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Risk avoidance in surgical practice: Mitigating the inevitable
EDITORIAL J Oral Maxillofac Surg 62:1053-1054, 2004
Risk Avoidance in Surgical Practice: Mitigating the Inevitable An elderly lady has but few tangible memories of the family life she treasures. But her favorite is a plate given to her by her mother for her wedding. It sits in a place of honor on the credenza. Each day she lifts it carefully from the shelf, admires it, and polishes it thoroughly to preserve its beauty. One day as she replaces it on the shelf, the plate teeters and then topples to the floor. Picking up the pieces with detached rumination, she wonders whether the plate might have been safer if she left it in a drawer. She wonders if she was too inattentive, even negligent, in handling the plate? With a wry smile, she accepts the outcome. She realizes that the plate would never have gained meaning or value unless its beauty was enjoyed. —As told to me by Dan Laskin
based answers to common questions is also revealed in these papers. The clinical science of risk avoidance as it relates to a single clinical problem (third molars) in the pages of JOMS to follow makes these points:
A surgeon carefully elevates a vertically impacted third molar in the usual way. Like most of his colleagues, he creates a distobuccal trough to deliver the tooth to the buccal. During elevation he notes the lingual nerve adhered to the follicle still attached to the tooth. Too late he recognizes that the adherent follicle has torn the nerve. In the coming weeks, he obsessively replays the event in his mind, wrestling with its causes and constructing hypothetical preventive strategies that might mitigate future risk. Intertwined with this self-analysis, some terminology from the “new normal” of clinical practice emerges. Did his treatment meet “the standard of care?” Did he show good judgment “to a degree of medical certainty?” Did his patient have appropriate “indications for care?” Were “risk factors” adequately taken into account during treatment selection? Did he use “evidencebased medicine” to decide on the best course of treatment for this patient’s condition? Did he provide “adequate documentation” of the circumstances of the event? Our clinical practice and our clinical science are chronicles of the attempt to mitigate surgical risk. Aside from the clear medical-legal implications of this effort, risk mitigation is the obvious, rational, and expected activity of any advancing discipline (or advancing society). Facing risk, and then mitigating it, is the primary means that we use to offer advancements in surgical technology and technique. The small exercise of examining this September edition of JOMS might reveal the intensity of this constant activity of risk avoidance for the advancement of the clinical science of oral and maxillofacial surgery. The complexity of finding useful evidence1053
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The association between retained third molars and the risk of mandible fractures. The authors state that retained third molars affords a 2.8-times risk for angle fracture.1 Does this support the contention that elective removal of third molars is indicated for those individuals at risk for facial injury in contact sports or military activities? The answer can only be obtained with the reverse study of following those patients at risk who underwent elective third molar removal versus those at risk who did not. A demonstrated difference in fracture incidence, not fracture location, would be meaningful. The risk of lingual nerve injury with a new method for lingual flap retraction for third molar removal. In 250 patients, 4 temporary and no permanent lingual nerve paresthesias occurred when the lingual mucoperiosteum was elevated and retracted prior to bone removal or tooth sectioning.2 The authors raise the issue as to whether the absence of permanent lingual nerve injury in this series might indicate the utility of this technique to prevent laceration of the lingual nerve during third molar removal. Of note is that there is no parallel group of similar patients (or sides) in which the lingual flap was not elevated. Does this study indicate a need to examine standard surgical technique for third molar removal to reduce risk of permanent injury? If so, the size of the effort to compare with standard technique must include a well-designed study of thousands of randomized patients. The impact of retained third molars on symptoms and quality of life. One third of patients with retained third molars reported current or previous pain and two thirds reported impact on their quality of life in the previous 3 months.3 What are the implications for the need for removal and timing for removal of third molars? Is quality of life the driving indicator for this need, or should objective clinical findings carry greater weight in this clinical decision?
1054 ●
Removal of third molars associated with sagittal split osteotomy of the mandible. The evidence for and against simultaneous third molar removal during mandibular osteotomy is made.4,5 The evidence is carefully compared by the authors who wisely reflect on the available evidence. In the end, however, they are left with their personal experience and preference—what works well in their hands. For an issue with as many operator-dependent factors as this, it might be the best answer a reasonable clinician can ever produce.
The risk of surgery as an endeavor to improve health will never be more than marginally decreased. The bar will always be raised. Success at one level of clinical care opens the possibility for more aggressive and more remarkable impact on illnesses. The ravages of the ubiquitous effects of disease and aging will not diminish, but instead are being made more complex by the success of existing therapies. New technology raises the bar on patient expectations and the hopes of surgeons, while simultaneously (and temporarily)
EDITORIAL
raising risk. In an unrelenting cycle, the more risk is mitigated, the more clinical practice advances, only to reveal a new set of risks. Eventually every clinician is left with trying to mitigate the inevitable; the complications of surgery. LEON A. ASSAEL, DMD
References 1. Halmos DR, Ellis E III, Dodson TB: Mandibular third molars and angle fractures. J Oral Maxillofac Surg 62:1076, 2004 2. Pogrel MA, Goldman KE: Lingual flap retraction for third molar removal. J Oral Maxillofac Surg 62:1125, 2004 3. Slade GD, Foy SP, Shugars DA, et al: The impact of third molar symptoms, pain, and swelling on oral health–related quality of life. J Oral Maxillofac Surg 62:1118, 2004 4. Schwartz HC: Simultaneous removal of third molars during sagittal split osteotomies: The case against. J Oral Maxillofac Surg 62:1147, 2004 5. Precious DS: Removal of third molars with sagittal split osteotomies: The case for. J Oral Maxillofac Surg 62:1144 2004
© 2004 American Association of Oral and Maxillofacial Surgeons doi:10.1016/j.joms.2004.07.001
Risk Avoidance in Surgical Practice: Mitigating the Inevitable An elderly lady has but few tangible memories of the family life she treasures. But her favorite is a plate given to her by her mother for her wedding. It sits in a place of honor on the credenza. Each day she lifts it carefully from the shelf, admires it, and polishes it thoroughly to preserve its beauty. One day as she replaces it on the shelf, the plate teeters and then topples to the floor. Picking up the pieces with detached rumination, she wonders whether the plate might have been safer if she left it in a drawer. She wonders if she was too inattentive, even negligent, in handling the plate? With a wry smile, she accepts the outcome. She realizes that the plate would never have gained meaning or value unless its beauty was enjoyed. —As told to me by Dan Laskin
based answers to common questions is also revealed in these papers. The clinical science of risk avoidance as it relates to a single clinical problem (third molars) in the pages of JOMS to follow makes these points:
A surgeon carefully elevates a vertically impacted third molar in the usual way. Like most of his colleagues, he creates a distobuccal trough to deliver the tooth to the buccal. During elevation he notes the lingual nerve adhered to the follicle still attached to the tooth. Too late he recognizes that the adherent follicle has torn the nerve. In the coming weeks, he obsessively replays the event in his mind, wrestling with its causes and constructing hypothetical preventive strategies that might mitigate future risk. Intertwined with this self-analysis, some terminology from the “new normal” of clinical practice emerges. Did his treatment meet “the standard of care?” Did he show good judgment “to a degree of medical certainty?” Did his patient have appropriate “indications for care?” Were “risk factors” adequately taken into account during treatment selection? Did he use “evidencebased medicine” to decide on the best course of treatment for this patient’s condition? Did he provide “adequate documentation” of the circumstances of the event? Our clinical practice and our clinical science are chronicles of the attempt to mitigate surgical risk. Aside from the clear medical-legal implications of this effort, risk mitigation is the obvious, rational, and expected activity of any advancing discipline (or advancing society). Facing risk, and then mitigating it, is the primary means that we use to offer advancements in surgical technology and technique. The small exercise of examining this September edition of JOMS might reveal the intensity of this constant activity of risk avoidance for the advancement of the clinical science of oral and maxillofacial surgery. The complexity of finding useful evidence1053
●
●
●
The association between retained third molars and the risk of mandible fractures. The authors state that retained third molars affords a 2.8-times risk for angle fracture.1 Does this support the contention that elective removal of third molars is indicated for those individuals at risk for facial injury in contact sports or military activities? The answer can only be obtained with the reverse study of following those patients at risk who underwent elective third molar removal versus those at risk who did not. A demonstrated difference in fracture incidence, not fracture location, would be meaningful. The risk of lingual nerve injury with a new method for lingual flap retraction for third molar removal. In 250 patients, 4 temporary and no permanent lingual nerve paresthesias occurred when the lingual mucoperiosteum was elevated and retracted prior to bone removal or tooth sectioning.2 The authors raise the issue as to whether the absence of permanent lingual nerve injury in this series might indicate the utility of this technique to prevent laceration of the lingual nerve during third molar removal. Of note is that there is no parallel group of similar patients (or sides) in which the lingual flap was not elevated. Does this study indicate a need to examine standard surgical technique for third molar removal to reduce risk of permanent injury? If so, the size of the effort to compare with standard technique must include a well-designed study of thousands of randomized patients. The impact of retained third molars on symptoms and quality of life. One third of patients with retained third molars reported current or previous pain and two thirds reported impact on their quality of life in the previous 3 months.3 What are the implications for the need for removal and timing for removal of third molars? Is quality of life the driving indicator for this need, or should objective clinical findings carry greater weight in this clinical decision?
1054 ●
Removal of third molars associated with sagittal split osteotomy of the mandible. The evidence for and against simultaneous third molar removal during mandibular osteotomy is made.4,5 The evidence is carefully compared by the authors who wisely reflect on the available evidence. In the end, however, they are left with their personal experience and preference—what works well in their hands. For an issue with as many operator-dependent factors as this, it might be the best answer a reasonable clinician can ever produce.
The risk of surgery as an endeavor to improve health will never be more than marginally decreased. The bar will always be raised. Success at one level of clinical care opens the possibility for more aggressive and more remarkable impact on illnesses. The ravages of the ubiquitous effects of disease and aging will not diminish, but instead are being made more complex by the success of existing therapies. New technology raises the bar on patient expectations and the hopes of surgeons, while simultaneously (and temporarily)
EDITORIAL
raising risk. In an unrelenting cycle, the more risk is mitigated, the more clinical practice advances, only to reveal a new set of risks. Eventually every clinician is left with trying to mitigate the inevitable; the complications of surgery. LEON A. ASSAEL, DMD
References 1. Halmos DR, Ellis E III, Dodson TB: Mandibular third molars and angle fractures. J Oral Maxillofac Surg 62:1076, 2004 2. Pogrel MA, Goldman KE: Lingual flap retraction for third molar removal. J Oral Maxillofac Surg 62:1125, 2004 3. Slade GD, Foy SP, Shugars DA, et al: The impact of third molar symptoms, pain, and swelling on oral health–related quality of life. J Oral Maxillofac Surg 62:1118, 2004 4. Schwartz HC: Simultaneous removal of third molars during sagittal split osteotomies: The case against. J Oral Maxillofac Surg 62:1147, 2004 5. Precious DS: Removal of third molars with sagittal split osteotomies: The case for. J Oral Maxillofac Surg 62:1144 2004
© 2004 American Association of Oral and Maxillofacial Surgeons doi:10.1016/j.joms.2004.07.001