospital of NewYork-Presbyterian. Patients fulfilling the Centers for Disease Control and Prevention criteria for MIS-C were included in this study. The documented signs, symptoms, and laboratory values were collected and compared with the presence of oral or oropharyngeal findings. RESULTS: The mean (standard deviation) age of MIS-C patients was 9.0 (5.0) years (range, 1.3-20.0 years), and there was no obvious sex difference (51.1% male, 48.9% female). With respect to oral findings, 23 patients (48.9%) had red or swollen lips, whereas only 5 (10.6%) had a strawberry tongue. Oral or oropharyngeal findings were associated significantly with the presence of systemic rash (P = .04) and conjunctivitis (P = .02). CONCLUSIONS: The presence of oral or oropharyngeal changes may be an early indicator of MIS-C and should be considered suggestive of MIS-C in the setting of COVID-19 infection. PRACTICAL IMPLICATIONS: Dental care providers may play an integral role both in the early detection of oral manifestations of MIS-C and in the identification of oral lesions in hospitalized patients with confirmed MIS-C.

For Patients With Isolated Cleft Palate Does Revision Palatoplasty Have an Increased Risk of Inpatient Complication Compared to Primary Palatal Repair?

OBJECTIVE: The purpose of this study was to determine whether revision palatoplasty was associated with increased rates of inpatient complication and wound dehiscence compared to primary palatal repair. MATERIALS AND METHODS: This was a retrospective study of patients with isolated cleft palate treated with primary palatoplasty or revision surgery for fistula repair. The records were obtained from the Kids' Inpatient Database between 2000 and 2014. The primary predictor was the type of surgery, classified as either primary or revision palatoplasty. Secondary predictors included demographics and comorbidities. Primary study outcomes were the postoperative complication and dehiscence rates as noted during the hospitalization course. The secondary outcomes related to health care utilization as measured through length of stay (LOS) and hospital charges. RESULTS: A total of 5357 total admissions (95.5% primary, 4.5% revision) were included in the final sample. Fistula repairs (odds ratio = 14.37, P < .01) had significantly greater odds of wound dehiscence. The rates of inpatient complication ranged from 3.5% to 3.7%, and there were no significant differences between primary and revision surgery (P = .82). Complications were independently associated with insurance status and congenital anomalies. Complications and wound dehiscence both significantly increased the LOS and the hospital charges. Fistula repairs had a shorter mean LOS (P = .02), however this did not translate into cost savings (P = .60). CONCLUSIONS: Although the rates of inpatient complications were not significantly different, revision palatoplasty was associated with a greater odds of wound dehiscence. Failure of a primary repair may portend an increased risk of wound failure with subsequent surgeries.

The healthcare burden and associated adverse events from total alloplastic temporomandibular joint replacement: a national United States perspective.

The purpose of this study was to provide a United States perspective on alloplastic total joint replacement. We sought to estimate the inpatient burden and report the most common adverse events using two administrative datasets. The National Inpatient Sample was queried from October 2015 to December 2016 for total joint replacement admissions using International Classification of Diseases 10th revision codes, and the Manufacturer and User Facility Device Experience registry was queried from January 2009 to September 2019 using manufacturer brands. The combined final sample included 114 inpatient admissions and 392 adverse events. Mean age was 43.1 years, and most patients were white (82.7%) and female (86.0%). The mean hospital charge was $108,709.43 and the mean length of stay was 2.6 days. The most common adverse events were infection (26.3%), heterotopic bone (20.9%), and poor intraoperative fit (14.0%). Fifty-four percent of cases had bilateral total joint replacements, 24.6% had simultaneous subcutaneous abdominal fat grafting, and 11.4% had simultaneous maxillary repositioning. Fat grafting and maxillary repositioning were not associated with any significant difference in the length of stay or cost. Compared to unilateral cases, bilateral total joint replacements carried significantly greater charges (P<0.01), but no increased length of stay (P=0.70), suggesting that bilateral and unilateral cases may experience a similar postoperative course.

Grafting in Modern Rhinoplasty.

Rhinoplasty is considered one of the most technically difficult surgical procedures because of the limited access and requirement for three-dimensional visual perception and manipulation. Grafting is an essential part of primary and secondary rhinoplasties and forms the foundation for a successful functional and aesthetic outcome. Septal cartilage is the most commonly used grafting material, although many reliable alternatives exist. No randomized clinical trials have been conducted comparing graft materials and techniques for specific indications. In this review, the authors discuss the most common grafting materials and configurations used in the modern rhinoplasty.

What Are the Most Commonly Reported Complications With Cosmetic Botulinum Toxin Type A Treatments?

PURPOSE: The purpose of the present study was to determine the most commonly reported complications with cosmetic botulinum toxin type A (BTX-A) treatments. MATERIALS AND METHODS: The present study was a cross-sectional review of the US Food and Drug Administration (FDA) Adverse Event Reporting System. From January 2014 through September 2019, records were included in the study sample if they implicated Botox (onabotulinumtoxinA), Dysport (abobotulinumtoxinA), Xeomin (incobotulinumtoxinA), or Jeuveau (prabotulinumtoxinA-xvfs), and if the indication for use had been to perform a cosmetic skin procedure. The study predictors included patient (ie, age, weight, gender) and treatment (ie, product, country of treatment, 10 most common reactions) characteristics. The study outcome was the frequency of serious events as defined by the standard FDA definition for biologic products. A multivariate logistical regression model was created for the study outcome using all significant univariate predictors. RESULTS: The final sample included 10,577 reports detailing 29,471 adverse events and covering 1,473 reactions. The mean patient age was 48.4 ± 11.2 years, and nearly all patients were women (95.0%). The most commonly reported events were pain (9.3%), swelling (6.4%), and eyelid/brow ptosis (6.1%). Serious outcomes occurred in 13.5% of patients. In the multivariate model, serious outcomes were independently associated with older age, heavier weight, headache, allergy, vision changes, fatigue, facial paresis, and dizziness but notably were not associated with pain, swelling, or ptosis. CONCLUSIONS: A wide range of alleged complications have been reported to the FDA, many of which were likely not mediated through injection or direct toxin effects. Patients may have inaccurately attributed some of their symptoms to BTX-A, and providers should be prepared to dispel any misinformation. Local complications such as pain, swelling, and ptosis were the most common reactions but were not associated with serious patient outcomes. However, constitutional symptoms should be approached more carefully.

A 20-Year Analysis of Adverse Events and Litigation With Light-Based Skin Resurfacing Procedures.

PURPOSE: The popularity and availability of facial rejuvenation procedures have increased exponentially during the previous decade. The present study aimed to provide an overview of photorejuvenation and evaluate the complications and litigation related to light-based skin resurfacing procedures. MATERIALS AND METHODS: A retrospective study was performed using the US Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) registry and the Thomson Reuter Westlaw Edge database from May 1, 1999 to May 1, 2019. The MAUDE registry was queried using the manufacturer brands. Adverse events were individually reviewed, and data were gathered regarding the company, complication, body location, and device type. The litigation cases were individually reviewed, and information was gathered on plaintiff gender, defendant specialty, allegation, jury verdict, the appeals verdict, and the award amount, if applicable. RESULTS: A total of 697 adverse events were included in the final sample. The most commonly reported complications were burns (61.1%), followed by scarring (16.2%), hyperpigmentation (7.8%), and hypopigmentation (7.0%). More rare, noncosmetic complications included infection (3.9%) and nerve (1.4%) and ocular (1.3%) damage. The rates of scarring with facial treatments were greater (24.3 vs 10.3%; P < .01) and the rates of burns with ablative lasers were lower (25.9 vs 66.0%; P < .01). With respect to litigation, of the 9 cases identified, all the plaintiffs were women. The most common allegation was procedural negligence (88.8%), followed by cosmetic deformity (77.7%) and the lack of informed consent (55.5%). The jury ruled in favor of the plaintiff in 4 cases (44.4%), and the mean award was $656,000. CONCLUSIONS: The most common adverse events were burns, scars, and pigmentation changes. Patient expectations could play a role in the reporting of adverse events. Negligence was the most common basis for litigation, consistent with what has been reported for other procedures. Future studies should evaluate whether increasing exposure to cosmetic phototherapies during residency and fellowship training will reduce future complication rates and alleged malpractice.