Oral and Maxillofacial Surgery Training in the United States: Influences of Dental and Medical Education, Wartime Experiences, and Other External Factors.

Here, we trace the history of oral and maxillofacial surgery (OMS) education from the mid-19th century to the present. We consider the effects of separation of dentistry and medicine, discovery of anesthesia, antisepsis, antibiotics, and wars on surgical progress and training. In the 19th century, apprenticeships with well-known surgeons were the norm. In the 20th century, training evolved from nonintegrated dental school and hospital experiences to 3- and then 4-year integrated hospital programs. After World War II individual oral surgeons pursued the MD degree after residency. The formal dual degree OMS paradigm began in the 1970s.

Dual-degree Oral and Maxillofacial Surgery Training in the United States: "Back to the Future".

In the present report, we trace the history of education and training of oral and maxillofacial surgeons as it has evolved from the mid-19th century to the present. We consider the effects of the discovery of ether anesthesia, the separation of medicine and dentistry, and other milestones such as antisepsis (Lister), antibiotics (Fleming) and surgical progress during wartime. The main emphasis, however, is on the background, development, and implementation of current dual-degree oral and maxillofacial surgery training programs, the first 5 programs, the pioneer advocates for this training, and progress and challenges for the future.

Prognostic factors affecting the duration of disability after third molar removal.

PURPOSE: The purposes of this investigation were 1) to estimate the duration of disability after third molar removal and 2) to identify factors associated with prolonged recovery. MATERIALS AND METHODS: This was a prospective cohort study composed of subjects enrolled in the American Association of Oral and Maxillofacial Surgeons Age-Related Third Molar Study. The predictor variables were grouped as follows: demographic, health status, anatomic, pathologic, medications, and complications. The outcome variable was the duration of postoperative disability measured as the number of days the subject reported inability to perform normal daily activities after third molar removal. Bivariate and multiple linear regression analyses were used. The level of statistical significance was P < .05. RESULTS: The study sample included 4,004 subjects who had 8,748 third molars removed. The mean duration of postoperative disability was 1.4 ± 1.8 days (range, 0-26; median, 1 day). In the multiple linear regression model, age, female gender, number of third molars removed, mandibular third molar removal, full-bony impaction, sum of antibiotics or pain medications, and complications were associated with prolonged recovery (P < .05). Erupted third molars, periodontal disease or other preoperative pathology, and use of chlorhexidine were associated with earlier return to normal daily activities (P < .05). CONCLUSION: The study results suggest that third molar removal is associated with a mean delay in returning to normal activities of less than 2 days. Several factors were statistically associated with time to return to normal activities.

WITHDRAWN: Book review.

The publisher regrets that this article is an accidental duplication of an article that has already been published, doi:10.1006/ijom.2003.0514. The duplicate article has therefore been withdrawn.

The Dutch health care system: possible model for America?

Take a look at the pros and cons of the Dutch health care system and see what elements might enhance U.S. health care.

Risk factors for inflammatory complications following third molar surgery in adults.

PURPOSE: To estimate the frequency of inflammatory complications (surgical site infection and alveolar osteitis) following third molar (M3) extraction and identify risk factors for such complications. MATERIALS AND METHODS: This study was designed as a prospective cohort study and enrolled a sample composed of subjects having >or=1 M3 extracted as part of the American Association of Oral and Maxillofacial Surgeons' Age-Related Third Molar Study. Predictor variables were categorized as demographic, health status, anatomic, and pathologic factors. The outcome variable was the presence of a postoperative inflammatory complication (ie, surgical site infection or alveolar osteitis). Descriptive and bivariate statistics were computed. Variables with P values less than .15 in bivariate analyses were included in a multiple logistic regression model, used to identify factors associated with inflammatory complications. RESULTS: The study sample consisted of 4,004 subjects with a mean age of 39.8 +/- 13.6 years having 8,748 M3s extracted. In bivariate analyses, impaction level, periodontal disease in or around M3, pre-existing infection around M3, and M3 pathology were associated with postoperative inflammatory complications. In the multiple regression model, level of impaction (soft tissue: odds ratio [OR] = 2.5; 95% confidence interval [CI], 1.7, 3.7), partial bony OR = 4.7 (95% CI, 3.6, 6.1), full bony, 6.0 (95% CI, 4.7, 7.7); P < .0001), and pre-existing infection (OR = 1.3 [95% CI, 1.0, 1.6; P = .05) or pathology (OR = 3.1; 95% CI, 2.2, 4.3; P < .0001) were associated with an increased risk of inflammatory complications following M3 surgery. CONCLUSIONS: Level of impaction, pre-existing infection, and pathology were associated with increased risk for postoperative inflammatory complications following M3 surgery.

Comparison of methohexital and propofol use in ambulatory procedures in oral and maxillofacial surgery.

PURPOSE: Short-acting anesthetic agents, such as propofol and methohexital, are commonly used for ambulatory procedures in the practices of oral and maxillofacial surgeons (OMS). This study compares the safety and anesthetic outcomes of propofol and methohexital. In addition, the study compares the safety and outcomes of these agents when administered either by an OMS who simultaneously provides anesthesia and performs the procedure (anesthetist/surgeon), or by a non-OMS provider of anesthesia (anesthesiologist or certified registered nurse anesthetist; CRNA) whose sole obligation is to provide anesthesia. MATERIALS AND METHODS: This is a prospective study of anesthesia techniques used in an office-based ambulatory setting by OMS throughout the United States, in which either propofol or methohexital was used for sedation/anesthesia. The study variables included demographic information, anesthetic agent, adverse outcomes related to anesthesia, operative procedure, and provider of anesthesia. These variables were compared with the patient group that received a benzodiazepine/narcotics regimen for sedation (control group). Bivariate (contingency tables) and multivariate (logistic regression) analyses were conducted. P < or = .05 was considered statistically significant. RESULTS: The study included 47,710 patients who met the inclusion criteria: 26,147 (54.8%) patients were in the propofol group, 15,859 (33.2%) were in the methohexital group, and 5,704 (12.0%) were in the benzodiazepine group. Among all study patients, 333 (0.7%) had an adverse event. The most common complication was nausea and vomiting without aspiration. Of the patients in the propofol group, methohexital group, or benzodiazepine group, 0.4%, 1.1%, and 0.8% had an adverse event, respectively. The higher number of complications among patients in the methohexital group compared with patients in the other 2 groups was statistically significant. Of 26,147 patients in the propofol group, 23,799 (91.0%) received anesthesia from an anesthetist/surgeon (OMS), and 2,368 (9.1%) from an anesthesiologist or nurse anesthetist (non-OMS). A total of 109 patients (0.4%) had an adverse event. The majority of patients who received anesthesia from a non-OMS were in the propofol group (2,368 of 2,404 patients; 98.5%). There was no statistically significant difference in the occurrence of adverse outcomes when comparing patients in the propofol group who received anesthesia from an OMS with those who received anesthesia from a non-OMS (P = .24, bivariate analysis; P = .33, multivariate analysis). CONCLUSIONS: There is a statistically significant increase in adverse events related to methohexital compared with propofol or benzodiazepine/narcotics for anesthesia. Propofol appears to have the lowest risk for adverse events. There is no statistically significant difference in the number of adverse outcomes between the administration of propofol for ambulatory surgery by OMS as an anesthetist/surgeon and anesthesiologist/nurse anesthetist. It remains critical that our specialty maintains the highest standards, to provide safe anesthesia and to reduce adverse anesthetic events.

Anesthesia outside the operating room in the office-based setting.

PURPOSE OF REVIEW: The majority of anesthesia services provided outside the operating room or ambulatory surgery center is in the office-based setting. This review will focus on three areas that are critical to office-based anesthesia: safety, quality of care and patient satisfaction. RECENT FINDINGS: Data obtained from the State of Florida office-based surgery adverse event data repository indicate that, even with The American Society of Anesthesiology I patients, there remains opportunity to improve outcomes. Careful patient selection remains critical, especially the patient with a history of sleep apnea. While general anesthesia remains the gold standard, expanded use of local anesthesia, regional blocks and variation on sedation techniques offer alternatives that may reduce risks but still maintain a high quality of care. While there is limited office-based anesthesia satisfaction data, limiting postoperative nausea and vomiting remains a major patient satisfier of which an occurrence rate of zero may be possible. SUMMARY: There is rapid growth for the need of safe and high quality office-based anesthesia. To meet these needs, a special set of skills is required, which may require expanded exposure and experience during training. An office-based anesthesia central data repository is needed for benchmarking and identifying areas for improvement. Finally, with advances in surgical technology, there is a need for focused research in office-based anesthetic techniques and modalities and patient satisfaction.

Age as a risk factor for third molar surgery complications.

PURPOSE: The purpose of this study was to estimate the frequency of complications after third molar (M3) surgery, with age as the primary risk factor. PATIENTS AND METHODS: This was a prospective cohort study of a sample of subjects having at least 1 M3 extracted as part of the American Association of Oral and Maxillofacial Surgeons' Age-Related Third Molar Study. The predictor variables were categorized as demographic, health status, anatomic, and pathological. The outcome variable was overall complications, including both intraoperative and postoperative complications. Appropriate univariate and bivariate statistics were computed. A multiple logistic regression model was used to evaluate the simultaneous effects of multiple covariates. RESULTS: The study sample was comprised of 4,004 subjects having a total of 8,748 M3s removed. The mean age was 39.8 +/- 13.6 years, with 245 subjects (6.1%) age 25 and younger. Approximately half of the subjects were female. The overall complication rate was 19%. In bivariate analyses, age above 25 years, gender, American Society of Anesthesiologists classification, number of preoperatively identified risk factors for complication, impaction level of M3, evidence of periodontal disease, preoperative infection, and evidence of any pathology associated with M3 were associated with complications (P 25 years) appears to be associated with a higher complication rate for M3 extractions.

The American Association of Oral and Maxillofacial Surgeons Age-Related Third Molar Study.

PURPOSE: The purpose of this investigation was to assess the frequency of complications of third molar surgery, both intraoperatively and postoperatively, specifically for patients 25 years of age or older. MATERIALS AND METHODS: This prospective study evaluated 3,760 patients, 25 years of age or older, who were to undergo third molar surgery by oral and maxillofacial surgeons practicing in the United States. The predictor variables were categorized as demographic (age, gender), American Society of Anesthesiologists classification, chronic conditions and medical risk factors, and preoperative description of third molars (present or absent, type of impaction, abnormalities or association with pathology). Outcome variables were intraoperative and postoperative complications, as well as quality of life issues (days of work missed or normal activity curtailed). Frequencies for data collected were tabulated. RESULTS: The sample was provided by 63 surgeons, and was composed of 3,760 patients with 9,845 third molars who were 25 years of age or older, of which 8,333 third molars were removed. Alveolar osteitis was the most frequently encountered postoperative problem (0.2% to 12.7%). Postoperative inferior alveolar nerve anesthesia/paresthesia occurred with a frequency of 1.1% to 1.7%, while lingual nerve anesthesia/paresthesia was calculated as 0.3%. All other complications also occurred with a frequency of less than 1%. CONCLUSION: The findings of this study indicate that third molar surgery in patients 25 years of age or older is associated with minimal morbidity, a low incidence of postoperative complications, and minimal impact on the patients quality of life.

Office-based ambulatory anesthesia: Factors that influence patient satisfaction or dissatisfaction with deep sedation/general anesthesia.

PURPOSE: The purpose of this report was to analyze data collected in an outcomes study in an attempt to identify factors that may be significant predictors of either patient satisfaction or dissatisfaction with deep sedation/general anesthesia (DS/GA) administered in an office-based setting. MATERIALS AND METHODS: To address the research purpose, we used a prospective cohort study design and sample of patients undergoing procedures in the office-based ambulatory setting of oral and maxillofacial surgeons practicing in the United States who received local anesthesia (LA), conscious sedation (CS), or DS/GA. The predictor variables were categorized as demographic, anesthetic technique, adverse events, and patient-oriented outcomes (satisfaction/dissatisfaction). Appropriate descriptive and exact P values were completed as indicated. Statistical significance was set at P < .05. Multivariate analyses were performed to support the interpretation of univariate findings. RESULTS: The sample was composed of 34,191 patients, of whom 71.9% patients received DS/GA. There were 20,455 patient satisfaction forms completed, of which 14,912 forms were from patients undergoing DS/GA. Of patients who received DS/GA, 95.8% were extremely or moderately satisfied, 3.1% were neutral, and 1.1% moderately or extremely dissatisfied. Increased age and memory of postoperative instructions were identified as factors, which predicted satisfaction. The addition of nitrous oxide to some regimens also appeared to increase satisfaction. Young age, anxiety, pain, vomiting, and being awake during the procedure were predictors of dissatisfaction. CONCLUSIONS: The findings of this study indicate that patients are overwhelmingly satisfied with DS/GA provided in an office-based ambulatory setting. Items identified as significant predictors of dissatisfaction (anxiety, pain, vomiting, being awake) generally confirm preexistent suppositions. Surprisingly, patient age (<10 years old) and memory of postoperative instructions appear to have relevance to dissatisfaction as well. Lack of specific regimens and controls prevents confirmation that nitrous oxide improves patient satisfaction rates. Although statistically significant, the variations, which resulted in a higher or lower satisfaction rate, are of questionable clinical significance in many cases.

Resistance is futile: the unwitting insertion of analogical inferences in memory.

Analogical inferences can modify people's understanding, but can this occur even when the inferences are unpalatable? We report two experiments suggesting that this is the case. Participants read a source passage on the role and status of gay people in society. Half then read an analogy describing the historical persecution of left-handers. On a subsequent recognition test, the participants who read the analogy were more likely than the control participants to misrecognize analogical inferences as statements explicitly presented, but the two groups did not differ in recognition rates for other kinds of statements. A priori explicit attitudes toward gays did not moderate these findings, although the participants with more positive attitudes toward gays saw the analogy to left-handers as more sound. Our findings demonstrate that analogical inferences can be seamlessly integrated into mental representations of the target domain even when those inferences are unpalatable; in short, resistance to analogy is futile.

Efficacy and safety of acetaminophen vs ibuprofen for treating children's pain or fever: a meta-analysis.

OBJECTIVE: To summarize studies testing the efficacy and safety of single-dose acetaminophen and ibuprofen for treating children's pain or fever. DATA SOURCES: Reports were gathered by searching computerized databases (from their inception through May 2002) and registries, relevant journals, and bibliographies of key articles. STUDY SELECTION: Seventeen blinded, randomized controlled trials with children (<18 years) receiving either drug to treat fever or moderate to severe pain. DATA EXTRACTION: Under a fixed-effects model, outcome measures for an initial single dose of ibuprofen vs acetaminophen were the risk ratio for achieving more than 50% of maximum pain relief, effect size for febrile temperature reduction, and risk ratio for minor and major harm. DATA SYNTHESIS: Ibuprofen (4-10 mg/kg) and acetaminophen (7-15 mg/kg) showed comparable efficacy (3 pain relief trials; 186 children). The risk ratio point estimates was 1.14 (95%confidence interval [CI], 0.82-1.58) at 2 hours after receiving the dose, and 1.11 (95% CI, 0.89-1.38) at 4 hours. Ibuprofen (5-10 mg/kg) reduced temperature more than acetaminophen (10-15 mg/kg) at 2, 4, and 6 hours after treatment (respective weighted-effect sizes: 0.19 [95% CI, 0.05-0.33], 0.31 [95% CI, 0.19-0.44], and 0.33 [95% CI, 0.19-0.47]) (9 fever trials; 1078 children). For ibuprofen 10 mg/kg (acetaminophen, 10-15 mg/kg), corresponding effect sizes were 0.34 (95% CI, 0.12-0.56), 0.81 (95% CI, 0.56-1.03), and 0.66 (95% CI, 0.44-0.87). There was no evidence the drugs differed from each other (or placebo) in incidence of minor or major harm (17 safety trials; 1820 children). CONCLUSIONS: In children, single doses of ibuprofen (4-10 mg/kg) and acetaminophen (7-15 mg/kg) have similar efficacy for relieving moderate to severe pain, and similar safety as analgesics or antipyretics. Ibuprofen (5-10 mg/kg) was a more effective antipyretic than acetaminophen (10-15 mg/kg) at 2, 4, and 6 hours posttreatment.

Children's ratings of the intensity and unpleasantness of post-operative pain using facial expression scales.

This study explored whether global unidimensional self-report pain scales based on facial expression help children separately estimate the sensory and affective magnitude of post-operative pain. Ninety paediatric elective surgery patients (in two age groups: 5-9 and 10-15 years) used each of four scales to estimate pain intensity and pain affect during the first 2 days after surgery. The four scales were: Faces Pain Scale (FPS), Facial Affective Scale (FAS), and the Coloured Analogue Scale (CAS) (one for intensity and one for unpleasantness). As hypothesised, ratings on the FPS correlated more highly with analogue scale ratings for intensity than for unpleasantness, whereas ratings on the FAS correlated more highly with those on the analogue scale for unpleasantness than for intensity. Factor analysis indicated that although all measures loaded on a single dimension of distress, there was an additional weaker factor corresponding to a unique contribution of the FAS. No systematic age effects were observed. It was concluded that the FPS and the FAS may partly measure different aspects of the postoperative pain experience in children, although shared instrument variance may obscure true estimates of covariation in ratings of intensity and affective magnitude. The clinical relevance of the present results remains to be determined.

Distraction osteogenesis of the porcine mandible: histomorphometric evaluation of bone.

Distraction osteogenesis is a technique for skeletal lengthening that exploits the body's innate capacity for bone formation in response to tension forces on the repair callus. The authors developed a distraction osteogenesis model with a semiburied device in the Yucatan minipig mandible because of similarities between human and porcine mandibular anatomy, temporomandibular function, chewing patterns, and bone turnover rates. The purpose of this study was to measure histomorphometric bone fill after different latency periods, rates of distraction, and duration of neutral fixation in the minipig mandible. In addition, the relationship between histomorphometric bone fill and clinical stability was investigated. Mandibular osteotomies in 20 female Yucatan minipigs weighing 25 to 30 kg were distracted with modified semiburied distraction devices. Variables included 0-day or 4-day latency; 1-mm, 2-mm, or 4-mm daily distraction rates; gap size of 7 or 12 mm; and evaluation after neutral fixation for various lengths of time. Specimens were fixed in 2% paraformaldehyde, pH 7.4, before being embedded in methylmethacrylate. Sections were prepared from the region just below the inferior alveolar canal. The area of new bone formation within the gap was measured and expressed as a percentage of the total area of the distraction gap. Bone fill ranged from 0 to 100 percent. A pilot study with 7-mm advancements showed similar bone fill with 0-day or 4-day latency, but with poor reproducibility. Mandibles that were distracted to 12 mm at 1 mm per day exhibited nearly complete bone fill, either with 0-day latency (average, 93 percent) or 4-day latency (average, 100 percent). Mandibles that had been distracted for 3 days at 4 mm per day showed moderate osteogenesis and clinical stability with increasing time of neutral fixation. Bone fill was significantly correlated with clinical stability (Spearman r = 0.801, p = 0.001). Histological examination showed exuberant periosteal osteogenesis in distracted mandibles, even in those that showed poor bone fill and clinical stability. Thus, the periosteum appears to be a major source of new bone formation. These results show that osteogenesis was nearly complete with 1 mm per day and 0-day or 4-day latency. These results are consistent with the authors' previously reported clinical and radiographic observations that a latency period is not necessary for successful healing of the mandibular distraction osteogenesis wound.