Is Recreational Marijuana Use Associated With Changes in the Vital Signs or Anesthetic Requirements During Intravenous Sedation?

PURPOSE: The prevalence of tetrahydrocannabinol (THC) use is increasing in the general population due to its increased availability, legality, and cultural acceptability. The purpose of the current study was to measure the association of THC use on the vital signs and anesthetic requirements during intravenous (IV) sedation procedures in recreational marijuana users. METHODS: A retrospective cohort study was performed. A study sample was chosen from July 2018 to May 2022 based on the following inclusion criteria: patients who underwent toxicology screening due to their history of recent drug use and received IV sedation. The predictor variable of the present study is THC status grouped into THC+ and THC-. THC status was established using urine toxicology. Patients who screened positive for THC were coded THC+. Patients who screened negative for THC were coded THC-. Primary outcome variable was changes in vital signs, including mean arterial pressure (MAP), heart rate (HR), and respiratory rate (RR) during IV sedation procedures in THC+ and THC- groups. Secondary outcome variable was difference in medication (midazolam, fentanyl, propofol, and ketamine) requirements in THC+ and THC- groups. Covariates included age, gender, race, weight, duration of surgery, smoking history, and alcohol use, data on psychiatric diagnosis and psychiatric medications. Descriptive statistics and 2-sample t test were calculated. Statistical significance was set at P < .05. RESULTS: In total, 53 patients met the inclusion criteria and were included in the study, with 27 patients in the THC+ group and 26 patients in the THC- group. There were no significant statistical differences in the MAP%, HR%, and RR% at T5, T10, T20, and T30 between the THC+ and THC- groups. When comparing THC+ and THC- groups, in bivariate analyses, the THC+ group required, on average, higher doses of fentanyl [83.82 mcg compared to 65 mcg (P = .02)] and propofol [70 mg compared to 45.26 mg (P = .03)] during IV sedation. However, after adjusting the effect of age, gender, and weight, THC had no significant effect on midazolam (P-value = .28), fentanyl (P-value = .12), propofol (P-value = .06) and ketamine (P-value = .86) requirements. CONCLUSIONS: These findings suggest there are no differences in vital signs or anesthetic requirements between the THC+ and THC- groups.

Prosthetic temporomandibular joint replacement (TJR): Stock or custom? A single institution pilot comparison.

OBJECTIVE: The aim of this study was to compare stock (Biomet-Lorenz Stock, Parsippany, NJ) and custom (TMJ Concepts, Inc., Ventura, CA) total temporomandibular joint (TMJ) replacement prosthetics. METHOD: This was a retrospective cohort study of 17 consecutive patients operated by the same surgeon from 2015 to 2020 comparing stock and custom options for total joint replacement (TJR). The inclusion criteria were patients who documented 1 year of follow-up post-TJR without previous TMJ replacement surgery. The predictor variable was the TMJ prosthetic replacement. The primary clinical outcome variables was pain via Visual Analog Scale (VAS) measured at 1, 3, and 6 months postoperatively and maximum incisal opening measured pre and post-surgery. The other variables were grouped into the following categories: surgery time, length of stay, and unilateral vs bilateral replacements. RESULTS: Our review showed no statistically significant difference in maximum incisal opening, subjective pain score, hospital stay, surgical time, or complication rate between Biomet-Lorenz stock and TMJ Concepts, Inc. custom total joint replacement. Bilateral TJR, irrespective of prosthesis type, did have greater improvement in maximal incisal opening (MIO) compared with unilateral that was statistically significant (P < .05). CONCLUSIONS: There was no statistically significant difference in the pain VAS or MIO using either stock or custom TJR. Both should be considered good surgical options for improvements in patient function and long-term jaw stability.

Maxillofacial Implications of Scleroderma and Systemic Sclerosis: A Case Report and Literature Review.

Scleroderma and more generally systemic sclerosis comprise a group of autoimmune diseases characterized by increased collagen synthesis and deposition within connective tissue. The Scleroderma Foundation estimates that as many as 300,000 persons in the United States have scleroderma. Although the etiology of the disease is unknown, it is thought to be related to chronic inflammation secondary to autoimmune tissue damage. Scleroderma has variable presentations and may result in changes to the skin, blood vessels, muscles, and internal organs. Oral and maxillofacial findings can include limited mouth opening; xerostomia; periodontal disease; widening of the periodontal ligament space; zygomatic arch resorption; and resorption of the mandibular angle, coronoid process, and condyle. We present the case of a 26-year-old female patient with scleroderma who exhibited extreme maxillofacial manifestations of the disease.

Interdisciplinary Management of a Class III Anterior Open Bite Malocclusion in a Patient With Cerebral Palsy.

Dentofacial disharmony in patients with cerebral palsy (CP) can lead to low self-esteem and functional limitations. However, medical and behavioral challenges in patients with developmental disorders often prevent dental practitioners from offering the necessary treatment. This report describes the clinical interdisciplinary management of a 20-year-old man with CP, including orthodontic, periodontal, and orthognathic surgery therapy. The patient presented with the chief complaint of having difficulty chewing, was wheelchair dependent, had poor orofacial muscle control, and exhibited a Class III malocclusion with a skeletal anterior open bite. The lower midline was shifted 3 mm to the right, there was severe maxillary spacing, and the patient had gingival overgrowth. A combined orthodontic, periodontal, and orthognathic surgery treatment approach was chosen to meet the patient's interdisciplinary needs. Because of his physical limitations, it was necessary to avoid complicated and prolonged orthodontic treatment mechanics. Interdisciplinary therapy improved the patient's oral function, periodontal health, and facial esthetics and led to a good occlusion, which remained stable 1 year after treatment. Regardless of the treatment challenges, combined orthodontic and surgical therapy in the present patient with CP led to favorable treatment results and improved the patient's self-esteem, confidence in social interactions, and speaking and chewing abilities.

What Factors Necessitate Removal of Retained Ballistic Fragments in the Head and Neck?

PURPOSE: The purpose of this study was to estimate the frequency of retained ballistic fragment (RBF) removal and to identify factors associated with an increased risk for RBF removal. To date, there are no studies focused on identifying factors associated with removal of RBFs localized to the maxillofacial region. MATERIALS AND METHODS: Using a retrospective cohort study design, the authors enrolled a sample composed of patients with RBFs localized to the maxillofacial region. The predictor variables included bullet size, location, involvement of bone, involvement of sinus, antibiotics, multiple antibiotics, and multiple locations. The primary outcome variable was RBF retrieval. The secondary outcome variables were timing of operative retrieval, fragment site infection, and migration of RBF. Appropriate uni- and bivariate statistics were computed and logistic regression modeling was used. RESULTS: The sample was composed of 20 patients (mean age, 30 yr; 80% male) and 55% (11 patients) required or desired object removal overall. The number of projectiles ranged from 1 to 19 (total, 48) in the 20 patients. The logistic model identified larger size, final location of bone, final location of soft tissue, and final location of sinus as having a higher probability of removal that was statistically significant (P < .05); however, size was the only variable with a substantial odds ratio (OR; 1.96; P < .05). There was no evidence of migration and a low rate (2.3%) of infection was noted at subsequent follow-up radiography and clinical examination. CONCLUSION: Size was the only statistically significant predictor variable with a substantial OR (1.96; 95% confidence interval, 1.31-3.40; P < .05). There was a low risk of infection even when considering oral pharyngeal contamination and low risk of migration. Further studies could focus on prudent antibiotic use and larger patient populations.

Controversies in Traditional Oral and Maxillofacial Reconstruction.

Traditional reconstruction of the head and neck and significantly evolved over the last 20 to 30 years with advances in microvascular surgery, biologic materials such as bone morphogenic protein, and dental implant predictability. Earlier and more definitive reconstruction can now be achieved with combining therapies, allowing patients immediate restoration of function and improved cosmetics. Antiresorptive medications, such as Denosumab and bisphosphonates, have complicated bony reconstruction treatments with altered biology and less-predictable results. Virtual surgical planning is a major advancement for reconstruction pretreatment planning and designing of intraoperative tools to expedite the operation and achieve more predictable results.

Concomitant Suppurative Parotitis and Condylar Osteomyelitis.

Parotitis is a common occurrence in the immunocompromised, dehydrated, and malnourished patient as a result of dysfunctional ductal and parotid cells. Inflammation can be acute or chronic based on clinical history, and it can be suppurative based on the presence of micro or macro abscess formation within the substance of the gland. This report presents a case of concomitant condylar osteomyelitis and chronic suppurative parotitis in the setting of previous methicillin-susceptible Staphylococcus aureus foot infection. Ultimately, resection of osteomyelitis, drainage of parotid infection, and intravenous antibiotic therapy led to full resolution of the infection and symptoms. The final pathology of osteomyelitis of the temporomandibular joint and methicillin-resistant S aureus infection is an unusual consequence of chronic parotitis. The patient was restored with a total joint replacement approximately 3 months after resection with no recurrence of infection after 24 months.

Multiple primary squamous cell carcinomas of the oral cavity.

PURPOSE: There is a subset of patients who develop multiple primary squamous cell carcinomas (SCCs) of the oral cavity. The aim of this study was to better characterize this group of patients and determine whether there are any associated risk factors. MATERIALS AND METHODS: This is a retrospective review of all patients treated for oral SCCs at the University of Maryland Department of Oral and Maxillofacial Surgery from November 1989 to February 2013. The inclusion criteria were patients who developed at least 3 primary oral cancers. Lesions were considered separate primaries if they involved different anatomic regions within the oral cavity and were more than 2 cm apart or if they occurred more than 5 years apart. RESULTS: Of 1,478 patients treated during this time frame, 20 met the inclusion criteria. There were 14 women and 6 men (female-to-male ratio, 2.3:1). Nineteen were Caucasian and 1 was of Indian ethnicity. The average number of primaries per patient was 3.9 (range, 3 to 6 primaries). The mean age at first diagnosis was 63.3 years (44 to 86 yr). The mean interval between the different primaries was 32 months (0 to 228 months). The most common site involved was the gingiva (45% of cases), followed by the tongue, buccal mucosa, retromolar fossa, and soft or hard palate. The mean follow-up was 118 months (22 to 342 months). Eleven patients developed nodal disease. Of those 11 patients, 9 died of the disease (<20% survival). The average time to neck involvement was 66.4 months. The average time from last neck involvement to death was 11.5 months. More than half the patients were nonsmokers or had quit more than 10 years before the first diagnosis. All patients quit smoking during the course of their treatment yet continued to develop multiple primaries. Three patients had proliferative verrucous leukoplakia (PVL), and 4 patients had biopsy-proved lichen planus. CONCLUSION: The incidence of multiple primary SCCs within the oral cavity appears to more commonly involve Caucasian women without risk factors, although lichen planus and PVL might play a role. The gingiva appears to be the most commonly involved primary site, and subsequent primaries tend to be restricted to the oral cavity. Close observation and early expectant treatment appear to improve prognosis and survival in these patients. Cervical nodal metastases adversely affected survival (P = .02) as did the development of more than 4 primary carcinomas (P = .04).

Impact of collagen structure on matrix trafficking by human fibroblasts.

Biodegradation of collagen biomaterial matrices and the deposition of new collagen extracellular matrix (ECM) are critical to the integration of in vitro bioengineered materials and tissues in vivo. In previous studies, we observed significant impact of collagen matrix structure on primary lung fibroblast behavior in vitro. In the present work, to begin to understand the mechanistic basis for our previous observation, the response of human fibroblasts (IMR-90) to the structural state of collagen matrices was studied with respect to cell proliferation, cell morphology, beta-galactosidase level, and transcript content for collagen (Col-1), matrix metalloproteinases (MMP-1, MMP-2), tissue inhibitors of matrix metalloproteinase (TIMP-1 and TIMP-2). Collagen digestion was assessed quantitatively by uptake of collagen-coated fluorescent beads incorporated in the preformed collagen matrix. Transcript levels related to the deposition of new ECM proteins varied as a function of the structure of the collagen matrix presented to the cells. Col-1 expression was 2-fold higher and expression for MMP-1, MMP-2, TIMP-1, and TIMP-2 increased for cells when grown on 156 microg/cm2 denatured collagen compared with cells grown on tissue culture (TC) plastic. On 156 microg/cm2 nondenatured (native) collagen, Col-1 expression was decreased by half and MMP-2 was increased by 2.5-fold compared with cells grown on TC plastic. On 78 microg/cm2 denatured collagen, Col-1 expression was 80% whereas the MMPs and TIMPs were increased by 1.25- to 2-fold compared with cells grown on TC plastic. On 78 microg/cm2 nondenatured collagen expression of all 5 transcripts was reduced 60-90% of the levels determined for the cells grown on TC plastic. Cell viability, based on cell morphology and beta-galactosidase activity, was improved on the denatured collagen. A higher level of collagen matrix incorporation was observed for cells grown on denatured collagen than on nondenatured collagen or TC plastic. These data suggest that tissue engineering matrices incorporating denatured collagen may promote more active remodeling toward new ECM in comparison to cells grown on nondenatured collagen or cells grown on TC plastic.