Head and Neck Oncology—Teamwork

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LETTER TO THE EDITOR

message he gleaned from my words. Actually, here are the 3 points I was trying to put forth: 1. Our current accreditation standard, as written, is ambiguous and unenforceable. If our specialty truly wants all residents to do research, the standard and intent statement need to be rewritten to make this clear. 2. It will be problematic to have every resident do meaningful research during their training if they are not given the time and strong encouragement by their faculty, a large percentage of whom do not do research themselves. I would support a standard requiring all residents do research, but only if they are provided the time, support, and faculty coaching such endeavors require. Such research, though, should not be done at the expense of finishing the program clinically competent. 3. If all residents cannot do research, they should at least do some scholarly work. I agree that private practitioners can perform, and many do perform, valuable research; this is wonderful to see. My only caveat is that they submit their planned research protocol to a local institutional review board if it will involve human subjects, even if it only involves retrospective chart reviews. JAMES R. HUPP, DMD, MD, JD Editor-in-Chief

doi:10.1016/j.joms.2011.12.008

HEAD AND NECK ONCOLOGY—TEAMWORK We would like to congratulate the Editor-in-Chief of the Journal of Oral and Maxillofacial Surgery for his scholarly editorial entitled “Maxillofacial Surgical Oncology and OralMaxillofacial Surgery: A Perfect Fit,” which appeared in volume 69 of the Journal of Oral and Maxillofacial Surgery (p 2941) in 2011. The author has beautifully explained the advantages that we as dental graduates have over our medical colleagues in the management of oral cancer. He has rightfully explained that our specialization has a level of competence when it comes to rehabilitation in terms of occlusion and orofacial function. The author’s justification for bringing fellowships in maxillofacial surgical oncology and reconstruction under the umbrella of oral and maxillofacial surgery is indeed agreeable. However, we would like to highlight certain issues we think were overlooked. Oral cancer is a disease that never remains localized to a particular region of the head and neck; rather, the tumor tends to metastasize to various other body parts through the lymphatics, blood vessels, and so on. The tumor in the maxillofacial region can either be primary with or without metastases to other body parts or it can be secondary with the primary lesion located elsewhere in the body, such as the lungs. Therefore, maxillofacial surgical oncology requires essential teamwork involving specialist surgeons from various disciplines, including maxillofacial surgery, oncologic surgery, otolaryngology, general surgery, and plastic surgery. The nature of this disease precludes its confinement to a particular branch of medicine. Therefore, we strongly suggest that we not try to function in isolation, that it not be a race of expansion and encroachment into each other’s boundaries. Instead, let us work in coordination with each other, sharing our knowl-

edge and experience for the (extra) benefit of the patient. The need of the hour is that oral and maxillofacial surgeons should be an integral part of the tumor board of hospitals, and we should hold joint conferences and research studies with our medical and surgical colleagues on common clinical issues and upcoming challenges. We are sure that such thinking will attract mutual respect and coordination among the providers of healthcare profession, and this, in turn, will make possible the creation of an environment beneficial to all humans in the days to come. DHAMEJA MUKESH, MDS District Solan, Himachal Pardesh, India DHAMEJA KOMAL, BDS Panchkula City, Haryana, India SETHI AMIT, MDS District Solan, Himachal Pardesh, India

doi:10.1016/j.joms.2011.12.020

In reply:—I thank Dr Dhameja and colleagues for their letter. I entirely agree with their promotion of the idea of a team approach to managing patients with maxillofacial malignancies. Hopefully, this will be the practice in institutions where such patients are treated. Unfortunately, local and even national political realities may interfere with well-intentioned and planned attempts to form teams. Our specialty should take the high road, however, by promoting multidisciplinary approaches to managing head and neck cancer. JAMES R. HUPP, DMD, MD, JD EDITOR-IN-CHIEF Journal of Oral and Maxillofacial Surgery

doi:10.1016/j.joms.2011.12.019

METHODOLOGICAL LIMITATIONS OF A SYSTEMATIC REVIEW EVALUATING INFERIOR OR DOUBLE JOINT SPACES INJECTION VERSUS SUPERIOR JOINT SPACE INJECTION FOR TEMPOROMANDIBULAR DISORDERS I read with great interest the review performed by Li et al, titled “Inferior or Double Joint Spaces Injection Versus Superior Joint Space Injection for Temporomandibular Disorders: A Systematic Review and Meta-Analysis.”1 After quantitatively synthesizing the evidence from 4 trials, the authors reported, “this systematic review proved that inferior joint space injection or double joint space injection is more effective in treating temporomandibular disorders.” The strength of this review is its systematic approach, including a comprehensive search strategy and manual hand search of references, no restriction to English-only trials, independent and duplicate data extraction, and the use of a priori subgroup hypotheses to explain heterogeneity. This systematic review is, however, not without key methodologic limitations. First, the authors reported pain, maximal mouth opening, and synthesized clinical variables as their outcomes of interest. It might have been best to specify outcomes that are only of importance to the patients.2 Aside from pain, I question whether the other outcomes are patient important. Second, it would have been valuable to use the minimal important difference (MID) to help readers interpret the effect for pain measured using