Perioperative Optimization and Management of the Oral and Maxillofacial Surgical Patient: A Narrative Review on Updates in Anticoagulation, Hypertension and Diabetes Medications.

PURPOSE: The preoperative management guidelines of surgical patients are constantly evolving as newer evidence-based research is published. Oral and maxillofacial surgeons need to be current with the increasingly more complex new drug therapies and updated national association(s) guidelines. This narrative review provides a synopsis with important reference tables for updated preoperative optimization guidelines for anticoagulation, antiplatelet therapy, antihypertensive management, and glycemic control in the preoperative period for the oral and maxillofacial surgery patient. It also includes the most current anesthesia guidelines on glucagon-like peptide receptor agonists. METHODS: The search strategy utilized pubmed.gov to identify the most recent national society guidelines and review articles pertinent to perioperative anticoagulation, antiplatelet therapy, antihypertensive management, and glycemic control. RESULTS: The search identified 75 articles from the American College of Surgeons, American Heart Association, American Society of Anesthesiologists, American College of Cardiologists, in addition to recent reviews discussing the standard of care for optimization of patients in the perioperative period. CONCLUSION: Medical optimization prior to surgery is important for safe and efficient surgical practice and has been shown to improve overall mortality. This narrative review provides a summary of the current data with recommendations focusing on four key points.

Does a Submental Airway Compared to a Tracheostomy Reduce Length of Stay in Craniomaxillofacial Trauma?

BACKGROUND: Patients with craniomaxillofacial trauma (CMT) are at increased risk of airway compromise and may necessitate airway stabilization via a tracheostomy (TO) or cricothyroidotomy. The submental airway (SMA) is an alternative airway and can avoid complications related to TO. PURPOSE: The purpose of this study was to compare the SMA to the TO with respect to hospital length of stay (LOS) and number of days with an advanced airway, termed airway days (ADs). STUDY DESIGN, SETTING, SAMPLE: This single-center retrospective cohort study included subjects with isolated CMT who required operative treatment with either a TO or SMA at Harborview Medical Center. Subjects were excluded if they required a TO for reasons other than treating their CMT. PREDICTOR VARIABLE: The predictor variable was airway type. MAIN OUTCOME VARIABLE: Primary outcome variables were LOS and ADs measured as number of days between admission and discharge dates, and days between establishment of airway and extubation or decannulation dates, respectively. COVARIATES: Covariates included age, sex, American Society of Anesthesiology classification, weight, body mass index, substance use, hospital status, facial injury severity scale scores, and airway placement location. ANALYSES: Bivariate analysis using independent t test, Mann-Whitney U test, and multiple linear regression analyses were used. P value of <.05 was considered significant. RESULTS: Of the 14 subjects identified, 6 underwent a TO and 8 a SMA. The mean LOS in the TO group was 20.3 ± 15.8 days versus 3.9 ± 4.7 days in the SMA group (P = .02). Mean AD in the TO group was 13.2 ± 8.4 versus 0.6 ± 0.7 in the SMA group (P = .01). The TO group had a higher number of operations at 2.0 ± 0.6 versus 1.1 ± 0.4 with a SMA (P = .02). After linear regression analysis adjusting for sex, age, weight, and facial injury severity scale, there were no statistically significant differences between the groups. CONCLUSIONS AND RELEVANCE: Compared to, SMA has a 5-fold decrease in LOS and 22-fold decrease in ADs on bivariate analysis. An SMA is a viable airway management option for operative treatment of isolated CMT. Further studies are warranted with a larger sample size.

Have Incidence and Severity of Craniomaxillofacial Fractures Changed Since SARS-CoV-2?

BACKGROUND: An increase in severity and a decrease in incidence of craniomaxillofacial fractures (CMFs) were identified during the first several months of the SARS-CoV-2 pandemic. It is unclear if these changes have persisted in the current timeframe. PURPOSE: The investigators hypothesize that the incidence and severity of CMF will not return to baseline prepandemic (control) levels as the pandemic stabilizes and becomes endemic. STUDY DESIGN, SETTING, SAMPLE: This retrospective cohort study enrolled subjects who presented to Harborview Medical Center a Level 1 trauma center for the evaluation and management of CMF. Inclusion criteria were 1) Presentation timeline 2018 through 2022, 2) CMF identified by the 10th International Classification of Disease. Exclusion criteria were: 1) Undocumented etiology of facial fracture and 2) inadequate/unclear documentation otherwise. PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE: The predictor variable was year of injury relating to the start of the pandemic. The groups were the prepandemic (2018, 2019) and postpandemic (2020, 2021. 2022). MAIN OUTCOME VARIABLES: The primary outcome variable was the CMF diagnosis identified using the corresponding International Classification of Disease, 10th Edition codes. The secondary outcome variables were mechanism of injury and injury severity. COVARIATES: The covariates were age, sex, race/ethnicity, admission status, alcohol intoxication, toxicology screen, reimbursement source, abuse reported, and abuse investigated. ANALYSES: Univariate and bivariate analyses were performed with statistical significance at P < .05. RESULTS: The sample was composed of 5203 subjects. The annual volumes of subjects presenting with CMF were consistent over the study period (2018, 2019, 2020, 2021, 2022 n = 1018, 963, 1020, 1062, 1140, respectively). The incidence of Hispanics increased (2018, 2019, 2020, 2021, 2022: 11.1, 9.6, 12.2, 13.9, 13.2% (P < .05)) as did firearm CMF injuries (2018, 2019, 2020, 2021, 2022: 4.13, 4.98, 4.71, 7.16, 6.75% (P < .05)). The Injury Severity Score and Abbreviated Injury Scale were both lower postpandemic compared to prepandemic; mean Injury Severity Score post [18.27 ± 12.46] versus pre [19.25 ± 12.89] (P < .05), mean Abbreviated Injury Scale post [2.94 ± 1.15] versus pre [3.04 ± 1.14] (P < .05). CONCLUSIONS AND RELEVANCE: While the severity of CMF decreased postpandemic, Hispanic and firearm CMF increased. The overall CMF incidence remained the same. The significant rise in firearm injuries warrants further study.

A Comparison of Maxillofacial and Head Injuries Following Electric Scooter and Bicycle Accidents.

BACKGROUND: The prevalence of maxillofacial and head injuries associated with electric scooters (e-scooter, ES) has risen in concordance with its popularity. PURPOSE: The purpose of this study was to compare maxillofacial and head injury location, type, and severity related to ES and bicycle accidents and to identify factors contributing to injury severity. STUDY DESIGN, SETTING, SAMPLE: The authors implemented a multicenter retrospective cohort study in Seattle, Washington, and enrolled a sample of ES riders and bicyclists who sustained maxillofacial injuries between September 2020 and September 2022. The exclusion criteria included nonmotorized scooters, motorized bicycles, injuries with other operators, or vehicles, and pre-evaluation deaths. PREDICTOR VARIABLE: The predictor variable was vehicle type, bicycle or ES. OUTCOME VARIABLES: The outcome variables included maxillofacial injury location, distinguished by horizontal facial thirds and injury type, defined as hard or soft tissue. Associated head injury types were also reported as hard (calvaria) or soft (scalp) tissue injuries. The severity of these injuries was quantified using both the injury severity score and the face and head abbreviated injury scale. COVARIATES: Demographic, injury, and treatment-related variables were collected. ANALYSES: Bivariate, multivariate, and regression statistics were computed. Statistical significance was P < .05. RESULTS: The final sample was composed of 205 total subjects, of which 52 (25.4%) were in the ES group and 153 (74.6%) in the bicycle group. Isolated midface injuries were the most common hard tissue location in the ES (15.4%) and bicycle (29.4%) groups. The most common soft tissue injury location included the upper face and midface in the ES group (19.2%) and the midface in the bicycle group (22.9%). Both hard and soft tissue head injuries were more prevalent in the ES group (P < .0002 and P < .0001). Moreover, intracranial injuries were seen in 36.5% of ES subjects compared to 9.8% bicycle subjects (P < .0001). Between the two groups there was no difference in maxillofacial injury severity, but head injuries were more severe in the ES group (P < .0002). Using regression analysis, drug use was found to have a significant impact on the mean injury severity score (P < .002) and helmet use did not have significant impact on face or head injury severity. CONCLUSION: Maxillofacial injury location, type, and severity are comparable among ES and bicycles. However, ES riders are at greater risk of severe head injuries compared to bicycles, and riding while intoxicated has the greatest effect on injury severity.

What Is the 5-year Incidence of Recurrent Disease of Odontogenic Keratocysts?

PURPOSE: There is no consensus on the ideal treatment of odontogenic keratocysts (OKCs). Certain risk factors may modify the disease recurrence rate. The purpose of this study was: 1) to estimate the incidence of OKC recurrence in a statistically rigorous manner; and 2) to identify risk factors associated with OKC recurrence. METHODS: The investigators designed and implemented a retrospective cohort study and enrolled a sample derived from the population of patients presenting to the Department of Oral and Maxillofacial Surgery outpatient clinics at the University of Washington School of Dentistry and Harborview Medical Center for evaluation and management of OKCs between January 1, 2010, and December 31, 2020. Predictor variables included demographics (age, gender), radiographic characteristics (location of lesion, locularity, size, and cortical perforation), and type of operation performed (decompression + cystectomy, enucleation ± adjuvant therapy, or resection). The primary outcome variable was time to recurrent disease, defined as the time from treatment to radiographic or clinical evidence of a new lesion (recorded in months). Kaplan-Meier analysis was used to estimate median time to recurrence, and Cox proportional hazards models were used to identify covariates statistically associated with recurrent disease (P ≤ .05). RESULTS: The sample was composed of 60 subjects with 63 previously untreated lesions. Eight subjects (13%) developed a recurrent lesion during the study interval with a median time to recurrence of 31 (interquartile range, 24 to 48) months. One of the 8 recurrences occurred within 12 months of treatment and 7 of the 8 recurrences occurred more than 21 months after treatment. Based on using Kaplan-Meier analysis, the 5-year incidence of disease recurrence was estimated to be 34%. Lesions with cortical perforation were 8.3 times more likely to recur (95% confidence interval [1.7, 41.3]; P-value = .01), and multilocular lesions were 10.6 times more likely to recur (95% confidence interval [1.3, 86.9]; P-value = .03). The sample size was the limiting factor to performing regression analyses. CONCLUSIONS: Virtually every publication on OKCs to date reports frequencies of disease recurrence rather than applying appropriate survival analyses commonly used to estimate outcomes in cancer research. Failure to use the appropriate statistical analyses underestimates the risk of disease recurrence. Our study is no exception. The estimated frequency of disease recurrence during the study interval was 13% (8/60). When survival analyses are applied that account for varying months of follow-up, the incidence of disease recurrence is 34 per 100 per 5 years. We recommend the application of time-to-event analyses in the study of disease entities with the potential for recurrence.

Surgical Management of Post-Traumatic Trigeminal Neuralgia - Case Report and Review of the Literature.

Post-traumatic trigeminal neuralgia (PTTN), also known as anesthesia dolorosa , is at times a debilitating affliction, but remains a condition with minimal research and without definitive treatment, specifically in the periorbital and malar regions. Below we present a case of PTTN in a patient with historic facial trauma who has successfully achieved resolution of pain. We describe diagnostic and therapeutic anesthesia blocks and ablative procedures targeting the zygomaticofacial and zygomaticotemporal nerves. We promote awareness for the procedures and the potential large impact on the oral and maxillofacial surgery community when treating those suffering from facial pain. Finally, we present an algorithm that can aid surgeons in diagnosing and treating patients with PTTN.

Severe Mucositis Secondary to Pembrolizumab: Reports of Two Cases, Review of the Literature, and an Algorithm for Management.

The indications for use of programed cell death receptor (PD-1) inhibitors to treat cancer continues to expand rapidly. Treatment with PD-1 inhibitors has been associated with numerous immune-mediated mucocutaneous side effects. Here, we report 2 cases of severe mucositis caused by the PD-1 inhibitor pembrolizumab and review the defining features of similar cases. Recognition of mucocutaneous toxicities of PD-1 inhibitors is increasingly important as their use continues to expand. A stepwise approach to diagnosis and management is also reviewed.

The Burden of Head and Neck Cancer in the United States, 1990 - 2017.

PURPOSE: Head and neck cancers (HNC) are among the most common malignancies in the United States and are a significant cause of morbidity and mortality. Traditional risk factors for HNC include tobacco, alcohol, and Human Papilloma Virus (HPV) infection. Geographic location has also been shown to play a role, whether directly or indirectly. The purpose of this study was to describe the incidence, mortality and geographic variability of HNC within the United States between 1990 and 2017. MATERIALS AND METHODS: The Global Burden of Diseases Study 2017, which models incidence and mortality, was used to obtain incidence and mortality data for "lip and oral cavity cancer", "nasopharynx cancer", "other pharynx cancer" (tonsil, oropharynx, and hypopharynx) and "larynx cancer" for the United States between 1990 and 2017. RESULTS: The overall incidence rate of HNC increased (annual percent change (APC) = 0.23. 95% CI: 0.1-0.3) from 1990 through 2017 while overall mortality decreased (APC = -0.37. 95% CI: -0.4 to -0.3). The anatomic sub-site which saw the largest increase in incidence was "other pharynx" (APC=1.07. 95% CI: 0.9-1.2). In 2017, those in the West had the lowest incidence while those in the South had the highest (15.7 and 20.8 per 100,000 individuals, respectively). CONCLUSIONS: The incidence of HNC in the United States increased between 1990 and 2017. This was driven by larger increases in those sites more prone to HPV-related HNC. While there exists geographic variability in the burden of this disease, additional studies are needed to further understand the impact of patient-specific factors.

What Is the Effect of COVID-19 Social Distancing on Oral and Maxillofacial Trauma Related to Domestic Violence?

PURPOSE: To understand the impact of social distancing policies on the incidence and severity of oral and maxillofacial trauma (OMT) secondary to interpersonal violence (IPV) and domestic violence (DV). METHODS: The authors designed a retrospective cohort study enrolling subjects who presented to an urban Level 1 trauma center in Seattle, WA, for the evaluation and management of OMT between January 1 and December 31 in the years 2018 through 2020. The primary predictor variable was evaluation of OMT during periods with (2020: investigational group) or without (2018 or 2019: control group) social distancing policies in place. The primary outcome variables were the mechanism and severity of injury, defined as IPV, DV or neither, the abbreviated injury scale (AIS) and the injury severity score (ISS). Descriptive, univariate and bivariate analyses were performed with statistical significance at P < .05. RESULTS: Eight hundred twenty-eight subjects; 737 (89%) IPV and 91(11%) IPV due to DV. The incidence of OMT secondary to IPV or DV was unchanged (P = .81, P = .57 respectively). There was a nonsignificant increase in ISS for IPV (P = .07) and no change for DV (P = .46). AIS scores were unchanged for IPV (P = .36). For DV, AIS scores were lower in 2020 when compared to 2019 (P = .04) but unchanged from 2018 (P = .58). At least half of the DV victims were male (50% in 2018, 59% in 2019, and 53% in 2020). Of these, 65% were under 18, and represented the pediatric majority (62%). A nonsignificant increase in non-white subjects presenting with DV in 2020 (P = .15) was seen. CONCLUSIONS: The COVID-19 pandemic did not change the number or severity of OMT cases secondary to IPV or DV in this region of Washington. Pediatric males were more likely to be victims of DV.

What Is the Effect of COVID-19-Related Social Distancing on Oral and Maxillofacial Trauma?

PURPOSE: The purpose of this study was to understand the impact of social distancing policies enacted during the COVID-19 pandemic on the epidemiology of oral and maxillofacial fractures at an urban, Level I trauma center in the United States. MATERIALS AND METHODS: The investigators designed a retrospective cohort study and enrolled a sample of 883 subjects who presented for evaluation of oral and maxillofacial fractures (OMF) between March 1 and June 30 in the years 2018 through 2020. The primary predictor variable was the evaluation of OMF during a period with social distancing policies (2020 - experimental group) or without social distancing policies in place (2018 or 2019 - control group). The primary outcome variables were the facial fracture diagnosis, the abbreviated injury scale (AIS), injury severity score (ISS), and the mechanism of injury. Appropriate univariate and bivariate statistics were computed, and the level of significance was set at P < .05 for all tests. RESULTS: The number of subjects presenting with OMF was lower during the period of social distancing (n = 235 in 2020) than during the periods without (2018: n = 330; 2019: n = 318). During the period of social distancing, there were more individuals who presented secondary to assault, whereas fewer individuals presented secondary to falls (P = .05). On average, those who presented in 2020 had more severe oral and maxillofacial injuries (mean AIS = 3.2 ± 1.2 in 2020 vs 3.0 ± 1.1 in 2019 and 3.0 ± 1.1 in 2018. P = .03) and more overall injuries (mean ISS = 20.7 ± 13.1 in 2020 vs 19.2 ± 12.5 in 2019; 17.8 ± 12.8 in 2018. P = .03). CONCLUSIONS: The investigators found that during the period of social distancing through the COVID-19 pandemic, the number of OMF cases decreased but that the severity of oral and maxillofacial and overall injuries was higher.

Are Oral Antibiotics an Effective Alternative to Intravenous Antibiotics in Treatment of Osteomyelitis of the Jaw?

PURPOSE: To review treatment of osteomyelitis of the jaw (OMJ) and determine whether antibiotic route and/or length of administration impacts resolution of infection postsurgically. METHODS: The investigators designed a retrospective cohort study enrolling a sample of patients treated at Harborview Medical Center from January 1, 2009 to December 31, 2019. The primary predictor variable was antibiotic administration route: oral (PO) only, intravenous (IV) only, IV transitioned to PO (IV + PO), or none. The secondary predictor was duration of antibiotic therapy (≤6 weeks or >6 weeks). The primary outcome variable was resolution of infection at 2 months follow-up posttreatment completion. The secondary outcome variable was number of surgeries to resolution of infection. Descriptive, bivariate, and multiple linear regression statistics were computed, with statistical significance set at P < .05. RESULTS: Sixty-seven individuals met inclusion criteria (38 male), mean age 51 years (18 to 88). Forty-nine (73%) received PO antibiotics, 12 (18%) IV + PO, 3 (4%) IV, and 3 (4%) none. Both PO and IV antibiotics were associated with clinical resolution (P = .022, .005, respectively) compared with debridement alone. Antibiotic duration of ≤6 weeks compared with >6 weeks was not significant. Seventy-six percent (51 of 67) required only 1 surgery. In the multivariate logistic regression, PO was associated with clinical resolution (P = .025, OR = 5.05). Penicillin allergy (P = 0.049, OR = 0.223) and diabetes (P = .008, OR = 0.104) were adversely associated with outcome. CONCLUSIONS: OMJ was successfully treated with oral antibiotics and surgery. Prescribing 6 weeks of IV antibiotics may be antiquated. Clinicians should consider oral penicillins as first line whenever possible. Further studies are recommended.

Is Distance Between Home and Treatment Site a Risk Factor for Complications After Treating Mandibular Fractures?

PURPOSE: Our level I trauma center provides care over a large geographic area including Alaska, Washington, Idaho, Montana, and Wyoming, with many patients traveling hundreds of miles to receive care. Distance to a treatment site is documented to be an independent risk factor for complications after multisystem trauma, but it is unclear if it is a risk factor for isolated mandibular fractures. The study purpose was to measure the association between distance to treatment site and risk for postoperative complications after treatment of isolated mandibular fractures. MATERIALS AND METHODS: The investigators designed and implemented a retrospective cohort study and enrolled a sample derived from patients treated for isolated mandibular fractures at Harborview Medical Center by the oral and maxillofacial surgery service between June 2012 and December 2016. The primary predictor variable was distance (miles) between the patient's residence and site of treatment (Harborview Medical Center). The primary outcome variable was postoperative complication (yes or no), subcategorized as major and minor. Secondary outcome variables were time to treatment between injury and operative treatment (days) and length of hospital stay (LOS) (days). Descriptive, bivariate, and multiple logistic regression statistics were computed to measure the association between distance to treatment site and postoperative complications, time to treatment, and LOS. The level of statistical significance was set at P ≤ .05. RESULTS: The study sample was composed of 403 subjects with a mean age of 32.6 ± 14.3 years and 80% were men. The average distance from the patient's residence to treatment site was 44.8 ± 128.6 miles (range, 0 to 1,440 miles; median, 20.4 miles). Major complications occurred in 11.6% of patients. The average distance between patients with and without postoperative complications was not significantly different (42.3 ± 55.8 miles vs 45.5 ± 141.7 miles; P = .8). Increasing distance was significantly associated with longer LOS (r = 0.16; P < .001) but not time to treatment (r = .04; P = .4). CONCLUSIONS: In contrast to other studies regarding multisystem trauma, complications after treating isolated mandible fractures were not associated with increasing distance to treatment site. Increasing distance may be associated with longer LOS but not time to treatment.

Odontogenic Infections: Disease Burden During COVID-19 at a Single Institution.

PURPOSE: The purpose of this study was to document the effect of coronavirus disease 2019 (COVID-19) on patients presenting to the University of Washington Oral and Maxillofacial Surgery (UW OMS) with an odontogenic infection. MATERIALS AND METHODS: The investigators designed a retrospective cohort study and enrolled a sample of 889 subjects who presented for an odontogenic infection from March 19 to June 18 in the years 2017, 2018, 2019, and 2020. The primary predictor variable was OMS consultation for an odontogenic infection during a non-COVID-19 (2017, 2018, and 2019) year (control) or during the COVID-19 pandemic in 2020 (experimental). The primary outcome variable was treatment rendered. Appropriate univariate and bivariate statistics were computed, and the level of significance was set at .05 for all tests. RESULTS: There was no significant difference in the incidence of OMS consults in the 2 cohorts (P > .05). The number of patients presenting to the UW emergency department (ED) for an odontogenic infection decreased from an average of 246 in non-COVID years to 151 in 2020. Patients in the experimental cohort were more likely (55 vs 30.0%; P = .04) to present primarily to UW than a dentist and were less likely to undergo an incision and drainage (70.0 vs 88.8%; P = .04), aerosol-generating procedure (70.0 vs 88.8%; P = .04), and incision and drainage in the ED (15.0 vs 41.3%; P = .03). CONCLUSIONS: The investigators did not find evidence of increased hospital or ED burden by odontogenic infections during the COVID-19 pandemic.

Early Effects of COVID-19 on Oral and Maxillofacial Surgery Residency Training-Results From a National Survey.

PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic has had an immense impact on the healthcare industry. Oral and maxillofacial surgery (OMS) clinical practice uniquely exposes providers to COVID-19. The purpose of the present study was to understand the effect of the COVID-19 pandemic on OMS residency training programs (OMSRTPs): 1) training and education; 2) availability and use of personal protective equipment (PPE); 3) experience with, and use of, screening and viral testing; 4) resident experience; and 5) program director (PD) experience and observations of the immediate and future effects on OMSRTPs. MATERIALS AND METHODS: OMS residents and PDs in OMSRTPs in the United States were invited to participate in the present cross-sectional study from April 1, 2020 to May 1, 2020. A 51-question survey was used to evaluate the effects of COVID-19 on OMSRTPs and to assess the 5 specific aims of the present study. RESULTS: A total of 160 residents and 13 PDs participated in the survey, representing 83% of US states or territories with OMSRTPs. Almost all residents (96.5%) reported modifications to their training program, and 14% had been reassigned to off-service clinical rotations (eg, medicine, intensive care unit). The use of an N95 respirator mask plus standard PPE precautions during aerosol-generating procedures varied by procedure location, with 36.8% reporting limited access to these respirators. Widespread screening practices were in use, with 83.6% using laboratory-based viral testing. Residents scheduled to graduate in 2022 were most concerned with the completion of the graduation requirements and with decreased operative experience. Most residents (94.2%) had moved to web-based didactics, and a plurality (47%) had found increased value in the didactics. CONCLUSIONS: Sweeping alterations to OMS clinical practice have occurred for those in OMSRTPs during the COVID-19 pandemic. Although the overall OMSRTP response has been favorable, residents' concerns regarding the ubiquitous availability of appropriate PPE, operative experience, and completion of graduation requirements requires further deliberation.

Communities With Bikeshare Programs Might Have a Lower Risk of Bicycle-Related Maxillofacial Injuries: Results From an Early Adopter of Bikeshare Programs.

PURPOSE: Although bikeshare programs can relieve traffic congestion, concerns for cyclist safety have been reported, secondary to the low frequency of helmet use observed among bikeshare users. The purpose of the present study was to measure and compare the risk of cycling-related maxillofacial injuries in communities with and without bikeshare programs. MATERIALS AND METHODS: We designed a retrospective cohort study and enrolled a sample of patients who had presented to a level 1 trauma center for evaluation of bicycle-related injuries. The primary predictor variable was the community's status regarding bikeshare programs, coded as present or absent. The primary outcome variable was the presence of a facial injury, coded as present or absent. Other study variables included demographic and injury-related parameters. Uni-, bi-, and multivariate statistics were computed, and statistical significance was set at P ≤ .05. RESULTS: The study sample included 1346 subjects. Of the 1346 patients, 507 (37.7%) had been injured in communities with bikeshare systems, and facial injuries were present in 305 (22.7%). Facial injuries were less common in the patients injured in communities with bikeshare than in those injured in communities without bikeshare (18.1 vs 25.4%; relative risk, 0.7; P = .002). CONCLUSIONS: In contrast to expectations, bicyclists injured in communities with bikeshare programs had a 30% decreased risk of maxillofacial injuries compared with bicyclists injured in communities without bikeshare programs. This finding might be partially explained by the low performance associated with the current bikeshare bicycles.

Evolution of COVID-19 Guidelines for University of Washington Oral and Maxillofacial Surgery Patient Care.

The emergence of coronavirus disease 2019 (COVID-19), caused by the SARS-CoV-2 (SC2) virus, in late December 2019 has placed an overwhelming strain on healthcare institutions nationwide. The modern healthcare system has never managed a pandemic of this magnitude, the ramifications of which will undoubtedly lead to lasting changes in policy and protocol development for viral testing guidelines, personal protective equipment (PPE), surgical scheduling, and residency education and training. The State of Washington had the first reported case and death related to COVID-19 in the United States. Oral and maxillofacial surgeons have a unique risk of exposure to SC2 and developing COVID-19 because of our proximity of working in and around the oropharynx and nasopharynx. The present report has summarized the evolution of COVID-19 guidelines in 4 key areas: 1) preoperative SC2 testing; 2) PPE stewardship; 3) surgical scheduling guidelines; and 4) resident education and training for oral and maxillofacial surgery at the University of Washington, Seattle, Washington.

Children Have an Increased Risk of Periorbital Dog Bite Injuries.

PURPOSE: Dog bites to the head, neck, and face (HNF) disproportionately affect children. It is unclear if specific facial regions are uniquely at risk in this population. Both the periorbital region and the central target area (CTA; nose, lips, and cheeks) have been proposed as being at increased risk. This study addressed the following question: Among individuals sustaining a dog bite injury to the HNF, are children, when compared with adults, at greater risk of injury to the periorbital region or CTA? PATIENTS AND METHODS: Using a retrospective cohort design, we enrolled a sample composed of patients presenting with HNF dog bite injuries. The predictor variable was age category: pediatric or adult (≥18 years). The primary outcome variable was injury location: isolated periorbital, isolated CTA, both periorbital and CTA, or other HNF location (neither periorbital nor CTA). Other variables included specific facial structures injured, demographic characteristics, injury circumstances, and clinical course. Descriptive and bivariate statistics were calculated. RESULTS: The sample consisted of 183 pediatric (58.5%) and 130 adult (41.5%) patients. Isolated periorbital injuries were more common in the pediatric group (relative risk [RR], 2.2 [95% confidence interval (CI), 1.3 to 3.7]; P = .003), as was injury to both periorbital and CTA regions (RR, 2.0 [95% CI, 1.2 to 3.5]; P = .01). Isolated CTA injury was the most common injury pattern overall in both children and adults, but children were at significantly less risk than adults (RR, 0.7 [95% CI, 0.5 to 0.9]; P = .002). Children were also less likely to sustain an injury to other HNF regions (RR, 0.6 [95% CI, 0.3 to 0.97]; P = .038). CONCLUSIONS: Children were twice as likely as adults to incur a periorbital dog bite, but no such increased risk was observed for the CTA. This may reflect unique anatomic risks in children or targeting of their eyes by attacking dogs, contributing to higher rates of HNF injury in this population. Public health measures should recommend against children being at eye level with dogs, even if familiar or under adult supervision.

Is Ultrasound a Useful Adjunct in the Management of Oral Squamous Cell Carcinoma?

PURPOSE: In patients with oral squamous cell carcinoma (OSCC), depth of tumor invasion (DOI) is correlated with prognosis. Tumor thickness (TT) is often used as a surrogate measurement of DOI. The aim of this study was to estimate TT in a sample of patients with OSCC using ultrasound sonography (USS), magnetic resonance imaging (MRI), and clinical assessment and compare these estimates with TT of the final surgical specimen. MATERIALS AND METHODS: The authors designed and implemented a prospective cohort study and enrolled patients presenting for management of OSCC. Eligible subjects had biopsy-proved OSCC and received clinical assessment, staging by MRI, and USS. The predictor variable was measurement technique by clinical assessment, USS, or MRI. The primary outcome variable was the maximal TT (centimeters) obtained from the final histopathologic specimen. Appropriate uni- and bivariate statistics were computed. RESULTS: The sample included 10 patients (mean age, 62.7 ± 13.6 yr; 70% men). Two of the 10 tumors (20%) were not adequately visualized with USS. Three of the 10 tumors (30%) were not seen with MRI because of dental artifact. These 3 patients' tumors were visualized by USS. One of the 10 tumors (10%) could not be palpated clinically. Three of the 10 patients (30%) did not go to surgery and were treated with chemoradiation because of the high tumor stage or the patient's health status. USS, MRI, and clinical TT measurements were underestimates compared with the specimen TT measurement (-0.6, -0.5, and -0.3 cm, respectively; P = .9). CONCLUSIONS: All 3 measurement modalities (clinical examination, MRI, and USS) underestimated OSCC TT compared with the final surgical specimen. There were no statistical differences in mean measurement or absolute value mean differences among measurement modalities. Notably, USS visualized the OSCC in the 3 patients (30%) whose tumors were poorly visualized or not visualized with MRI.

Helmets Decrease Risk of Bicyclist-Related Maxillofacial Injuries But Not Severity.

PURPOSE: Given the increasing use of bicycles for local transportation and recreation, the purpose of the present study was to measure the effects of bicycle helmets on the frequency and severity of maxillofacial injuries. The specific aims were to measure and compare the frequencies and severity of maxillofacial injuries between injured bicyclists who had or had not worn helmets. MATERIALS AND METHODS: We implemented a retrospective cohort study and enrolled a sample of bicyclists who had been injured from January 4, 2012 to March 31, 2018 and had presented to Harborview Medical Center for evaluation and treatment. The primary predictor variable was helmet use (yes vs no). The primary outcome variables were 1) the presence of a maxillofacial injury (yes vs no); and 2) injury severity, measured using the Face Abbreviated Injury Scale (FAIS). The other study variables were grouped into demographic or injury-related variables. The appropriate univariate, bivariate, and multivariate logistic regressions statistics were computed, and statistical significance was set at P < .05. RESULTS: The sample included 1379 subjects, with a mean age of 39.6 ± 18.9 years (range, 1 to 91 years), and 78.4% were male. The frequency of facial injuries between the helmeted and nonhelmeted bicyclists was 17.3% and 30.6%, respectively (relative risk, 0.6; 95% confidence interval, 0.5 to 0.7; P < .0001). The protective effect held after adjusting for age, gender, and alcohol exposure. The FAIS score between the helmeted and nonhelmeted riders was 1.8 ± 0.5 and 1.9 ± 0.6, respectively (P = .8). CONCLUSIONS: The helmeted bicyclists were 40% less likely to have a facial injury from bicycle accidents. For those cyclists with a facial injury, however, the injury severity was not different between the helmeted and nonhelmeted wearers. This might have been because, that unlike American football helmets, standard bicycle helmets do not include a face mask to protect the face.

Perceptions of Sexual Harassment in Oral and Maxillofacial Surgery Training and Practice.

PURPOSE: Despite increased awareness of sexually harassing behavior (SHB) and national movements such as #MeToo, SHB remains a persistent problem for women training in medical and surgical fields. The aims of the present study were to 1) estimate the prevalence and nature of SHBs in a set of female oral and maxillofacial surgery (OMS) residents and practicing surgeons in the United States; 2) measure and describe the subjective effects of SHBs on the professional development of female OMSs; and 3) measure the effect of SHB education in training programs and its association with its prevalence. MATERIALS AND METHODS: A cross-sectional study was conducted using an adapted validated Sexual Experiences questionnaire. The 22-question survey was e-mailed to female members of the American Association of Oral and Maxillofacial Surgeons' women's clinical interest group. Descriptive statistics and bivariate analyses were computed using age and SHB training as predictor variables for the prevalence of SHBs. RESULTS: A total of 89 participants were e-mailed, and 67 responded (75%). Of the 67 respondents, 53 were practicing OMSs (79%) and 14 were OMS residents (21%). Of the 67 respondents, 96% had experienced at least 1 form of SHB. Specifically, 96% reported gender harassment, 52% unwanted sexual attention, and 9% sexual coercion. An "intimidating, hostile, or offensive environment" was associated with "having a negative effect on yourself as a professional" (P < .01). Of the respondents, 61% had not received education on SHBs during training, with those older than 35 years least likely to have received SHB training (P = .001). CONCLUSIONS: Our results have shown that SHBs received by female OMSs is common. Our findings suggest that SHBs erodes the personal confidence and career development of female OMS practitioners and residents. We recommend SHB educational training for all residents, faculty, and staff to ensure personal and academic growth in a safe environment.