Characteristics of Alcohol-Related Facial Fractures.

PURPOSE: Excessive indulgence in alcohol is a key causative factor in facial fractures especially in settings of interpersonal violence (IPV) and motor vehicle accidents. This study aims to explore characteristics of alcohol-involved facial fractures in the state of Victoria, Australia, over a 10-year period. MATERIALS AND METHODS: This retrospective study analyzed data from the Victorian Admitted Episodes Dataset between 2004 and 2014; the Victorian Admitted Episodes Dataset is a standardized database reported by all Victorian hospitals for every admission. Admission details included patient age group and gender, fracture site (or sites), injury cause, and surgical management. RESULTS: During the study period, 4,293 patients were treated for alcohol-related facial fractures, 27% of whom were in the 20- to 29-year-old age group. The male-to-female ratio was 7:1. There was a rising trend over most of the study period. Of the patients, 36% had multiple facial bone fractures, followed by nasal and midface fractures (22% and 6%, respectively). IPV was the most frequent cause (38%), followed by falls and transport-related injuries (30% and 18%, respectively). Surgery was required in 16% of patients, and 62% were inpatients for 1 to 3 days. Concomitant fractures were frequently reported; 20% of patients had fractures of another site, 12% had skull fractures, and 4% had cervical spine fractures. There were statistically significant relationships between age group and gender, between gender and fracture site, and between fracture site and need for surgery (P < .05). CONCLUSIONS: This study reports a high incidence of alcohol-involved facial fractures in young men with IPV being a predominant cause. Such injuries often involve multiple facial bone fractures and severe concomitant trauma necessitating brief hospitalizations, but a high proportion of patients were treated nonsurgically.

Addressing alcohol-related harms within maxillofacial trauma practice.

PURPOSE: A brief intervention, conducted in the short-term care setting after an alcohol-related injury, has been reported to be highly beneficial in reducing the risk of reinjury and in reducing the subsequent level of alcohol consumption. This project aimed to understand Australasian oral and maxillofacial surgeons' attitudes, knowledge, and skills in alcohol screening and brief intervention within short-term care settings for patients admitted with facial trauma. MATERIALS AND METHODS: A Web-based survey was made available to all members of the Australian and New Zealand Association of Oral and Maxillofacial Surgeons (200 to 250 members), promoted through a number of e-mail bulletins sent by the association to all members. Implied consent was assumed for participants who completed the online survey. The survey explored the surgeons' current level of involvement in treating patients with alcohol-related facial trauma, as well as their knowledge of and attitudes toward alcohol screening and brief intervention. The survey also explored their willingness to undergo further training and involvement in implementing a screening and brief intervention program. Parts of the survey were based on a hypothetical case with facial injury and a drinking history that was presented to the participants, and the participants were asked to give their response to this scenario. RESULTS: A total of 58 surgeons completed the online survey. Of the surgeons surveyed, 91% were men and 88% were consultant surgeons. Seventy-one percent would take an alcohol history, 29% would deliver a brief alcohol intervention, and 14% would refer the patient to an alcohol treatment service or clinician. Forty percent agreed that they had adequate training in managing patients with alcohol-related injuries, whereas 17% and 19% indicated that they had adequate time and adequate resources, respectively. Of the surgeons, 76% reported the need for more information on where to refer patients for appropriate alcohol treatment. CONCLUSIONS: The study findings confirm the challenges and barriers to implementing a brief alcohol intervention in current practice. Service gaps, as well as opportunities for training, exist.

To shield or not to shield: application of bismuth breast shields.

OBJECTIVE: The purposes of this essay are to describe the effects of bismuth breast shielding on radiation exposure of the breast and posterior chest wall and to present arguments for and against the use of breast shields. CONCLUSION: Breast tissue may receive substantial radiation doses during CT examinations. Bismuth shields effectively reduce breast exposure at the expense of increased noise and artifacts. Because bismuth shields reduce radiation transmission in all directions, posterior-to-anterior irradiation results in wasted exposure of posterior tissues. Similar breast radiation reductions can be achieved without shielding by globally reducing tube current. In general, more advanced methods of reducing exposure, including dose modulation and iterative reconstruction techniques, are superior if available.

Cardiovascular imaging of the pregnant patient.

OBJECTIVE: The purpose of this review is to describe the selection and methods of imaging of pregnant women with cardiovascular conditions. CONCLUSION: Common cardiovascular conditions may occur in 1% of all pregnant women. The selection and methods of imaging studies require thoughtful planning. Use of radiation, radiopharmaceuticals, and contrast agents should be minimized. Pulmonary and cardiac CT angiography deliver minimal fetal radiation, and ventilation-perfusion scintigraphy presents relatively low fetal irradiation. Cardiac catheterization, coronary angiography, and electrophysiologic procedures, including complex interventions, also cause relatively low fetal exposure. Even nuclear cardiology procedures are unlikely to exceed negligible-risk (50 mGy cutoff) fetal radiation doses.

Features of odontogenic infections in hospitalised and non-hospitalised settings.

OBJECTIVE: To compare the sociodemographic and clinical features of odontogenic infections between hospitalised and non-hospitalised adult patients. METHODS: The two study groups consisted of inpatients (IP) and outpatients (OP) with odontogenic infections who were treated at Christchurch Hospital, New Zealand. Clinical and sociodemographic data were collected retrospectively from patients' hospital records. RESULTS: The study sample consisted of 28 IP (13.9%) and 174 OP (86.1%). There were no significant differences in age, gender or ethnicity between the two groups. A higher proportion of IP had trismus (75.0% IP; 6.9% OP), floor of the mouth oedema (10.7% IP; 0.6% OP) and decreased tongue mobility (10.7% IP; 1.7% OP). The IP group also had a greater proportion of multiple-space infections (39.3%) than the OP group (18.9%). The most commonly involved anatomical space in the OP group was the buccal space (49.4%), while that in the IP group was the submandibular space (57.1%). The submandibular, submental and submasseteric spaces were more likely to be involved in the IP group (p<0.05). The most common source of odontogenic infections in the IP group was the mandibular third molars (20.8%) and first/second molars (20.8%), while that in the OP group was the mandibular first/second molars (30.9%). CONCLUSIONS: There are important differences in the features of odontogenic infections between hospitalised and non-hospitalised patients. Some of these clinical signs may assist in recognising severe courses of odontogenic infections that may potentially require hospitalisation.

Interpersonal violence and facial fractures.

PURPOSE: Interpersonal violence is a major health hazard that contributes to the high volume of trauma seen in the emergency department. It is also one of the principal causes of maxillofacial fractures. MATERIALS AND METHODS: The present study was a retrospective analysis of patients referred to, and treated at, the Oral and Maxillofacial Surgery Unit at Christchurch Hospital during an 11-year period (1996 to 2006). The variables examined included patient demographics, fracture types, mode of injury, and treatment delivered. RESULTS: An increase was found in the number of fractures due to interpersonal violence in the second half of the study, although the proportion remained the same. The age of the patients ranged from 9 to 89 years (mean 28). The male-to-female ratio was 9:1. Of the patients, 87% had alcohol involvement. The mandible was the most common site of fracture, followed by the zygoma. Other midface fractures, including Le Fort fractures, were less frequently observed. Of the patients, 59% were hospitalized and 56% required surgery, with internal fixation necessary in 41% of patients. CONCLUSION: An increase occurred in the number of facial fractures associated with interpersonal violence during the study period. Young male adults were the most affected demographic group, with alcohol a main contributing factor. Violence-related facial fracture is a health hazard that deserves more public awareness and implementation of preventive programs.

Zygomatic fractures presenting to a tertiary trauma centre, 1996-2006.

The zygoma occupies an anatomically prominent position in the face. Fracture of the zygoma is a common facial injury and can be associated with significant functional deficit and cosmetic disfigurement. From a database of patients presenting to a tertiary trauma centre during an 11-year period, 941 individuals with zygomatic fractures were identified. Variables examined included demographic characteristics, type of fracture, mode of injury and treatment delivered. The study found a male-to-female ratio of 8:2. The age of patients at presentation ranged between 1 and 93 years, with a mean age of 36 years. Interpersonal violence was the most common cause of injury. Alcohol was involved in 47% of cases. Of the 52% of patients who had surgery, 61% required internal fixation. Some 62% of patients were hospitalised. In conclusion, most zygomatic fractures presenting to the Unit occurred in males. Interpersonal violence was the most common aetiological factor, with alcohol an important contributor. Hospitalisation and surgery were required for a large proportion of the fractures.

Sports-related maxillofacial fractures over an 11-year period.

PURPOSE: To investigate the prevalence, anatomic sites, and management of sports-related maxillofacial fractures in New Zealand. PATIENTS AND METHODS: A retrospective analysis of 561 patients presenting with sports-related maxillofacial fractures between 1996 and 2006 was conducted. Variables analyzed included sociodemographic data, cause of injury, site of fracture, and method of treatment. RESULTS: The mean patient age was 26.2 years, with a male:female ratio of 9:1. Sports-related facial fractures accounted for 21.7% of all fractures, with most of these secondary to rugby (52.0%), cycling (15.3%), cricket (7.1%), and soccer (4.8%). Mandibular fractures were the most frequent presentation (41.4), followed by zygomatic (29.4%) and orbital floor fractures (16.9%). Almost 50% of the patients from each sport required active treatment, with the majority requiring open reduction and internal fixation of the fracture (60.3%). The prevalence of sports-related facial fractures increased between the first 6 years (17.6%) and the next 5 years (25.8%) of the 11-year study period. The March-to-August period had a considerably higher number of fractures compared with the rest of the year. CONCLUSIONS: Nearly 20% of all maxillofacial fractures were sports-related, with most occurring in males. The prevalence of sports-related facial fractures increased over the study period. Most of the fractures involved the mandible and zygoma. Active intervention was required for almost 50% of the injuries.

Psychosocial Support Following Maxillofacial Trauma and its Impact on Trauma Recurrence.

BACKGROUND: Injuries sustained to the maxillofacial region can result in significant physical trauma and long lasting psychosocial impairment. Maxillofacial trauma has been reported in literature to be a potentially recurrent disease. Patients who suffer maxillofacial trauma can benefit from psychological support. AIM: This study aims to identify maxillofacial trauma patient characteristics, investigate maxillofacial re-injury rate after provision of psychological support and report incidence of post traumatic stress disorder symptoms after maxillofacial trauma. METHOD: A total of 100 patients were identified from the departmental trauma database over two time periods at Royal Darwin Hospital; 50 patients did not have psychosocial intervention and 50 patients received intervention. Data on demographics, trauma pattern and aetiology were collected. A brief counselling session was conducted on second patient group by a trained mental health nurse and a survey using Trauma Screening Questionnaire was completed one month following injury. RESULTS: The most common cause of injuries was assault in both groups followed by falls and the most common site of injuries was in the mandible in both groups. Almost half of all patients were in the15-24 and 25-34 age groups. 17 % of patients in pre-intervention period and 4 % of patients in intervention period had injury recurrence at 3 year follow up. Patient groups at risk of developing post traumatic symptoms included male, non-indigenous population, employed group with no alcohol involvement. CONCLUSION: Maxillofacial trauma can cause considerable psychological morbidity and expose the patient to high risk of post traumatic disorder symptoms. This type of injury was found to affect particular groups of population and is associated with high rate of recurrence. Psychological support should be provided to these patients as a routine part of trauma aftercare.

Current practice in provision of alcohol assessment and support for patients following alcohol related facial fractures.

OBJECTIVES: The algorithm for maxillofacial trauma management is well defined; however, provision of alcohol assessment for patients after trauma is not widely practiced. This study aims to investigate the rate of alcohol assessment achieved within the demographic characteristics of patients with facial trauma and the circumstances where this intervention was implemented. STUDY DESIGN: This study retrospectively examined the Victorian Admitted Episodes Data Set (VAED) from 2004 to 2013. RESULTS: Of a total of 54,730 presentations with facial fractures to all Victorian hospitals, 0.9% in the non-alcohol-involved group and 4.3% in the alcohol-involved group received alcohol assessment during their inpatient stay (P < .001). Among patients with alcohol involvement, the likelihood of assessment was significantly different with regard to length of stay, age, trauma mechanism, and gender. Positive blood alcohol test did not relate to probability of assessment. Those with acute alcohol intoxication were less likely to be assessed (P < .001), whereas those with harmful alcohol use, alcohol dependence, or alcohol withdrawal state were much more likely to be assessed (P < .001). CONCLUSIONS: This study found no consistent practice of alcohol support to patients following alcohol-related facial fractures. Post-trauma alcohol support may optimize perioperative management of patients and education regarding alcohol harm and may reduce future trauma risk. Development and refinement of such practice is an area for further research.

Comparison between interpersonal violence and motor vehicle accidents in the aetiology of maxillofacial fractures.

BACKGROUND: Maxillofacial fractures commonly present to the emergency department, interpersonal violence (IPV) and motor vehicle accidents (MVA) being two of the main causes. There is a changing trend in these two aetiologies, which is reflected in a change in demographics, the pattern of fractures and the treatment of maxillofacial fractures. METHODS: A prospective database of patients presenting to the Oral and Maxillofacial Surgery service at Christchurch Hospital during an 11-year period was reviewed. Of a total of 2581 patients with radiographic confirmation of facial fractures, 1135 patients sustained injuries following IPV and 286 patients following MVA. Variables examined include demographics, type of fracture, mode of injury, and treatment. RESULTS: The male:female ratio was 9:1 in patients following IPV and 7:3 following MVA; 16-30-year-olds accounted for greatest proportion of injuries (48 and 68%, respectively). There was alcohol involvement in 87% of fractures caused by IPV, compared with 58% for MVA. Mid-facial fractures were more frequently seen in MVA, whereas mandibular fractures were more prevalent in IPV. Sixty-two per cent of the patients from MVA required active treatment and 87% were hospitalized, compared with 56% actively treated and 59% hospitalized in the IPV group. CONCLUSION: Interpersonal violence has continued to be the main cause of maxillofacial fractures. Both IPV and MVA commonly involve alcohol and young male adults. They frequently require hospitalization and surgical intervention.

A case of recurrent pyogenic granuloma.

Dental practitioners are usually the first health professionals to examine and diagnose patients with oral pyogenic granuloma. Usually of traumatic origin, the lesion results from an overly aggressive immune response. Despite several accepted methods of treatment, recurrence is common. This paper reports on a case of recurrent pyogenic granuloma and reviews the relevant literature.

Should alcohol screening be a routine practice in alcohol-related facial trauma care? A narrative review.

The link between alcohol intoxication and Emergency Department (ED) attendance for management of alcohol-related injuries has been well documented. The acute settings such as ED and surgical wards may not be the most appropriate environment for treatment of chronic conditions, but traumatic episode presentation to ED may offer the most opportunistic time to focus on screening against harmful alcohol use in order to provide timely feedback and support. Although ED provides an opportunity to identify patients with alcohol problems, the initial challenge is finding suitable ways to identify and screen affected patients. This paper is a narrative review on methods of alcohol screening and its effectiveness and efficacy in trauma care setting. It is second part in a series on implementation of screening and brief intervention in managing trauma patients.

Brief alcohol intervention in alcohol involved facial fracture patients-a survey of patient attitudes to screening and intervention.

PURPOSE: Alcohol intoxication is an important contributor to traumatic facial injuries. The period following injuries afford clinicians a useful window of opportunity to provide alcohol screening and brief intervention (SBI) which may affect changes in patients' future drinking behaviour. Although SBI has been reported to decrease at risk drinking and potentially trauma recurrence, it is not routinely utilised in most clinical settings in the world. This study aims to assess utilisation of, as well as patients' knowledge and attitude towards SBI in the management of patients presenting with alcohol-related facial fractures. METHODS: Twenty consecutive patients who presented to Western Health with facial fractures who met selection criteria were offered an alcohol screening and survey questionnaire. RESULTS: Ninety percent of patients were male and 50% were aged between 19 and 34. ASSIST score showed 65% were in the moderate risk category; 75% reported this was their first admission with alcohol related trauma. Although 75% acknowledged alcohol as a main cause of injury, only 40% agreed they drink too much. Forty-four percent felt that talking to a healthcare worker might help and 33% would consider accepting help. Forty-seven percent felt reading materials would be helpful in changing future drinking habits. Whilst 63% would like to know safe drinking limit, only 45% would like to have a discussion about alcohol-related harms. CONCLUSIONS: Most patients presented in this survey were in moderate risk category who are amenable to behavioural change with provision of SBI. However, there is resistance to implementation of this intervention due to lack of knowledge, self-awareness and willingness to change. Nonetheless, patients are prepared to accept advice from clinicians and some formats of intervention. It is important to formulate a simple screening questionnaire and intervention strategy that are easy to administer to affect positive changes in patients with harmful drinking behaviours.

Temporal distribution of alcohol related facial fractures.

OBJECTIVES: This study aimed to address 2 important aspects of temporal pattern in alcohol-related facial fractures: (1) comparison of temporal pattern of alcohol-related facial fracture (alcohol group) presentation with non-alcohol-related fracture (non-alcohol group) presentation; (2) temporal pattern of patient demographic characteristics, injury characteristics, and surgical management in the alcohol group presentation. STUDY DESIGN: This study retrospectively examined the Victorian admitted episodes data set (VAED) for the years 2010 to 2013. VAED is a standardized set of data collected during all hospital presentations in Victoria. RESULTS: The study found higher incidence of alcohol-related facial fracture presentations during weekends and during the summer and spring months compared with non-alcohol-related fractures (statistically significant). Alcohol-related facial fractures are more likely to involve male patients in the 20- to 29-year age group, occur as a result of interpersonal violence, and require shorter hospital stays during weekend admissions (statistically significant). No statistically significant relationship has been observed in seasonal variation across all variables. CONCLUSIONS: This study found distinct characteristics in temporal distribution of alcohol-related facial fractures. These characteristics are, in particular, significant in weekend trauma admissions. Such information is important in workforce planning, resource distribution, and implementation of injury prevention programs.

Would brief alcohol intervention be helpful in facial trauma patients?A Narrative Review.

Facial trauma is commonly associated with excessive consumption of alcohol and is often associated with interpersonal violence or motor vehicle accidents. Alcohol-related trauma presentation to hospitals causes a major service burden, and there have been efforts to reduce such trauma load with educational programs and social support. Brief alcohol intervention (BAI) in an acute setting (emergency department or trauma centre) has been shown as an effective means to reduce future alcohol intake and the incidence of future alcohol-related injuries, especially in the period immediately following injuries. Less is known about the potential benefit of BAI when provided by the surgical team in the same clinical context. This article explores the individual component of brief alcohol intervention and its provision by an acute surgical service by way of a narrative review. The progress of research into brief alcohol intervention for facial trauma patients is also reviewed. The methods and rationale behind screening patients for targeted BAI are discussed in a separate article.

Emergency Physician Screening and Management of Trauma Patients with Alcohol Involvement.

BACKGROUND: Alcohol screening and brief intervention (SBI) in trauma patients has been reported in literature to be effective in changing harmful drinking patterns and injury recurrence. Despite good evidence that SBI can benefit patients and provide a more holistic care, it is not routinely implemented in acute medical settings in Australia, in particular emergency departments (EDs). OBJECTIVE: This paper aims to assess the knowledge, confidence, and practice of alcohol SBI in trauma patients by emergency physicians throughout Australia and New Zealand through an online survey. METHODS: Major EDs in Australia and Zealand were approached to participate in an online survey. Results from the survey were analyzed using simple descriptive summary statistics. RESULTS: Fifty-eight physicians participated in the online survey. Almost all physicians reported at least 10% of all patients managed in ED had traumatic injuries and 35% had alcohol involvement. About 66% were consultant physicians and 84% had 5 or more years of practice. Sixty-four percent agreed to have adequate training in SBI, 22% had adequate time and resources, 47% would like more training in patient screening, and 72% were more likely to deliver SBI in 5 min. Limited time and resources were seen as major barriers. It was found that better understating of SBI may lead to higher confidence and more practice, or vice versa. CONCLUSION: High proportion of participants in this survey felt under-equipped to deliver SBI due to time limitation, perceived lack of resources, unsuitable environment, and supportive staff. There exists an opportunity to develop a shortened and efficient SBI program that can improve utilization of SBI in an emergency setting.

An Unusual Presentation of Stafne Bone Cyst.

Stafne bone cyst is a rare mandibular defect. It is a developmental abnormality that commonly presents as a small, well demarcated, and asymptomatic radiolucency seen at the angle of the mandible below the mandibular canal. There are usually no clinical signs nor symptoms. Diagnosis is commonly by plain X-ray, but use of more accurate imaging such as MRI is required in atypical cases. This case study reports an unusual presentation of Stafne bone cyst in the ramus of the mandible in a young man and reviews the relevant literature.

Maxillofacial fractures sustained by unmounted equestrians.

Facial injuries caused by horses are relatively common among riding enthusiasts, but little is known about the nature of maxillofacial fractures sustained by those not mounted. We collected data on patients' characteristics, fractures sites, mechanisms of injury, and treatment of these fractures from the departmental records of the oral and maxillofacial unit at Christchurch Hospital, New Zealand between 1996 and 2008. Of 49 patients with equine-related facial fractures, 35 (mean (SD) age 35.8 (16.7) years) had sustained their injuries while unmounted (71%). Most of the fractures occurred in women (66%), of whom 39% were aged between 16 and 30 years. There was an increasing trend in the incidence of these fractures over much of the 13-year period. Most injuries were caused by kicks (69%), followed by head-butts (26%), and trampling (6%). The zygoma was the most common fracture site (63%), followed by the mandible (34%), and orbital floor (31%). Surgical intervention was required in 60% of cases.

Oral white lesions: pitfalls of diagnosis.

General practitioners are often the first point of contact for patients with oral white lesions, which represent a wide spectrum of diagnoses of varying seriousness. Some clinical features are classical and others overlap between different diagnoses; they should be correlated with patient history, and sometimes other investigations, for diagnosis. Leukoplakia is a clinical term, and is a diagnosis of exclusion with no histopathological connotation. It has been redefined to describe a predominantly white lesion with premalignant potential. Patients with lesions that are potentially malignant should be referred to an oral medicine specialist or oral maxillofacial surgeon for systematic management.