Are Industry Payments Associated With the Level of Evidence in Oral and Maxillofacial Surgery?

PURPOSE: The purpose of the present study was to determine whether the industry payments in oral and maxillofacial surgery (OMS) are associated with a study's level of evidence (LOE). MATERIALS AND METHODS: A retrospective cohort study was designed and implemented to query the Journal of Oral and Maxillofacial Surgery from 2002 to 2016. The primary predictor variables were the presence of a self-reported conflict of interest (COI) and the type of COI. The outcome variable was the LOE. The secondary outcome variables investigated were the topic of the study and the inclusion of trainees. The inclusion criteria entailed contributions from domestic academic OMS training programs. Disclosure of the COIs and type of COI, the LOE, topic of the study, and inclusion of trainees were recorded for every report from January 2002 until December 2016. Descriptive statistics were calculated, and χ2 tests were performed to determine a significant relationship primarily between the COIs and LOE. RESULTS: The sample included 1455 reports, and 4.2% of the sample size had disclosed a COI. The studies that disclosed industry payments demonstrated a significant positive correlation with the LOE (P < .01), especially for cohort studies. Also, the type of COI was significantly associated with the LOE (P < .05). Industry payments were not shown to be significantly related statistically to topic of the study (P = .16); however, the stock-related payments were associated with the topic (P < .05). No association was found between COI disclosure and trainee contribution. CONCLUSIONS: The results have indicated that industry payments are associated with the LOE in the OMS literature. Further studies are needed to elucidate both the accuracy of the financial disclosures by comparing them with publicly available open payment databases and the perceptions of the OMSs, their trainees, and their patients regarding the influence of industry payments on the specialty's academic interests.

Standing on the Shoulders of Giants: Dental Students Seek Academically Productive Mentors.

PURPOSE: The purpose of this study was to determine whether a strong statistical correlation exists between the involvement of trainee groups and the academic productivity of the senior author. MATERIALS AND METHODS: A retrospective cohort study of publications in the Journal of Oral and Maxillofacial Surgery from 2002 to 2016 was designed and implemented. The primary predictor variables were the presence of a trainee (dental student or oral and maxillofacial surgery [OMS] resident), year of publication, and study design and topic. The outcome variable was the Hirsch index (h-index) of the senior author. Author affiliations were queried using ScienceDirect, and the Scopus database was used to identify the h-index of the senior author from each publication spanning the previous 15 years. Descriptive statistics and t tests were performed to determine significance. RESULTS: Of the 6,398 articles published in the Journal of Oral and Maxillofacial Surgery from January 2002 to December 2016, 1,341 (21.0%) met the inclusion criteria. The mean h-index of senior authors of articles with trainees or OMS residents was not significantly different from the mean h-index of senior authors without trainees (P = .50) or OMS residents (P = .37), whereas the mean h-index of senior authors working with dental students was significantly greater than the h-index of those not working with dental students (P < .01). Dental student mentors had a mean h-index that was below the sample mean from 2002 to 2007 but rose above the sample mean from 2010 to 2016. Trainees were more likely to work with academically productive mentors in orthognathic surgery (P < .01), temporomandibular joint (P < .05), retrospective cohort (P < .05), and innovative technique (P < .05) studies but less likely in randomized controlled trials (P < .05). CONCLUSIONS: Dental students seek more academically productive mentors to a greater degree. More studies should be conducted to elucidate the attributes of the ideal mentor in academic OMS and to determine whether differences in mentorship exist between domestic and foreign OMS programs.

Retropalatal Cross-Sectional Area Is Predictive of Obstructive Sleep Apnea in Patients With Syndromic Craniosynostosis.

OBJECTIVE: There is a high rate of obstructive sleep apnea (OSA) in patients with syndromic craniosynostosis (SCS). Little is known about the airway anatomy in this population. The purpose of this study is to characterize the 3 dimensional (3D) upper airway in patients with SCS with and without OSA. DESIGN: This is a retrospective study of patients with SCS treated at Boston Children's Hospital from 2000 to 2015. Patients were divided into OSA and no-OSA groups based on polysomnography. Predictor variables included age, sex, body mass index (BMI), and 3D upper airway measurements. The primary outcome variable was the presence or absence of OSA. Secondary outcome variables were apnea-hypopnea index and oxygen saturation nadir. Descriptive and bivariate statistics were computed, and significance was set as P < .05. RESULTS: There were 24 patients: 16 in the OSA group and 8 in the no-OSA group. The 2 groups did not differ significantly by age, BMI, or syndromic diagnosis. The presence of OSA was associated with a smaller minimum retropalatal cross-sectional area (minRPCSA; P < .001). In a logistic regression model controlling for age, sex, and upper airway length, minRPCSA was the primary predictor of OSA (P ≤ .002). Receiver operating characteristic analysis determined minRPCSA = 55.3 mm2 to be the optimal diagnostic threshold for OSA, with sensitivity = 100% and specificity = 87.5% (P < .001). CONCLUSION: A minRPCSA ≤55.3 mm2 is predictive of the presence of OSA in patients with SCS.

Does Early Repair of Orbital Fractures Result in Superior Patient Outcomes? A Systematic Review and Meta-Analysis.

PURPOSE: To date, no clear evidence-based guidelines exist pertaining to the ideal timing to perform surgical treatment of orbital fractures. The purpose of this study was to determine if early treatment of orbital fractures resulted in better patient outcomes. MATERIALS AND METHODS: We designed and implemented a systematic review and meta-analysis to test the null hypothesis of no difference in outcomes between different time intervals between orbital injury and surgical intervention. PubMed, Embase, the Cochrane Library, the Elsevier text mining tool database, and clinicaltrials.gov trial registry were queried. The quality of evidence was based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. The predictor variable was the timing of operative repair (early vs late). The outcome variable was complete recovery. Other variables of interest were diplopia, enophthalmos, and preoperative motility restriction. Meta-analyses were performed when definitions of active and control interventions and patient outcomes were deemed similar. In addition, χ2 tests were performed to determine differences in clinical outcomes between early and late operative repair. RESULTS: Of the 1,160 articles reviewed, 20 met the inclusion criteria. Surgery performed less than 2 weeks after injury was significantly associated with greater odds of complete recovery of symptoms (odds ratio [OR], 6.9 [95% confidence interval (CI), 1.35-35.06]), as well as a lower incidence of postoperative diplopia (OR, 0.3 [95% CI, 0.1-0.9]) and enophthalmos (OR, 0.2 [95% CI, 0.1-0.9]). Repair performed less than 30 days after injury was associated complete resolution of preoperative motility restriction (OR, 24.6 [95% CI, 1.30-462.34]) as well as diplopia. CONCLUSIONS: Differences in the timing of surgery and definition of patient outcomes, as well as variations in methods of evaluating postoperative outcomes, potentiate the risk of bias and warrant downgrading of the quality of evidence in a study. The timing of repair varied among 2, 4, and 8 weeks after injury. However, a short time to surgical intervention was significantly associated with resolution of vertical dystopia, postoperative enophthalmos, and motility restriction.

Extracorporeal shockwave treatment impedes tooth movement in rats.

BACKGROUND: Accelerated tooth movement has been a topic of interest for orthodontic research recently. Surgically facilitated orthodontic treatment has been shown to be an effective approach to accelerate tooth movement; however, it remains invasive, requires additional surgery, and may increase post-operative complications. In this study, we evaluate the effects of extracorporeal shockwave treatment (ESWT), a non-invasive approach to regenerate alveolar bone, on orthodontic tooth movement in rats. MATERIALS AND METHODS: Seventy-two male rats, aged 10 weeks old, were subjected to 10-cN closed-coil nickel-titanium springs for unilateral maxillary first molar tooth movement. One group of rats received a single treatment of extracorporeal shockwave treatment at 500 impulses at energy flux density 0.1 mJ/mm2, with a pulse rate of 5 pulses per second immediately after spring installation while the non-ESWT-treated group served as a control group. The rats were sacrificed at day 3, 7, 14, 21 and 28 for tooth movement evaluation and sample analyses. Faxitron radiography, histological, double bone labeling and gene expression analyses were performed. Serum biochemistry was evaluated at day 3, 7 and 28 of the study. Kruskal-Wallis analysis of variance was used to determine the mean difference among groups, and multiple comparisons were analyzed by Mann-Whitney-U tests with a significance level = 0.05. RESULTS: The results demonstrated that tooth movement in the ESWT-treated rats (0.11 ± 0.07 mm) was impeded compared to the tooth movement in the non-ESWT-treated rats (0.44 ± 0.09 mm). ESWT up-regulated several osteoblastic and osteoclastic gene markers and cytokines; however, the effects on osteoclasts were only transient. Double-fluorescence bone labeling demonstrated that osteoblastic activity increased after ESWT treatment. There was no difference in systemic RANKL/OPG ratio between groups. CONCLUSIONS: ESWT at 500 impulse at energy flux density 0.1 mJ/mm2 increased osteoblast and osteoclast activities and imbalanced bone remodeling resulting in impeded tooth movement in rats.

Varanoid Tooth Eruption and Implantation Modes in a Late Cretaceous Mosasaur.

Erupting teeth are some of the oldest witnesses of developmental processes in the vertebrate fossil record and provide an important resource for vertebrate cladistics. Here, we have examined a mosasaur jaw fragment from central Texas using ultrathin ground section histology and 3D tomographic imaging to assess features critical for the cladistic placement of mosasaurs among varanoids vs. snakes: (i) the orientation of replacement teeth compared to the major tooth axis, (ii) the occurrence of resorption pits, and (iii) the mode of tooth implantation/attachment to the tooth bearing element (TBE). The replacement tooth studied here developed in an inclined position slightly distal of the deciduous parent tooth, similar to another varanoid squamate, the Gila monster Heloderma suspectum. Ground sections and tomographs also demonstrated that the replacement tooth attachment apparatus was entirely intact and that there was no evidence of mechanical deformation. Sections and tomographs further illustrated that the replacement tooth was located within a bony crypt and the inclination of the crypt matched the inclination of the replacement tooth. These preparations also revealed the presence of a resorption pit within the boundaries of the deciduous tooth that surrounded the developing replacement tooth. This finding suggests that developing mosasaur teeth developed within the walls of resorption pits similar to varanoid tooth germs and unlike developing snake teeth which are surrounded by fibrous connective tissue integuments. Finally, mosasaurs featured pseudo-thecodont tooth implantation with teeth anchored within a socket of mineralized tissue by means of a mineralized periodontal ligament. Together, these data indicate that the moderate inclination of the erupting mosasaur tooth studied here is neither a result of postmortem displacement nor a character representative of snakes, but rather a shared character between Mosasaurs and other varanoids such as Heloderma. In conjunction with the presence of resorption pits and the evidence for pseudothecodont tooth implantation, the tooth eruption and implantation characters described in the present study either place mosasaurs among the varanoids or suggest convergent evolution mechanisms between both clades, with mosasaurs evolving somewhat independently from a common varanoid ancestor.

Upper Airway Length is Predictive of Obstructive Sleep Apnea in Syndromic Craniosynostosis.

PURPOSE: Midfacial hypoplasia is a characteristic feature of the syndromic craniosynostoses and predisposes these patients to developing obstructive sleep apnea (OSA). The purpose of this study was to identify anatomic factors associated with airway obstruction in patients with syndromic craniosynostoses. MATERIALS AND METHODS: This was a retrospective cohort study. The authors enrolled a study sample composed of patients with syndromic craniosynostoses. The predictor variables were age, gender, body mass index (BMI), syndromic diagnosis, and parameters of upper airway length and size measured on lateral cephalograms. To control for age, upper airway length was corrected for differences in patient height. The outcome variable was OSA status (present or absent). Descriptive, bivariate, and regression statistics were computed. For all analyses, a P value less than or equal to .05 was considered statistically significant. RESULTS: The sample was composed of 50 patients with a mean age of 10.3 ± 0.6 years, 50% were boys, and 24 (48%) had OSA. Patients with and without OSA did not differ statistically in age, gender, BMI, or syndromic diagnosis. Those with OSA had increased upper airway length (P = .016), decreased posterior airway space (P = .001), and more severe midfacial retrusion (P = .022) compared to patients without OSA. After adjusting for covariates, the odds ratio for OSA was 32.9 in patients with an upper airway longer than 45.3 mm per meter of height (P = .018), and for every 1-mm decrease in posterior airway space, the risk of OSA increased by 30% (P = .022). CONCLUSIONS: Patients with syndromic craniosynostosis and OSA have a longer upper airway, smaller posterior airway space, and more severe midfacial retrusion than those without OSA.

Surgeon migration between developing countries and the United States: train, retain, and gain from brain drain.

BACKGROUND: The critical shortage of surgeons in many low- and middle-income countries (LMICs) prevents adequate responses to surgical needs, but the factors that affect surgeon migration have remained incompletely understood. The goal of this study was to examine the importance of personal, professional, and infrastructural factors on surgeon migration from LMICs to the United States. We hypothesized that the main drivers of surgeon migration can be addressed by providing adequate domestic surgical infrastructure, surgical training programs, and viable surgical career paths. METHODS: We conducted an internet-based nationwide survey of surgeons living in the US who originated from LMICs. RESULTS: 66 surgeons completed the survey. The most influential factors for primary migration were related to professional reasons (p ≤ 0.001). Nonprofessional factors, such as concern for remuneration, family, and security were significantly less important for the initial migration decisions, but adopted a more substantial role in deciding whether or not to return after training in the United States. Migration to the United States was initially considered temporary (44 %), and a majority of the surveyed surgeons have returned to their source countries in some capacity (56 %), often on multiple occasions (80 %), to contribute to clinical work, research, and education. CONCLUSIONS: This study suggests that surgically oriented medical graduates from LMICs migrate primarily for professional reasons. Initiatives to improve specialist education and surgical infrastructure in LMICs have the potential to promote retention of the surgical workforce. There may be formal ways for LMICs to gain from the international pool of relocated surgeons.

Survey of surgery and anesthesia infrastructure in Ethiopia.

BACKGROUND: Information regarding surgical capacity in the developing world is limited by the paucity of available data regarding surgical care, infrastructure, and human resources in the literature. The purpose of this study was to assess surgical and anesthesia infrastructure and human resources in Ethiopia as part of a larger study by the Harvard Humanitarian Initiative examining surgical and anesthesia capacity in ten low-income countries in Africa. METHODS: A comprehensive survey tool developed by the Harvard Humanitarian Initiative was used to assess surgical capacity of hospitals in Ethiopia. A total of 20 hospitals were surveyed through convenience sampling. Eight areas of surgical and anesthesia care were examined, including access and availability, access to human resources, infrastructure, outcomes, operating room information and procedures, equipment, nongovernmental organization delivery of surgical services, and pharmaceuticals. Results were obtained over a 1-month period during October 2011. RESULTS: There is wide variation in accessibility, with hospital-to-population ratios ranging from 1:99,010 to 1:1,082,761. The overall physician to population ratio ranges from 1:4715 to 1:107,602. The average hospital has one to two operating rooms, 4.2 surgeons, one gynecologist, and 4.5 anesthesia providers-although in all but three hospitals anesthesiology was provided by nonphysician personnel only (i.e., a nurse anesthetist). Access to continuous electricity, running water, essential medications, and monitoring systems is very limited in all hospitals surveyed, although such access did vary across regions. CONCLUSIONS: This survey of Ethiopia's hospital resources attempts to identify specific areas of need where resources, education, and development can be targeted. Because the major surgical mortality comes from late presentations, increasing accessibility through infrastructure development would likely provide a major improvement in surgical morbidity and mortality rates. Infrastructure limitations of electricity, water, oxygen, and blood banking do not prove to be significant barriers to surgical care. The increasing number of physicians is promising, although efforts should be directed specifically toward increasing the number of anesthesiologists and surgeons in the country.