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Re: Classification of Potential Risk Factors for Trigeminocardiac Reflex in Craniomaxillofacial Surgery
960
LETTERS TO THE EDITOR
received the standard protocol of chemotherapy. Those with multiple myeloma also received steroids for short durations as part of the vincristine, Adriamycin, and dexamethasone protocol. Only 2 of the patients with multiple myeloma were receiving prolonged steroid therapy as part of the thalidomide protocol. None of our study patients received sunitinib,1 bevacizumab,2-4 or denosumab,5 the antiangiogenic/antiosteoclastic agents that were recently reported to cause osteonecrosis of the jaws. Moreover, no patients under oral BPs received prolonged steroid therapy. This low occurrence of steroid use among the patients under frequent IV BPs (12.5%) probably does not imply any correlation to the development of BRONJ in our group of patients. Only 2 patients were smokers: one was receiving an oral BP for the treatment of osteoporosis, and the other was receiving frequent IV BPs for the treatment of multiple myeloma. Type II diabetes mellitus was diagnosed in 3 patients, 2 of whom were receiving oral BP treatment for osteoporosis and 1 of whom was receiving frequent IV BP treatment for prostate carcinoma. We have diagnosed and treated more than 180 patients with BRONJ over the past few years. The rates of type II diabetes mellitus among patients under oral BPs (17%) and those under frequent IV BPs (15.5%) are close to its occurrence in the general population in this age group.6,7 Therefore, in our experience, type II diabetes mellitus does not appear to be a predisposing factor for either the development or the progression of BRONJ. TOWY SOREL LAZAROVICI, DMD NOAM YAROM, DMD Tel Hashomer, Israel
escaped the attention of the authors. The authors classified potential risk factors for trigeminocardiac reflex (TCR) and recommended prophylactic administration of a vagolytic drug (atropine) right before any surgical manipulation known to be risky for TCR. However, a simpler alternative to avoid this rare intraoperative complication would be to ensure that the surgical site is blocked with suitable regional nerve blocks using vasoconstrictors. This is routinely done during maxillofacial surgical procedures to ensure minimal bleeding and decrease postoperative pain. More importantly, local anesthesia blocks possible afferent pathways and prevents the reflex from occurring.2 I have personally never experienced TCR during maxillofacial surgical procedures, probably due to this reason. This is an easier alternative to prophylactic administration of vagolytic agents. A recorded instance of this complication during removal of a mesiodens was explained by possible inadequacy of local anesthesia in an already high-risk patient.3 Moreover, oral and maxillofacial surgical procedures usually require the preoperative administration of antisialagogues. Glycopyrrolate is more commonly used in our institution and this has a certain degree of vagolytic activity, albeit lower than that of atropine. Occurrence of TCR despite these precautions will require intravenous atropine as recommended by the authors. “To be forewarned is to be forearmed” is the conclusion of the article. “Prevention is better than cure” may be the more appropriate mantra. BALASUBRAMANIAN KRISHNAN, MDS, DNB, MOMSRCPS (GLASG) Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) Pondicherry, India
References
References
1. Brunello A, Saia G, Bedogni A, et al: Worsening of osteonecrosis of the jaw during treatment with sunitinib in a patient with metastatic renal cell carcinoma. Bone 44:173, 2009 2. Guarneri V, Miles D, Robert N, et al: Bevacizumab and osteonecrosis of the jaw: Incidence and association with bisphosphonate therapy in three large prospective trials in advanced breast cancer. Breast Cancer Res Treat, 122:181, 2010 3. Serra E, Paolantonio M, Spoto G, et al: Bevacizumab-related osteonecrosis of the jaw. Int J Immunopathol Pharmacol 22: 1121, 2009 4. Greuter S, Schmid F, Ruhstaller T, et al: Bevacizumab-associated osteonecrosis of the jaw. Ann Oncol 19:2091, 2008 5. Aghaloo TL, Felsenfeld AL, Tetradis S: Osteonecrosis of the jaw in a patient on denosumab. J Oral Maxillofac Surg 68:959, 2010 6. Varas-Lorenzo C, Rueda de Castro AM, Maguire A, et al: Prevalence of glucose metabolism abnormalities and cardiovascular co-morbidity in the US elderly adult population. Pharmacoepidemiol Drug Saf 15:317, 2006 7. Forouhi NG, Merrick D, Goyder E, et al: Diabetes prevalence in England, 2001— estimates from an epidemiological model. Diabet Med 23:189, 2006
1. Lübbers HT, Zweifel D, Grätz KW, Kruse A: Classification of potential risk factors for trigeminocardiac reflex in craniomaxillofacial surgery. J Oral Maxillofac Surg 68:1317, 2010 2. Bohluli B, Ashtiani AK, Khayampoor A, et al: Trigeminocardiac reflex: A MaxFax literature review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 108:184, 2009 3. Webb MD, Unkel JH: Anesthetic management of trigeminocardiac reflex during mesiodens removal–a case report. Anesth Prog 54:7, 2007
doi:10.1016/j.joms.2010.06.191
RE: CLASSIFICATION OF POTENTIAL RISK FACTORS FOR TRIGEMINOCARDIAC REFLEX IN CRANIOMAXILLOFACIAL SURGERY To the Editor:—I recently read the article “Classification of potential risk factors for trigeminocardiac reflex in craniomaxillofacial surgery”1 published in this journal. I would like to note a small yet pertinent point that seems to have
doi:10.1016/j.joms.2010.10.049
ABOUT THE DIFFICULTIES OF LOCAL ANESTHESIA FOR PREVENTION OF TRIGEMINOCARDIAC REFLEX OCCURRING UNDER GENERAL ANESTHESIA To the Editor:—We thank Dr Krishnan for his contribution.1 We agree that local anesthesia can inhibit the occurrence of the trigeminocardiac reflex (TCR) and that it should be a basic part of any maxillofacial procedure, even under general anesthesia. It is perhaps because local anesthesia is such a basic measure that we failed to mention it explicitly. However, we do not agree that this has any impact on the classification and its conclusions as proposed in the article.2 First, we do not recommend prophylactic administration of vagolytic drugs before any manipulation known to be risky, but only before “high-risk procedures” according to our classification.2 For craniomaxillofacial surgery, this would include “orbital exenteration” and “fractures in children with cardiac disease.” Both procedures are those in which
LETTERS TO THE EDITOR
received the standard protocol of chemotherapy. Those with multiple myeloma also received steroids for short durations as part of the vincristine, Adriamycin, and dexamethasone protocol. Only 2 of the patients with multiple myeloma were receiving prolonged steroid therapy as part of the thalidomide protocol. None of our study patients received sunitinib,1 bevacizumab,2-4 or denosumab,5 the antiangiogenic/antiosteoclastic agents that were recently reported to cause osteonecrosis of the jaws. Moreover, no patients under oral BPs received prolonged steroid therapy. This low occurrence of steroid use among the patients under frequent IV BPs (12.5%) probably does not imply any correlation to the development of BRONJ in our group of patients. Only 2 patients were smokers: one was receiving an oral BP for the treatment of osteoporosis, and the other was receiving frequent IV BPs for the treatment of multiple myeloma. Type II diabetes mellitus was diagnosed in 3 patients, 2 of whom were receiving oral BP treatment for osteoporosis and 1 of whom was receiving frequent IV BP treatment for prostate carcinoma. We have diagnosed and treated more than 180 patients with BRONJ over the past few years. The rates of type II diabetes mellitus among patients under oral BPs (17%) and those under frequent IV BPs (15.5%) are close to its occurrence in the general population in this age group.6,7 Therefore, in our experience, type II diabetes mellitus does not appear to be a predisposing factor for either the development or the progression of BRONJ. TOWY SOREL LAZAROVICI, DMD NOAM YAROM, DMD Tel Hashomer, Israel
escaped the attention of the authors. The authors classified potential risk factors for trigeminocardiac reflex (TCR) and recommended prophylactic administration of a vagolytic drug (atropine) right before any surgical manipulation known to be risky for TCR. However, a simpler alternative to avoid this rare intraoperative complication would be to ensure that the surgical site is blocked with suitable regional nerve blocks using vasoconstrictors. This is routinely done during maxillofacial surgical procedures to ensure minimal bleeding and decrease postoperative pain. More importantly, local anesthesia blocks possible afferent pathways and prevents the reflex from occurring.2 I have personally never experienced TCR during maxillofacial surgical procedures, probably due to this reason. This is an easier alternative to prophylactic administration of vagolytic agents. A recorded instance of this complication during removal of a mesiodens was explained by possible inadequacy of local anesthesia in an already high-risk patient.3 Moreover, oral and maxillofacial surgical procedures usually require the preoperative administration of antisialagogues. Glycopyrrolate is more commonly used in our institution and this has a certain degree of vagolytic activity, albeit lower than that of atropine. Occurrence of TCR despite these precautions will require intravenous atropine as recommended by the authors. “To be forewarned is to be forearmed” is the conclusion of the article. “Prevention is better than cure” may be the more appropriate mantra. BALASUBRAMANIAN KRISHNAN, MDS, DNB, MOMSRCPS (GLASG) Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) Pondicherry, India
References
References
1. Brunello A, Saia G, Bedogni A, et al: Worsening of osteonecrosis of the jaw during treatment with sunitinib in a patient with metastatic renal cell carcinoma. Bone 44:173, 2009 2. Guarneri V, Miles D, Robert N, et al: Bevacizumab and osteonecrosis of the jaw: Incidence and association with bisphosphonate therapy in three large prospective trials in advanced breast cancer. Breast Cancer Res Treat, 122:181, 2010 3. Serra E, Paolantonio M, Spoto G, et al: Bevacizumab-related osteonecrosis of the jaw. Int J Immunopathol Pharmacol 22: 1121, 2009 4. Greuter S, Schmid F, Ruhstaller T, et al: Bevacizumab-associated osteonecrosis of the jaw. Ann Oncol 19:2091, 2008 5. Aghaloo TL, Felsenfeld AL, Tetradis S: Osteonecrosis of the jaw in a patient on denosumab. J Oral Maxillofac Surg 68:959, 2010 6. Varas-Lorenzo C, Rueda de Castro AM, Maguire A, et al: Prevalence of glucose metabolism abnormalities and cardiovascular co-morbidity in the US elderly adult population. Pharmacoepidemiol Drug Saf 15:317, 2006 7. Forouhi NG, Merrick D, Goyder E, et al: Diabetes prevalence in England, 2001— estimates from an epidemiological model. Diabet Med 23:189, 2006
1. Lübbers HT, Zweifel D, Grätz KW, Kruse A: Classification of potential risk factors for trigeminocardiac reflex in craniomaxillofacial surgery. J Oral Maxillofac Surg 68:1317, 2010 2. Bohluli B, Ashtiani AK, Khayampoor A, et al: Trigeminocardiac reflex: A MaxFax literature review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 108:184, 2009 3. Webb MD, Unkel JH: Anesthetic management of trigeminocardiac reflex during mesiodens removal–a case report. Anesth Prog 54:7, 2007
doi:10.1016/j.joms.2010.06.191
RE: CLASSIFICATION OF POTENTIAL RISK FACTORS FOR TRIGEMINOCARDIAC REFLEX IN CRANIOMAXILLOFACIAL SURGERY To the Editor:—I recently read the article “Classification of potential risk factors for trigeminocardiac reflex in craniomaxillofacial surgery”1 published in this journal. I would like to note a small yet pertinent point that seems to have
doi:10.1016/j.joms.2010.10.049
ABOUT THE DIFFICULTIES OF LOCAL ANESTHESIA FOR PREVENTION OF TRIGEMINOCARDIAC REFLEX OCCURRING UNDER GENERAL ANESTHESIA To the Editor:—We thank Dr Krishnan for his contribution.1 We agree that local anesthesia can inhibit the occurrence of the trigeminocardiac reflex (TCR) and that it should be a basic part of any maxillofacial procedure, even under general anesthesia. It is perhaps because local anesthesia is such a basic measure that we failed to mention it explicitly. However, we do not agree that this has any impact on the classification and its conclusions as proposed in the article.2 First, we do not recommend prophylactic administration of vagolytic drugs before any manipulation known to be risky, but only before “high-risk procedures” according to our classification.2 For craniomaxillofacial surgery, this would include “orbital exenteration” and “fractures in children with cardiac disease.” Both procedures are those in which