- Email: [email protected]
Epidemiology
Oral Abstract Session 9 ANESTHESIA/EPIDEMIOLOGY Friday, September 14, 2001, 10:45 am - 12:00 noon
Utilization of Sedation and Adjunctive Services for Pediatric Dental Patients William G. Flick, DDS, MPH, University of Illinois, College of Dentistry, 801 S Paulina, Chicago, IL 60612 (Adel Al-Asfour, BDS, BA) Purpose: Sedation, general anesthesia, or hospital admission may be required for the management of certain pediatric dental patients. Recent deaths in dental offices have prompted public scrutiny concerning this area of practice. This survey describes the extent and types of sedation, with special emphasis on oral sedation. It focuses on the agents used, monitoring, and the training level of practitioners. Methods: A 14-question survey was distributed to 815 randomly selected dentists in Illinois. The respondents were anonymous and grouped by specialty area of practice. IRB approval was from The University of Illinois Chicago. A computer database and spreadsheet were used for tabulation and analysis. Dentists not treating pediatric patients, retired, or not in clinical practice were excluded. Results: Four hundred five questionnaires (n ⫽ 405) were returned and found acceptable for inclusion in the study. Sedation in all forms is a significant treatment modality used in the management of pediatric dental patients. In Illinois, it was estimated from the survey that in excess of 50,000 pediatric patients receive some type of sedation. Oral sedation, the treatment modality currently drawing the most public scrutiny, is primarily used by oral maxillofacial surgeons and pediatric dentists. Use by general dentists appears to be less than 10% of dentists who treat pediatric patients. The anesthesia education and training, for practitioners using oral sedation, ranges from none to full anesthesia residency. Likewise there appears to be no uniform standard of care for monitoring during oral sedation. Pulse oximetry is used by the OMS and pediatric dentists, but seldom by general dentists. The EKG is utilized by 50% of OMS, but by 0% of pediatric dentists. Midazolam was the primary agent used by the OMS, whereas pediatric and general dentists favored chloral hydrate. From the study it was also estimated that more than 3,000 pediatric patients are admitted to a hospital or surgical center for dental care when medically necessary. An equal number of pediatric patients were identified who required admission for dental care but were denied this service because of lack of health insurance coverage. Conclusions: The wide variance in training and mon58
itoring poses several questions. Do current educational programs provide enough opportunities for all dentists to obtain adequate training, and do current anesthesia regulations covering the administration of oral sedation adequately protect the public? With approximately 50% of pediatric patients lacking insurance benefits for medically required admissions, do current health insurance programs provide the necessary access to care for pediatric patients with special needs? References American Dental Association News, 60 Minutes II Targets Tragedies, V 29, No. 22, p 1, 1998 American Dental Association Policy Statement: Use of Conscious Sedation, ADA House of Delegates, October 1999
Oral and Maxillofacial Surgery in Patients With Chronic Oral, Facial, and Head Pain Howard A. Israel, DDS, 12 Bond St, Great Neck, NY 11021 (J. Desmond Ward, DDS; Brenda Horrell, DDS, MS; Steven J. Scrivani, DDS, DSc) Patients with chronic oral, facial, and head pain (COFHP) frequently have a history of oral and maxillofacial surgery (OMS) procedures that fail to relieve symptoms. The source of COFHP is often elusive and misdiagnosis with failed treatments is common. Localized dentoalveolar and temporomandibular joint (TMJ) pain may cause frustrated patients to request additional surgery to eliminate the source of pain. The purpose of this investigation was to profile a population of patients with COFHP and evaluate: 1) previous OMS procedures, 2) the frequency of significant misdiagnoses, and 3) the number of patients who were recommended for OMS procedures by an interdisciplinary orofacial pain team. The patient population included individuals referred to the Center for Oral, Facial and Head Pain at New York Presbyterian Hospital (1/99 to 4/01). These patients had pain for greater than 6 months, had seen multiple clinicians, and underwent multiple unsuccessful treatments. The center includes an interdisciplinary team of specialists who diagnose and manage COFHP patients. Patient profile data included age, gender, duration of symptoms, number of previous clinicians/specialists, previous OMS procedures, evidence of significant misdiagnoses, diagnosis by the center team, and treatments recommended by the center. The study population included: 120 patients, female: male ⫽ 3:1, mean age ⫽ 49 years, average pain duraAAOMS • 2001
Oral Abstract Session 9: Anesthesia/Epidemiology tion ⫽ 81 months, and average number of previous clinicians/specialists ⫽ 6. Previous OMS procedures were reported in 38/120 (32%) patients. Procedures performed prior to our evaluation included: endodontics (30%), extractions (27%), apicoectomies (12%), TMJ surgery (6%), neurolysis (5%), orthognathic surgery (3%), and debridement of bone cavities (2%). Surgical intervention clearly exacerbated pain in 21/120 (18%) patients. Seven of the patients underwent 26 TMJ surgical procedures. Two of these patients, who had TMJ fibrosis, underwent 12 TMJ surgeries. The diagnoses following evaluation by the center included: masticatory myospasm (50%), atypical facial neuralgia (40%), depression (30%), TMJ synovitis (14%), TMJ osteoarthritis (12%), trigeminal neuralgia (10%), and TMJ fibrosis (2%). Evidence of previous misdiagnoses was present in virtually all patients. However, gross misdiagnoses leading to serious sequelae occurred in 6/120 (5%) patients. One of these patients, treated for a TMJ disorder for over 1 year, was diagnosed by the center with an adenocarcinoma of the deep lobe of the parotid with base of skull invasion. Treatment of patients with COFHP by the center included medications (91%), physical therapy (36%), psychiatric management (30%), trigger injections (15%), oral appliances (13%), biofeedback (13%), acupuncture (8%), surgery (4%), and Botox injections (1%). Surgical intervention was recommended in 5 patients, which included neurolysis, coronoidectomies with arthroscopies, removal of a foreign body, sinus surgery, and removal of a parotid tumor. Our population of COFHP patients had multiple failed OMS procedures prior to presentation to our center. Surgical treatment is rarely indicated as a treatment for pain relief in these patients and may precipitate or exacerbate COFHP. The oral and maxillofacial surgeon must be extremely selective in recommending surgery in this patient population. Misdiagnosis is common in patients with COFHP and when symptoms continue, one must reevaluate the diagnosis and investigate further for other potentially serious conditions as the cause of COFHP. References Okeson JP: The differential diagnosis of orofacial pains. Oral Maxillofac Surg Clin North Am 12:205, 2000 Israel HA, Scrivani SJ: The interdisciplinary approach to oral, facial and head pain. J Am Dent Assoc 131:919, 2000
Evaluation of 0.5% Ropivacaine and 0.5% Marcaine for Mandibular Third Molar Extraction Jose Ruiz Villanueva, DDS, 2005 N Piedras, El Paso, TX 79920-5001 (Clark Michael Comeaux, DDS; Donald Charles Hofheins, DDS) AAOMS • 2001
Local anesthesia using a combination of 2% lidocaine, 1:100,000 epipinephrine and bupivacaine provides rapid onset and extended postoperative analgesia that is particularly suitable for third molar surgery. Ropivacaine (Naropin, Astra USA, Inc, Westborough, MA) is a pipecoloxylidide amino-amide local anesthetic with less cardiovascular toxicity and slightly less duration of action than bupivacaine. It has unique vasoconstrictor properties that limit the need for the addition of a vasoconstrictor. Ropivacaine has been widely investigated and is currently used for local anesthesia in a broad range of surgical applications but has not been reported for use in third molar surgery. The purpose of this study is to determine the efficacy of ropivacaine compared with bupivacaine for mandibular third molar surgery when used in combination with 2% lidocaine, 1:100,000 epinephrine. This is a prospective, randomized, doubleblind study designed to include 90 patients electing to have bilateral mandibular third molar extractions performed under local anesthesia. Patients requiring unilateral maxillary third molar extractions were excluded from the investigation. Vital signs including pulse oximetry, noninvasive blood pressure, and EKG were monitored preoperatively, intraoperatively, and postoperatively. Local anesthetic in the form of 2% lidocaine with 1:100,000 epinephrine was administered to the maxillary and mandibular surgical sites in a routine fashion to provide appropriate block and infiltration anesthesia. The study anesthetics consisting of 1.8 cm3 of 0.5% ropivacaine and 1.8 cm3 of 0.5% bupivacaine with 1:200,000 epinephrine aspirating syringes labeled “right” and “left” were injected into the specified mandibular surgical sites by inferior alveolar, lingual, and long buccal nerve block technique. One clinician administered all anesthetic injections and performed all of the surgeries in a standard fashion. Before discharge, each patient indicated quality of numbness during surgery and discomfort experienced during surgery for R and L sides using an 11.8 cm Visual Analog Scale (VAS). At home, the patients recorded the time and side that first caused need for analgesic medication, level of discomfort after surgery for R and L sides using the VAS, and the time that sensation returned to the lower lip. The patients were examined the following day and data collection was completed. For the initial 29 subjects, there was a mean age of 22.6 years with ages ranging from 19 to 34 years. Twelve patients indicated that discomfort from the bupivacaine side first required postoperative pain medication. Fourteen patients reported that analgesics were needed first for the side anesthetized using ropivacaine. Two patients reported that analgesics were first necessary for bilateral discomfort. One patient reported that no medication was necessary. The average quality of numbness during surgery on the bupivacaine side was 8.52 cm on the VAS compared with 8.00 cm for ropivacaine. The P value of the paired t-test is 0.48 which was 59
Oral Abstract Session 9: Anesthesia/Epidemiology not significant. The average amount of discomfort during surgery for bupivacaine was 2.60 cm on the VAS compared with 3.32 cm for ropivacaine. The P value of the paired t-test was 0.34 which was not significant. The average amount of discomfort after surgery for bupivacaine was 3.54 cm on the VAS compared with 4.37 cm for ropivacaine. The P value of the paired t-test is 0.34 and is not significant. The average time for return to full sensation for bupivacaine was 5.98 hours compared with 5.25 hours for ropivacaine. The P value for the paired t-test is 0.059 which was almost significant. The average amount of time for patients to take medication from initial block, with no distinction between bupivacaine and ropivacaine was 3.82 hours with a 95% confidence interval for the population mean. There were no adverse effects noted to date in this investigation. Subjectively, the anesthetic combinations studied seem to offer roughly equivalent clinical efficacy. Assessment of intraoperative and immediate postoperative comfort levels is heavily influenced by inclusion of lidocaine in the technique. Currently, there are insufficient data to statistically confirm the efficacy of ropivacaine compared with that of bupivacaine for use in combination with lidocaine to provide extended postoperative analgesia for mandibular third molar surgery. This investigation is ongoing pending completion of the desired subject number of 90 patients. References McClure JH: Ropivacaine. Br J Anaesth 76:300, 1996 de Jong RH: Ropivacaine, white knight or dark horse. Reg Anesth 20:474, 1995 Funding Source: United States Army.
scores and number of attempts each resident took to pass the USMLE Step 1. The number of years of medical school each program required was also included. The data were analyzed using a Pearson’s correlation coefficient to determine any relationship between NDBE score and the number of attempts each candidate took to pass USMLE Step 1. The resident pool was divided into 3 groups for analysis: all OMS residents, residents who completed at least a portion of the second year of medical school as part of their OMS program, and residents who did not complete any basic medical sciences as part of the OMS program. Results: Questionnaires were received from 26 of 52 (50%) dual degree OMS programs regarding 426 residents. Five residents were excluded because they completed medical school before entering the residency program. The overall average of NDBE Part 1 was 92.6 (range, 83 to 99). For all residents, there was a significant negative correlation (r ⫽ ⫺0.37) between passing USMLE on the first attempt and NDBE; the higher the NDBE score, the fewer attempts for successful completion of USMLE. For residents who completed 1 or more years of basic medical sciences through medical school, there was a less of a negative correlation (r ⫽ ⫺0.32). There was a greater negative correlation (r ⫽ ⫺0.50) between passing the USMLE on the first attempt and NDBE if the resident did not complete any basic medical sciences within the OMS program. All residents with a NDBE greater than 95 passed USMLE on the first attempt. Conclusion: There is a significant negative correlation between the ability of an OMS resident to pass the USMLE Step 1 on the first attempt and performance on the NDBE Part 1. References
Is There a Correlation Between Performance on Dental and Medical Board Examinations? Troy Petersen, DMD, MD, 983010 Nebraska Medical Center, Omaha, NE 68198-3010 (Michael Miloro, DMD, MD) Statement of the Problem: The OMS resident selection process evaulates grade point average, class rank, board scores, and other less concrete candidate characteristics. For many reasons, a primary concern of OMS program directors is the ability of the resident to pass the USMLE Step 1, but the predictive factors involved are unclear. Purpose: The purpose of this study was to determine whether a correlation exists between passing the USMLE Step 1 on the first attempt and performance on National Dental Board Examination Part 1 (NDBE). Materials and Methods: Questionnaires were sent to all program directors of 52 dual degree OMS programs. The information requested concerned residents of each program from 1990 to the present, and included NDBE 60
Ellis E, Haug RH: A comparison of performance on the OMSITE and ABOMS written qualifying examination. J Oral Maxillofac Surg 58:1401, 2000 Fine PL, Hayward RA: Do the criteria of resident selection committees predict residents’ performances? Acad Med 70:834, 1995
Scheduling Preferences for Third Molar Surgery Piyush P. Patel, DDS, 324 22nd Ave N, Nashville, TN 37203 (Jeffrey B. Carter, DMD, MD; Richard J. Martin, DDS; Anthony Green, DDS; Mary Dietrich, PhD) As patients become more involved in directing their own health care, and in today’s increasingly competitive health care marketplace, oral surgeons will need to evolve their practices to satisfy the total needs of their patients. Vuori sums up the case for patient satisfaction when he asserts, “put simply, care cannot be of high quality unless the patient is satisfied.” Elective wisdom tooth removal is a common surgical procedure. Directives from third-party payors and OMFS AAOMS • 2001
Oral Abstract Session 9: Anesthesia/Epidemiology risk management advisors advocate that patients should present for a consultation visit before scheduling surgery. We sought to evaluate the characteristics of patients presenting for wisdom tooth removal and assessed their scheduling preferences. Materials and Methods: A prospective study of 104 patients who presented at a multilocation practice with both urban and rural offices was carried out over a 2-month period. Patients completed a questionnaire that gathered information about their age, gender, education, distance/time traveled, financial responsibility, their familiarity with friends and relatives who had wisdom tooth surgery, awareness of risks and morbidity, and their emotional readiness. Descriptive statistics were used to summarize the data. Group comparisons were conducted using independent t-tests and cross tabulation procedures. Results: Fifty-three patients (51%) had same-day surgery (SDS) and 51 patients (49%) elected a consultative visit. The statistically significant differences between these 2 groups include education, financial responsibility, and distance/time traveled. Those with lower educational backgrounds who travel great distances and have limited financial responsibility opted for SDS. It was significant that both groups were well aware of the risks and morbidity involved, and had high scores in familiarity of the procedure. Gender, age, and relationship to other people known to have surgery were not significant between the 2 groups. Upon further questioning of the patients who elected
AAOMS • 2001
a consultation (N ⫽ 51), 61% (N ⫽ 31) would have elected to have SDS. There were no significant differences noted in the age, gender, distance/time traveled, or their familiarity score between this population and those that desired a return visit. However, educational background and level of financial responsibility were significant. Those who had no or full responsibility were more likely to desire SDS. Citing lack of psychological preparation for the surgery, 19% of the 104 patients surveyed desired a return visit. Confirming insurance coverage was statistically significant for their choice. Wanting to meet the office staff or the surgeon was not a statistically significant factor. Conclusions: The results clearly indicate that an overwhelming majority of patients support SDS. Patients are well informed about the risks and morbidity involved. Out of those who presented for SDS, 100% arrived prepared for anesthesia, indicating that directions from referring offices, as well as appointment-making protocols, are effective. The arguments of third-party payors and risk management advisors are at odds with the desires of our patient pool. References Vuori H: Patient satisfaction—an attribute or indicator of the quality of care? Qual Rev Bull 13, 106, 1987 Donabedian A: The Definition of Quality and Approaches to Its Assessment, Exploration in Quality Assessment and Monitoring, Vol 1. Ann Arbor MI, Health Administration Press, 1980 Funding Source: Oral Surgical Institute.
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Utilization of Sedation and Adjunctive Services for Pediatric Dental Patients William G. Flick, DDS, MPH, University of Illinois, College of Dentistry, 801 S Paulina, Chicago, IL 60612 (Adel Al-Asfour, BDS, BA) Purpose: Sedation, general anesthesia, or hospital admission may be required for the management of certain pediatric dental patients. Recent deaths in dental offices have prompted public scrutiny concerning this area of practice. This survey describes the extent and types of sedation, with special emphasis on oral sedation. It focuses on the agents used, monitoring, and the training level of practitioners. Methods: A 14-question survey was distributed to 815 randomly selected dentists in Illinois. The respondents were anonymous and grouped by specialty area of practice. IRB approval was from The University of Illinois Chicago. A computer database and spreadsheet were used for tabulation and analysis. Dentists not treating pediatric patients, retired, or not in clinical practice were excluded. Results: Four hundred five questionnaires (n ⫽ 405) were returned and found acceptable for inclusion in the study. Sedation in all forms is a significant treatment modality used in the management of pediatric dental patients. In Illinois, it was estimated from the survey that in excess of 50,000 pediatric patients receive some type of sedation. Oral sedation, the treatment modality currently drawing the most public scrutiny, is primarily used by oral maxillofacial surgeons and pediatric dentists. Use by general dentists appears to be less than 10% of dentists who treat pediatric patients. The anesthesia education and training, for practitioners using oral sedation, ranges from none to full anesthesia residency. Likewise there appears to be no uniform standard of care for monitoring during oral sedation. Pulse oximetry is used by the OMS and pediatric dentists, but seldom by general dentists. The EKG is utilized by 50% of OMS, but by 0% of pediatric dentists. Midazolam was the primary agent used by the OMS, whereas pediatric and general dentists favored chloral hydrate. From the study it was also estimated that more than 3,000 pediatric patients are admitted to a hospital or surgical center for dental care when medically necessary. An equal number of pediatric patients were identified who required admission for dental care but were denied this service because of lack of health insurance coverage. Conclusions: The wide variance in training and mon58
itoring poses several questions. Do current educational programs provide enough opportunities for all dentists to obtain adequate training, and do current anesthesia regulations covering the administration of oral sedation adequately protect the public? With approximately 50% of pediatric patients lacking insurance benefits for medically required admissions, do current health insurance programs provide the necessary access to care for pediatric patients with special needs? References American Dental Association News, 60 Minutes II Targets Tragedies, V 29, No. 22, p 1, 1998 American Dental Association Policy Statement: Use of Conscious Sedation, ADA House of Delegates, October 1999
Oral and Maxillofacial Surgery in Patients With Chronic Oral, Facial, and Head Pain Howard A. Israel, DDS, 12 Bond St, Great Neck, NY 11021 (J. Desmond Ward, DDS; Brenda Horrell, DDS, MS; Steven J. Scrivani, DDS, DSc) Patients with chronic oral, facial, and head pain (COFHP) frequently have a history of oral and maxillofacial surgery (OMS) procedures that fail to relieve symptoms. The source of COFHP is often elusive and misdiagnosis with failed treatments is common. Localized dentoalveolar and temporomandibular joint (TMJ) pain may cause frustrated patients to request additional surgery to eliminate the source of pain. The purpose of this investigation was to profile a population of patients with COFHP and evaluate: 1) previous OMS procedures, 2) the frequency of significant misdiagnoses, and 3) the number of patients who were recommended for OMS procedures by an interdisciplinary orofacial pain team. The patient population included individuals referred to the Center for Oral, Facial and Head Pain at New York Presbyterian Hospital (1/99 to 4/01). These patients had pain for greater than 6 months, had seen multiple clinicians, and underwent multiple unsuccessful treatments. The center includes an interdisciplinary team of specialists who diagnose and manage COFHP patients. Patient profile data included age, gender, duration of symptoms, number of previous clinicians/specialists, previous OMS procedures, evidence of significant misdiagnoses, diagnosis by the center team, and treatments recommended by the center. The study population included: 120 patients, female: male ⫽ 3:1, mean age ⫽ 49 years, average pain duraAAOMS • 2001
Oral Abstract Session 9: Anesthesia/Epidemiology tion ⫽ 81 months, and average number of previous clinicians/specialists ⫽ 6. Previous OMS procedures were reported in 38/120 (32%) patients. Procedures performed prior to our evaluation included: endodontics (30%), extractions (27%), apicoectomies (12%), TMJ surgery (6%), neurolysis (5%), orthognathic surgery (3%), and debridement of bone cavities (2%). Surgical intervention clearly exacerbated pain in 21/120 (18%) patients. Seven of the patients underwent 26 TMJ surgical procedures. Two of these patients, who had TMJ fibrosis, underwent 12 TMJ surgeries. The diagnoses following evaluation by the center included: masticatory myospasm (50%), atypical facial neuralgia (40%), depression (30%), TMJ synovitis (14%), TMJ osteoarthritis (12%), trigeminal neuralgia (10%), and TMJ fibrosis (2%). Evidence of previous misdiagnoses was present in virtually all patients. However, gross misdiagnoses leading to serious sequelae occurred in 6/120 (5%) patients. One of these patients, treated for a TMJ disorder for over 1 year, was diagnosed by the center with an adenocarcinoma of the deep lobe of the parotid with base of skull invasion. Treatment of patients with COFHP by the center included medications (91%), physical therapy (36%), psychiatric management (30%), trigger injections (15%), oral appliances (13%), biofeedback (13%), acupuncture (8%), surgery (4%), and Botox injections (1%). Surgical intervention was recommended in 5 patients, which included neurolysis, coronoidectomies with arthroscopies, removal of a foreign body, sinus surgery, and removal of a parotid tumor. Our population of COFHP patients had multiple failed OMS procedures prior to presentation to our center. Surgical treatment is rarely indicated as a treatment for pain relief in these patients and may precipitate or exacerbate COFHP. The oral and maxillofacial surgeon must be extremely selective in recommending surgery in this patient population. Misdiagnosis is common in patients with COFHP and when symptoms continue, one must reevaluate the diagnosis and investigate further for other potentially serious conditions as the cause of COFHP. References Okeson JP: The differential diagnosis of orofacial pains. Oral Maxillofac Surg Clin North Am 12:205, 2000 Israel HA, Scrivani SJ: The interdisciplinary approach to oral, facial and head pain. J Am Dent Assoc 131:919, 2000
Evaluation of 0.5% Ropivacaine and 0.5% Marcaine for Mandibular Third Molar Extraction Jose Ruiz Villanueva, DDS, 2005 N Piedras, El Paso, TX 79920-5001 (Clark Michael Comeaux, DDS; Donald Charles Hofheins, DDS) AAOMS • 2001
Local anesthesia using a combination of 2% lidocaine, 1:100,000 epipinephrine and bupivacaine provides rapid onset and extended postoperative analgesia that is particularly suitable for third molar surgery. Ropivacaine (Naropin, Astra USA, Inc, Westborough, MA) is a pipecoloxylidide amino-amide local anesthetic with less cardiovascular toxicity and slightly less duration of action than bupivacaine. It has unique vasoconstrictor properties that limit the need for the addition of a vasoconstrictor. Ropivacaine has been widely investigated and is currently used for local anesthesia in a broad range of surgical applications but has not been reported for use in third molar surgery. The purpose of this study is to determine the efficacy of ropivacaine compared with bupivacaine for mandibular third molar surgery when used in combination with 2% lidocaine, 1:100,000 epinephrine. This is a prospective, randomized, doubleblind study designed to include 90 patients electing to have bilateral mandibular third molar extractions performed under local anesthesia. Patients requiring unilateral maxillary third molar extractions were excluded from the investigation. Vital signs including pulse oximetry, noninvasive blood pressure, and EKG were monitored preoperatively, intraoperatively, and postoperatively. Local anesthetic in the form of 2% lidocaine with 1:100,000 epinephrine was administered to the maxillary and mandibular surgical sites in a routine fashion to provide appropriate block and infiltration anesthesia. The study anesthetics consisting of 1.8 cm3 of 0.5% ropivacaine and 1.8 cm3 of 0.5% bupivacaine with 1:200,000 epinephrine aspirating syringes labeled “right” and “left” were injected into the specified mandibular surgical sites by inferior alveolar, lingual, and long buccal nerve block technique. One clinician administered all anesthetic injections and performed all of the surgeries in a standard fashion. Before discharge, each patient indicated quality of numbness during surgery and discomfort experienced during surgery for R and L sides using an 11.8 cm Visual Analog Scale (VAS). At home, the patients recorded the time and side that first caused need for analgesic medication, level of discomfort after surgery for R and L sides using the VAS, and the time that sensation returned to the lower lip. The patients were examined the following day and data collection was completed. For the initial 29 subjects, there was a mean age of 22.6 years with ages ranging from 19 to 34 years. Twelve patients indicated that discomfort from the bupivacaine side first required postoperative pain medication. Fourteen patients reported that analgesics were needed first for the side anesthetized using ropivacaine. Two patients reported that analgesics were first necessary for bilateral discomfort. One patient reported that no medication was necessary. The average quality of numbness during surgery on the bupivacaine side was 8.52 cm on the VAS compared with 8.00 cm for ropivacaine. The P value of the paired t-test is 0.48 which was 59
Oral Abstract Session 9: Anesthesia/Epidemiology not significant. The average amount of discomfort during surgery for bupivacaine was 2.60 cm on the VAS compared with 3.32 cm for ropivacaine. The P value of the paired t-test was 0.34 which was not significant. The average amount of discomfort after surgery for bupivacaine was 3.54 cm on the VAS compared with 4.37 cm for ropivacaine. The P value of the paired t-test is 0.34 and is not significant. The average time for return to full sensation for bupivacaine was 5.98 hours compared with 5.25 hours for ropivacaine. The P value for the paired t-test is 0.059 which was almost significant. The average amount of time for patients to take medication from initial block, with no distinction between bupivacaine and ropivacaine was 3.82 hours with a 95% confidence interval for the population mean. There were no adverse effects noted to date in this investigation. Subjectively, the anesthetic combinations studied seem to offer roughly equivalent clinical efficacy. Assessment of intraoperative and immediate postoperative comfort levels is heavily influenced by inclusion of lidocaine in the technique. Currently, there are insufficient data to statistically confirm the efficacy of ropivacaine compared with that of bupivacaine for use in combination with lidocaine to provide extended postoperative analgesia for mandibular third molar surgery. This investigation is ongoing pending completion of the desired subject number of 90 patients. References McClure JH: Ropivacaine. Br J Anaesth 76:300, 1996 de Jong RH: Ropivacaine, white knight or dark horse. Reg Anesth 20:474, 1995 Funding Source: United States Army.
scores and number of attempts each resident took to pass the USMLE Step 1. The number of years of medical school each program required was also included. The data were analyzed using a Pearson’s correlation coefficient to determine any relationship between NDBE score and the number of attempts each candidate took to pass USMLE Step 1. The resident pool was divided into 3 groups for analysis: all OMS residents, residents who completed at least a portion of the second year of medical school as part of their OMS program, and residents who did not complete any basic medical sciences as part of the OMS program. Results: Questionnaires were received from 26 of 52 (50%) dual degree OMS programs regarding 426 residents. Five residents were excluded because they completed medical school before entering the residency program. The overall average of NDBE Part 1 was 92.6 (range, 83 to 99). For all residents, there was a significant negative correlation (r ⫽ ⫺0.37) between passing USMLE on the first attempt and NDBE; the higher the NDBE score, the fewer attempts for successful completion of USMLE. For residents who completed 1 or more years of basic medical sciences through medical school, there was a less of a negative correlation (r ⫽ ⫺0.32). There was a greater negative correlation (r ⫽ ⫺0.50) between passing the USMLE on the first attempt and NDBE if the resident did not complete any basic medical sciences within the OMS program. All residents with a NDBE greater than 95 passed USMLE on the first attempt. Conclusion: There is a significant negative correlation between the ability of an OMS resident to pass the USMLE Step 1 on the first attempt and performance on the NDBE Part 1. References
Is There a Correlation Between Performance on Dental and Medical Board Examinations? Troy Petersen, DMD, MD, 983010 Nebraska Medical Center, Omaha, NE 68198-3010 (Michael Miloro, DMD, MD) Statement of the Problem: The OMS resident selection process evaulates grade point average, class rank, board scores, and other less concrete candidate characteristics. For many reasons, a primary concern of OMS program directors is the ability of the resident to pass the USMLE Step 1, but the predictive factors involved are unclear. Purpose: The purpose of this study was to determine whether a correlation exists between passing the USMLE Step 1 on the first attempt and performance on National Dental Board Examination Part 1 (NDBE). Materials and Methods: Questionnaires were sent to all program directors of 52 dual degree OMS programs. The information requested concerned residents of each program from 1990 to the present, and included NDBE 60
Ellis E, Haug RH: A comparison of performance on the OMSITE and ABOMS written qualifying examination. J Oral Maxillofac Surg 58:1401, 2000 Fine PL, Hayward RA: Do the criteria of resident selection committees predict residents’ performances? Acad Med 70:834, 1995
Scheduling Preferences for Third Molar Surgery Piyush P. Patel, DDS, 324 22nd Ave N, Nashville, TN 37203 (Jeffrey B. Carter, DMD, MD; Richard J. Martin, DDS; Anthony Green, DDS; Mary Dietrich, PhD) As patients become more involved in directing their own health care, and in today’s increasingly competitive health care marketplace, oral surgeons will need to evolve their practices to satisfy the total needs of their patients. Vuori sums up the case for patient satisfaction when he asserts, “put simply, care cannot be of high quality unless the patient is satisfied.” Elective wisdom tooth removal is a common surgical procedure. Directives from third-party payors and OMFS AAOMS • 2001
Oral Abstract Session 9: Anesthesia/Epidemiology risk management advisors advocate that patients should present for a consultation visit before scheduling surgery. We sought to evaluate the characteristics of patients presenting for wisdom tooth removal and assessed their scheduling preferences. Materials and Methods: A prospective study of 104 patients who presented at a multilocation practice with both urban and rural offices was carried out over a 2-month period. Patients completed a questionnaire that gathered information about their age, gender, education, distance/time traveled, financial responsibility, their familiarity with friends and relatives who had wisdom tooth surgery, awareness of risks and morbidity, and their emotional readiness. Descriptive statistics were used to summarize the data. Group comparisons were conducted using independent t-tests and cross tabulation procedures. Results: Fifty-three patients (51%) had same-day surgery (SDS) and 51 patients (49%) elected a consultative visit. The statistically significant differences between these 2 groups include education, financial responsibility, and distance/time traveled. Those with lower educational backgrounds who travel great distances and have limited financial responsibility opted for SDS. It was significant that both groups were well aware of the risks and morbidity involved, and had high scores in familiarity of the procedure. Gender, age, and relationship to other people known to have surgery were not significant between the 2 groups. Upon further questioning of the patients who elected
AAOMS • 2001
a consultation (N ⫽ 51), 61% (N ⫽ 31) would have elected to have SDS. There were no significant differences noted in the age, gender, distance/time traveled, or their familiarity score between this population and those that desired a return visit. However, educational background and level of financial responsibility were significant. Those who had no or full responsibility were more likely to desire SDS. Citing lack of psychological preparation for the surgery, 19% of the 104 patients surveyed desired a return visit. Confirming insurance coverage was statistically significant for their choice. Wanting to meet the office staff or the surgeon was not a statistically significant factor. Conclusions: The results clearly indicate that an overwhelming majority of patients support SDS. Patients are well informed about the risks and morbidity involved. Out of those who presented for SDS, 100% arrived prepared for anesthesia, indicating that directions from referring offices, as well as appointment-making protocols, are effective. The arguments of third-party payors and risk management advisors are at odds with the desires of our patient pool. References Vuori H: Patient satisfaction—an attribute or indicator of the quality of care? Qual Rev Bull 13, 106, 1987 Donabedian A: The Definition of Quality and Approaches to Its Assessment, Exploration in Quality Assessment and Monitoring, Vol 1. Ann Arbor MI, Health Administration Press, 1980 Funding Source: Oral Surgical Institute.
61