Is Dose Volume a Better Predictor of Osteoradionecrosis Risk Than Total Dose for Patients Who Have Received Head and Neck Radiation?

PURPOSE: Oral and maxillofacial surgeons frequently encounter patients who require extractions following exposure to head and neck radiation, and they must assess the risk of extraction and consider alternatives such as deliberate root retention. The purpose of this study was to determine whether dose volume would be a better predictor for osteoradionecrosis (ORN) than total dose. METHODS: This is a retrospective cohort study of patients diagnosed with ORN following head and neck radiation (administered between January 2006 and December 2018) and a comparison group selected based on site and dosage who did not develop ORN. The predictor variables were total radiation dose and mandibular dose volume, and the outcome variable was ORN occurrence. Covariates included age, sex, cancer stage and site, radiation therapy type, smoking status, alcohol use, adjuvant chemotherapy use, medical comorbidities, and concomitant tumor surgery. Logistic regression models were employed and area under receiver operating characteristic curve (AUROC) and model accuracy (Acc) were used to determine the better predictor. RESULTS: A total of 56 patients were included in the study: 27 ORN positive (ORN+) and 29 matched controls who did not develop ORN (ORN-). Most patients were male (76.8%), considered smokers (78.6%), used alcohol (80.4%), were in stage IV (66.1%), received chemotherapy (75.0%), and received intensity modulated radiation therapy radiation (55.4%). The statistical models with V50 Gy (cc) and V65 Gy (cc) dosage variables exhibited greater predictability of ORN occurrence than total dose (AUROC: 0.90 vs 0.76 and model accuracy: 0.82 vs 0.75, respectively). CONCLUSIONS: The results suggest that following head and neck radiation, dose volume may be a better predictor of ORN risk than total dose. This finding is significant, both for the oral and maxillofacial surgeon who is preoperatively assessing ORN risk following radiation exposure, and for the radiation oncologist striving to minimize the risk associated with their treatment.

Is Maximal Dosage for Local Anesthetics Taught Consistently Across U.S. Dental Schools? A National Survey.

Administration of safe and effective local anesthesia is a cornerstone of dental practice, but there is some discrepancy in recommendations for maximum doses, with the Council on Dental Therapeutics and American Academy of Pediatric Dentistry's guidelines differing from the guidelines of manufacturers and contemporary textbooks. The aim of this study was to determine the level of uniformity across U.S. dental schools in teaching maximal safe doses for commonly used local anesthetics. Faculty members primarily responsible for teaching local anesthesia to dental students at all 62 U.S. dental schools that had graduated classes were invited to participate in a survey in March 2017. The survey included questions about maximum doses taught, awareness of the existence of two differing guidelines, and whether one or both guidelines were commonly taught to students. A total of 37 responses were received, for a response rate of 60%. The respondents included oral and maxillofacial surgeons, general dentists, dental anesthesiologists, and periodontists. Of the respondents, 22% reported being unaware of the existence of more than one standard, and there was inconsistency in teaching practices. A majority (73%) reported teaching the higher maximum dose (7 mg/kg) for lidocaine, while a similar but smaller majority (60%) reported teaching the lower dose threshold (4.4 mg/kg) for mepivacaine. This study found no standard recommended maximum dose of lidocaine or mepivacaine being taught in U.S dental schools. Students should be made aware that there is more than one standard, and teaching should emphasize sound medical and pharmacologic principles. There is also a need to ensure that questions on dental licensing examinations are consistent regarding maximum safe doses for local anesthesia.

Is Treating Oral and Maxillofacial Trauma Profitable? An Analysis of Hospital and Surgeon Reimbursement at an Academic Medical Center.

PURPOSE: During the past 2 decades, there has been a marked decrease in the willingness of community-based oral and maxillofacial surgeons to participate in trauma call. Although many factors can influence the decision not to take trauma call, 1 primary disincentive is the perception that managing facial trauma might be profitable for the hospital, but not profitable for the surgeon. The purpose of this study was to compare the profitability of facial trauma management for the hospital and the surgeon at the Virginia Commonwealth University (VCU) Medical Center (Richmond, VA). MATERIALS AND METHODS: In this retrospective cohort study, records were collected for patients who were seen for primary trauma management by the Department of Oral and Maxillofacial Surgery at VCU (VCUOMS) from June 2011 through July 2014. Cost and reimbursement data were analyzed for these patients from the VCU Health System (VCUHS) and the VCUOMS. For the hospital, actual cost data were provided; for the surgeon, cost was calculated based on an average overhead of 50%. For uniformity, patients were excluded if they remained in the hospital for longer than a 23-hour observation period. Patients younger than 18 years also were excluded. RESULTS: In total, 169 patients met the inclusion criteria. There was a statistically relevant difference in the percentage of costs recouped and the actual profit. The average percentage of costs recouped was 230% for the VCUHS versus 47% for the VCUOMS. This amounts to an average profit per case of $3,461 for the hospital versus a loss of $1,162 for the surgeon. CONCLUSIONS: The results of this study indicate that in the VCU Medical Center, maxillofacial trauma yields a net profit for the hospital and a net loss for the operating surgeon. Although the results are limited to outpatient management at 1 academic institution, they suggest that hospitals in some settings might be in a position to incentivize surgeons for trauma management.

Improving the Medical Curriculum in Predoctoral Dental Education: Recommendations From the American Association of Oral and Maxillofacial Surgeons Committee on Predoctoral Education and Training.

Dental procedures are often performed on patients who present with some level of medical fragility. In many dental schools, the exercise of taking a medical history is all too often a transcription of information to the dental chart, with little emphasis on the presurgical risk assessment and the development of a treatment plan appropriate to the medical status of the dental patient. Changes in dentistry, driven by an increasingly medically complex population of dental patients, combined with treatment advances rooted in the biomedical sciences necessitate the adaptation of our dental education to include a stronger background in systemic health. Many predoctoral educators in the American Association of Oral and Maxillofacial Surgeons (AAOMS) have expressed concern about the medical preparedness of our dental students; therefore, the AAOMS and its Committee on Predoctoral Education and Training have provided recommendations for improving the medical curriculum in predoctoral dental education, including a strengthening of training in clinical medicine and biomedical sciences, with specific recommendations for improved training of our dental students and dental faculty.

Is There Uniformity and Satisfaction Among Clinical Practice Models and Faculty Compensation Plans in US Dental School-Based Oral and Maxillofacial Surgery Departments?

PURPOSE: There is a lack of information regarding clinical practice models and faculty compensation plans used by dental school-based departments of oral and maxillofacial surgery (OMS) and their effectiveness. The purpose of this study was to examine 1) the level of uniformity in clinical practice models and faculty compensation plans for US dental school-based OMS departments and 2) the level of satisfaction expressed by faculty with their current compensation plan. MATERIALS AND METHODS: A survey was sent to the chairs of the 40 US dental school-based OMS departments asking them specific information regarding their current practice model, the faculty compensation plan, and their satisfaction with their current plan. RESULTS: Twenty-four of the 40 department chairs returned the survey, for a 60% response rate. The OMS practice was part of the dental school faculty practice in 50% of the departments and a separate entity in 33%. The most common faculty compensation plan consisted of an academic salary plus a faculty practice salary based on a collection-based incentive (38%), but in 25% it was based on production. Fifty-seven percent of the responding chairs stated they were not satisfied with their current practice and compensation plans. CONCLUSIONS: There is considerable variation in the practice models and compensation plans in US dental school-based OMS departments. More than half the department chairs expressed a general dissatisfaction with their current compensation plans. The survey data indicate a need for alternative models, and this report presents one such model.

Case for tort reform in medical malpractice.

Under tort law, injured parties have the basic right to seek indemnity for wrongful injury, including injury from medical malpractice. Unfortunately, the present system is associated with many undesirable secondary effects, including problems of patient access to care, excessive testing or overtreatment, and undertreatment due to doctors' fear of malpractice. Nationwide, there are innumerable cases of doctors abandoning obstetrical or other high risk practices, or migrating away from states with less friendly tort laws. The California MICRA legislation of 1976 is often cited as a model for tort reform, but even this model legislation may be insufficient to restore a beleaguered trust between medical providers and their patients. Several key research studies suggest that the jury system fails to fairly and reliably compensate injured patients, and fails to deter or discipline errant doctors. To adequately meet the common needs of patients and health care providers, there must be an appropriate emphasis on aggressive risk management, quality improvement, patient safety, professional oversight, and responsible insurance underwriting. Moreover, there must be a systemic improvement of the current tort system as it pertains to medical malpractice. Although incremental reforms at the state level are slowly occurring and should certainly be supported, a greater reward may ultimately stem from more radical restructuring to a system of medical tribunals.