Osteonecrosis of the jaws: A complex group of disorders

1248 edge base. According to the medical model of education, this general medical knowledge base acquired during medical school consolidates during the year of ACGME internship, and during residency the specialty is learned. This is why the states require post-graduate medical education for medical licensure. While the acquisition of the medical degree in of itself is laudable for those of us interested in a broader foundation in medicine, undergraduate medical training is educationally incomplete without internship. All of the states and U.S. territories require an internship or more in an ACGME accredited program and passage of the United States Medical Licensing Examination Parts I, II, and III for medical licensure. Alternate but equivalent pathways are available to foreign medical graduates. To simply add the MD degree after one’s name without the full complement of medical examinations and training at best confuses the public and at worst misrepresents the doctor’s credentials. How would the dental profession react if plastic surgeons or otolaryngologists added the DDS credential after eighteen months of offshore dental school? In fact, AAOMS Today recently recounted the difficulties of Dr. Fred Smith who graduated from medical school in Oregon with the desire to become an OMS. After completing a year of general surgery, he was required to complete a year of OMS residency that included didactic instruction in dentistry at the University of Louisville, School of Dentistry, followed by two years of dental school and finally another two years of OMS residency. He completed a total of six years of training after receiving his medical degree.3 The sequence was different, but the training was certainly consistent with that of the dual-degree programs in this country. It is time that we as a specialty embrace and recognize the value of the additional training and sacrifice made by those among us who have acquired the medical degree with license and promote parallel recognition of that unique qualification within the ranks of medicine as well as dentistry. The medical license is an option available to those who select additional training and not a requirement of board certification in OMS. But it is a valuable and important asset for any OMS, and in many states allows one to truly practice the full scope of the specialty. There have already been several instances of state boards of medicine asking for representatives of AAOMS and ABOMS to clarify the scope of practice. Two recent instances come to mind in Florida and Connecticut. In both cases the doctors’ credentials were unclear and the scopes of practices inappropriate even by AAOMS criteria. Both of these were reported in the media and did not help the public’s perception of OMS as a specialty. The strategy adopted by AAOMS to allow its members to practice the full scope of OMS in many states has been to lobby the various state legislatures to change the dental practice acts. Even when legislatures are sympathetic and allow for the expanded scope of practice, at least one governor, Arnold Schwarzenegger of California, has vetoed the legislative initiative. The re-writing of fifty states’ dental practice acts appears to me to be a monumental task that would require significant financial expenditures, comprehensive legal and lobbying efforts with the risk of an undesirable outcome. Promotion of medical credentialing and recognition of these credentials by such bodies as ACGME would go much further to promote the specialty than trying to take on fifty state legislatures and governors. Those who opt to pursue single degree training should not feel diminished in any way. Realism requires that those individuals

LETTERS TO THE EDITOR will simply have to abide by the dental and medical regulatory bodies within the states in which they practice. Acquisition of additional knowledge through offshore medical training may be laudable as an intellectual pursuit as claimed by Dr. Guttenberg, but it is not enough for medical licensure.4 The MD degree, it should be remembered, is a professional degree and not an academic degree. Universities do not even grant honorary medical degrees as they imply a certain level of medical training and competency. I suggest that those who desire pursuing a medical degree after OMS residency not only attend medical school but undergo applicable licensing exams and post-graduate medical training as well, culminating with medical licensure. The degree would not be merely cosmetic; it would be beyond reproach. We as a specialty should be promoting education and knowledge, but realistically this needs to be done within the highly regulated arena of health care. The public, the health professions, and certainly our specialty are not well served by acquisition and advertising of the medical degree by individuals whose credentials may be incomplete. The trend towards getting these degrees without the appropriate follow-through has the effect of bringing into question the training of those among us who are legitimately licensed and credentialed. More importantly it confuses the public who have no means of distinguishing one from the other. Finally, it polarizes us as a group and alienates our medical colleagues. When we as a specialty fully embrace the medical dimensions of OMS and recognize the worth of complete credentialing, we will be above reproach and unfettered in practicing the full clinical and legally available scope of oral and maxillofacial surgery if we so desire. JOHN C. MCCABE, DDS, MD Omaha, NE

References 1. Assael LA: The offshore medical degree: an opportunity to reflect on the future of our profession and specialty. J Oral Maxillofac Surg 63:1, 2005 2. Croasdale M: Oral surgeons bite at offshore MD degree. Available at http://www.ama-assn.org/amednews/2004/10/18/ prl21018.htm. Accessed January 21, 2005 3. Dierks E: Someone you should know. . .Dr. Fred Smith, from med school to OMS. AAOMS Today 3(2):15, 2005 4. Guttenberg S: Educational purpose and content: more on the offshore medical degree. J Oral Maxillofac Surg; 63:571, 2005

doi:10.1016/j.joms.2005.05.314

OSTEONECROSIS OF THE JAWS: A COMPLEX GROUP OF DISORDERS To the Editor:—While Hellstein and Marek’s use of the term “bis-phossy jaw” (J Oral Maxillofac Surg 63:682, 2005) may have some etymological flair, I am concerned that the readership might infer a scientific connection between phosphorous necrosis of the jaws (the term used in Kurt Thoma’s texts), and what I currently prefer to call bisphosphonate-associated osteonecrosis of the jaws. Phosphorus (P) is an element. It is highly reactive and highly toxic. Bisphosphonates are large organic molecules in which two phosphate groups (PO3) and two side chains are linked covalently to a carbon atom. These substances share

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LETTERS TO THE EDITOR no chemical relationship whatever. Furthermore, certain bisphosphonates are very important in the management of osteoporosis and of malignant bone disease. I would strongly recommend against adoption of the term. Hidden in the article is an outline of the several forms of osteonecrosis that primarily or exclusively affect the jaws: phosphorous necrosis, bisphosphonate-associated osteonecrosis, osteoradionecrosis, the osteonecrosis seen in osteopetrosis, and the osteonecrosis seen in florid osseous dysplasia. I only wish that the organization of the article allowed the reader to more easily compare and contrast these disorders. There are clearly similarities among them, but there are many differences as well. The differences deserve to be more carefully reviewed. Some of these disorders may have a common final pathway (perhaps antiangiogenesis or apoptosis), which accounts for similar clinical findings. Nothing has been proven, however. It is quite premature to draw any conclusions about these issues. The authors bring forth numerous theories about etiology, treatment, and prevention. Such theories are essential for the development of laboratory research and of clinical trials, but they must not be presented to clinicians as if they were anything more than unproven hypotheses. An example is the recommendation to obtain radionuclide bone scans on patients taking bisphosphonates. Much more has to be learned about all of these disorders before definitive recommendations can be made regarding clinical management. HARRY C. SCHWARTZ, DMD, MD Los Angeles, CA

doi:10.1016/j.joms.2005.05.315

ORAL TO NASAL ENDOTRACHEAL TUBE EXCHANGE FOLLOWING RECONSTRUCTIVE SURGERY OF THE ORAL CAVITY BY MEANS OF VASCULARIZED FREE FLAPS To the Editor:—Commonly, reconstruction of defects of the oral cavity following cancer ablation requires the use of microvascularized free flaps (MFF). In these cases, the oral cavity must be free of any endotracheal tube during the surgical procedure. In the immediate postoperative period, mechanical ventilation following complications, such as pneumonia or alcoholic deprivation, can be completely necessary. Moreover, deep sedation is often maintained in these patients, in order to decrease the mobility of the patient and thus the failure of the vascular anastomosis. Occasionally, due to the smaller diameter, it is necessary to change the nasotracheal tube (NTT) to an orotracheal tube (OTT). It is justified by the necessity of improved ventilation. However, as previously reported,1 a significant risk of losing airway during NTT to OTT exchange may be present. In our experience, patients= airways are treated by means of local 10% lidocaine spray, and they are sedated using intravenous propofol. Laryngoscopy is performed in order to visualize properly the OTT. The possibility of accidental extubation is lessened, as the tube is firmly grasped with a Magill forceps as high behind the uvula as possible. We use the Magill forceps to move downwards the NTT deeper in the trachea, in order to decrease risk of extubation. The proximal end of the existent NTT holding the connector is cut. After this, the laryngoscope is removed and a finger placed behind the tube pulls towards the anterior side of the oral cavity (Figs 1, 2). An endotracheal ventilation catheter (ETVC) is inserted through the NTT. The NTT is then

FIGURE 1. Scheme of the procedure.

withdrawn, leaving the ETVC in situ. The OTT is then loaded onto and threaded over the ETVC, as described by Cooper.2 Placement of the OTT is checked and the tube is retaped. The actual conversion takes less than 1 minute. Other techniques, such as the flexible fiberoptic bronchoscope (FFB)-guided nasotracheal intubation, have been used previously to effect safer conversion of NTT to OTT.3 It has also been reported that NTT in awake patients is better tolerated than OTT. Furthermore, extubation of a patient with a proven difficult airway, using a small diameter tube exchanger to maintain airway access, may be safer via the nasal route.4 However, we prefer maintaining deep sedation in patients treated by means of MFF. In these cases, the OTT may

FIGURE 2. Scheme of the procedure.