- Email: [email protected]
Sensory retraining after orthognathic surgery
for RAU, recurrent intraoral herpetic ulceration. Herpetic stomatitis has been treated successfully with vitamin B12 and should have been included. It was also unclear whether the aphthous ulceration reported in the groups was only minor RAU or included other varieties of the disorder.
Even with these deficiencies, 74% of the subjects were free of aphthous ulcers after 6 months compared to only 32% of the controls. This presents a strong argument for further investigation into the effectiveness of vitamin B12 as a treatment for RAU.
Procedurally, there were questions concerning the concealment of allocation sequences. The educational levels of the two groups were also disparate, with two-thirds of the intervention group considered highly educated but fewer than half of the control group at this level. Some relationships have been noted between low income/education and increased duration and intensity of pain compared with higher income/education status. No intention-totreat analysis was applied, so the efficacy of the intervention may have been overly optimistic.
Clinical Significance.—It would be wonderful to have a simple, inexpensive, and low-risk treatment for RAU. If vitamin B12 is proved to clear aphthous ulcers to the degree present in this study, it may be that treatment. Studies of larger groups of patients that address the shortfalls of the current study are needed.
The authors also failed to develop a consistent biological explanation for how vitamin B12 works with respect to RAS. Additionally, they did not consider alternative hypotheses such as the presence of Helicobacter pylori or the possibility that a factor causing RAU also causes vitamin B12 deficiency.
Carrozzo M: Vitamin B12 for the treatment of recurrent aphthous stomatitis. Evid Base Dent 10:114-115, 2009 Reprints available from M Carrozo, Dept of Oral Medicine, School of Dental Sciences, Univ of Newcastle upon Tyne, Newcastle upon Tyne, UK
Oral Surgery Sensory retraining after orthognathic surgery Background.—Nearly 100% of patients with dentofacial disharmony who undergo a bilateral sagittal split osteotomy (BSSO), either alone or with maxillary osteotomy, suffer inferior alveolar nerve injury intraoperatively. This demyelination or axonal damage manifests most often as altered sensation, with over 60% of patients reporting persistent altered sensation 6 months postoperatively. Most patients recover sensation but it may require several years. The reported alterations can have a negative impact on orofacial function and daily activities. Recent treatment approaches include simple facial exercises that can be performed at home. The facial sensory retraining exercises are performed with the standard opening exercises after BSSO. This approach often lessens the patient’s problems related to numbness, unusual sensations, and lip sensitivity compared with using the opening exercises only. It is believed that these exercises alter central nervous system (CNS) organization so that functionally useful information can be obtained from the disordered nerve signals after injury. Other factors that contribute to the development of altered sensation include older age and psychological distress, which are related to elevated pain and diminished satisfaction after surgery. The possibility that demographic, clinical, or presurgical psychological factors influence the self-reports of altered sensation 2 years after BSSO and
158
Dental Abstracts
the long-term effects of sensory retraining exercises were investigated. Methods.—A total of 186 patients were divided into two parallel groups. Patient reports of altered sensations obtained before surgery and after 1, 3, 6, 12, and 24 months postoperatively were recorded. The effect of sensory retraining (controlling for potential explanatory effects related to demographic, psychological, and clinical factors) on the odds of the patient reporting postoperative altered sensations was determined. Results.—One month after surgery, 99% of the subjects reported spontaneous or evoked altered sensation at one to four facial sites. This declined to 71% after 2 years. Age and the presurgical severity index showed a significant relationship with patient reports of altered sensation postoperatively (Table 2). Gender, optimism, and postoperative expectations were not related to these patient reports. At 2-year follow-up, the effects of sensory retraining exercises were marginally significant. Patient reports of altered sensation fell dramatically in the first year after surgery. The decline thereafter was not significant. After controlling for exercise retraining effects,
Table 2.—Generalized score test results from the preliminary models assessing the effects of demographic, psychological, and clinical factors as well as sensory retraining on patient report of altered sensations after surgery (time was included in all preliminary models and was statistically significant [P <0.0001] in all models) Effect
Age Sex Overall demographic factors Global severity index Optimism Expectations Overall psychological factors Jaw (n) Genioplasty Overall clinical factors Sensory retraining
DF
Chi-square statistics
P value
1 1 2 1 1 1 3 1 1 2 1
27.66 0.27 28.92 17.98 2.43 0.41 20.16 0.98 0.20 1.03 3.6
<0.0001 0.60 <0.0001 <0.0001 0.12 0.52 0.0002 0.32 0.65 0.60 0.06
(Courtesy of Phillips C, Kim SH, Essick G, et al: Sensory retraining after orthognathic surgery: Effect on patient report of altered sensations. Am J Orthod Dentofacial Orthop 136:788-794, 2009.)
age and the severity index were significantly related to the patient’s report of altered sensation. With each 10-year increase in age, the estimated odds of reporting altered sensation increased 2.3 times (Fig 1). With each increase of 1 standard deviation in global severity score, the estimated odds of reporting altered sensation increased 1.8 times. Compared with patients who used only the opening exercises, patients who performed the sensory retraining exercises were about 2.2 times less likely to report altered sensation (Fig 3), controlling for age and psychological distress. Both groups experienced a decline in reports of
Fig 3.—Estimated and observed likelihood of altered sensations after BSSO for patients who used the opening exercises only and those who also used the sensory retraining exercises after controlling for psychological distress and age. (Courtesy of Phillips C, Kim SH, Essick G, et al: Sensory retraining after orthognathic surgery: Effect on patient report of altered sensations. Am J Orthod Dentofacial Orthop 136:788-794, 2009.)
altered sensation over the 2-year period. The differences between the two groups increased as time passed. Discussion.—Patients who participated in the sensory retraining exercises had fewer problems with altered facial sensation after BSSO than patients who used only the opening exercises. It appears that after 2 years, the CNS is reorganized sufficiently to interpret disordered sensory signals from the injured inferior alveolar nerve. Both the treatment and control groups demonstrated a decline in reports of altered sensation over the 2-year period, but the treatment group had a significantly lower proportion of patients still reporting dysfunction.
Clinical Significance.—Laboratory and animal research has shown that sensory retraining helps the CNS reorganize so that it can make sense of the disordered signals from injured nerves. The reorganization of the CNS and response property changes in individual cortical neurons suggest that signals from the injury site are more accurately perceived and translated into functionally correct motor function. The simple, noninvasive exercise program proved useful in achieving this reorganization and permitting patients to recover sensation.
Fig 1.—Estimated likelihood of a patient reporting the presence of altered sensations after BSSO for patients who were less than 20 years of age at the surgery, between 20 and 30, and older than 30 after controlling for the effects of psychological distress and exercise group. (Courtesy of Phillips C, Kim SH, Essick G, et al: Sensory retraining after orthognathic surgery: Effect on patient report of altered sensations. Am J Orthod Dentofacial Orthop 136:788-794, 2009.)
Phillips C, Kim SH, Essick G, et al: Sensory retraining after orthognathic surgery: Effect on patient report of altered sensations. Am J Orthod Dentofacial Orthop 136:788-794, 2009 Reprints available from C Phillips, Dept of Orthodontics, CB 7450, Univ of North Carolina, Chapel Hill, NC 27599; e-mail: [email protected]
Volume 55
Issue 3
2010
159
Even with these deficiencies, 74% of the subjects were free of aphthous ulcers after 6 months compared to only 32% of the controls. This presents a strong argument for further investigation into the effectiveness of vitamin B12 as a treatment for RAU.
Procedurally, there were questions concerning the concealment of allocation sequences. The educational levels of the two groups were also disparate, with two-thirds of the intervention group considered highly educated but fewer than half of the control group at this level. Some relationships have been noted between low income/education and increased duration and intensity of pain compared with higher income/education status. No intention-totreat analysis was applied, so the efficacy of the intervention may have been overly optimistic.
Clinical Significance.—It would be wonderful to have a simple, inexpensive, and low-risk treatment for RAU. If vitamin B12 is proved to clear aphthous ulcers to the degree present in this study, it may be that treatment. Studies of larger groups of patients that address the shortfalls of the current study are needed.
The authors also failed to develop a consistent biological explanation for how vitamin B12 works with respect to RAS. Additionally, they did not consider alternative hypotheses such as the presence of Helicobacter pylori or the possibility that a factor causing RAU also causes vitamin B12 deficiency.
Carrozzo M: Vitamin B12 for the treatment of recurrent aphthous stomatitis. Evid Base Dent 10:114-115, 2009 Reprints available from M Carrozo, Dept of Oral Medicine, School of Dental Sciences, Univ of Newcastle upon Tyne, Newcastle upon Tyne, UK
Oral Surgery Sensory retraining after orthognathic surgery Background.—Nearly 100% of patients with dentofacial disharmony who undergo a bilateral sagittal split osteotomy (BSSO), either alone or with maxillary osteotomy, suffer inferior alveolar nerve injury intraoperatively. This demyelination or axonal damage manifests most often as altered sensation, with over 60% of patients reporting persistent altered sensation 6 months postoperatively. Most patients recover sensation but it may require several years. The reported alterations can have a negative impact on orofacial function and daily activities. Recent treatment approaches include simple facial exercises that can be performed at home. The facial sensory retraining exercises are performed with the standard opening exercises after BSSO. This approach often lessens the patient’s problems related to numbness, unusual sensations, and lip sensitivity compared with using the opening exercises only. It is believed that these exercises alter central nervous system (CNS) organization so that functionally useful information can be obtained from the disordered nerve signals after injury. Other factors that contribute to the development of altered sensation include older age and psychological distress, which are related to elevated pain and diminished satisfaction after surgery. The possibility that demographic, clinical, or presurgical psychological factors influence the self-reports of altered sensation 2 years after BSSO and
158
Dental Abstracts
the long-term effects of sensory retraining exercises were investigated. Methods.—A total of 186 patients were divided into two parallel groups. Patient reports of altered sensations obtained before surgery and after 1, 3, 6, 12, and 24 months postoperatively were recorded. The effect of sensory retraining (controlling for potential explanatory effects related to demographic, psychological, and clinical factors) on the odds of the patient reporting postoperative altered sensations was determined. Results.—One month after surgery, 99% of the subjects reported spontaneous or evoked altered sensation at one to four facial sites. This declined to 71% after 2 years. Age and the presurgical severity index showed a significant relationship with patient reports of altered sensation postoperatively (Table 2). Gender, optimism, and postoperative expectations were not related to these patient reports. At 2-year follow-up, the effects of sensory retraining exercises were marginally significant. Patient reports of altered sensation fell dramatically in the first year after surgery. The decline thereafter was not significant. After controlling for exercise retraining effects,
Table 2.—Generalized score test results from the preliminary models assessing the effects of demographic, psychological, and clinical factors as well as sensory retraining on patient report of altered sensations after surgery (time was included in all preliminary models and was statistically significant [P <0.0001] in all models) Effect
Age Sex Overall demographic factors Global severity index Optimism Expectations Overall psychological factors Jaw (n) Genioplasty Overall clinical factors Sensory retraining
DF
Chi-square statistics
P value
1 1 2 1 1 1 3 1 1 2 1
27.66 0.27 28.92 17.98 2.43 0.41 20.16 0.98 0.20 1.03 3.6
<0.0001 0.60 <0.0001 <0.0001 0.12 0.52 0.0002 0.32 0.65 0.60 0.06
(Courtesy of Phillips C, Kim SH, Essick G, et al: Sensory retraining after orthognathic surgery: Effect on patient report of altered sensations. Am J Orthod Dentofacial Orthop 136:788-794, 2009.)
age and the severity index were significantly related to the patient’s report of altered sensation. With each 10-year increase in age, the estimated odds of reporting altered sensation increased 2.3 times (Fig 1). With each increase of 1 standard deviation in global severity score, the estimated odds of reporting altered sensation increased 1.8 times. Compared with patients who used only the opening exercises, patients who performed the sensory retraining exercises were about 2.2 times less likely to report altered sensation (Fig 3), controlling for age and psychological distress. Both groups experienced a decline in reports of
Fig 3.—Estimated and observed likelihood of altered sensations after BSSO for patients who used the opening exercises only and those who also used the sensory retraining exercises after controlling for psychological distress and age. (Courtesy of Phillips C, Kim SH, Essick G, et al: Sensory retraining after orthognathic surgery: Effect on patient report of altered sensations. Am J Orthod Dentofacial Orthop 136:788-794, 2009.)
altered sensation over the 2-year period. The differences between the two groups increased as time passed. Discussion.—Patients who participated in the sensory retraining exercises had fewer problems with altered facial sensation after BSSO than patients who used only the opening exercises. It appears that after 2 years, the CNS is reorganized sufficiently to interpret disordered sensory signals from the injured inferior alveolar nerve. Both the treatment and control groups demonstrated a decline in reports of altered sensation over the 2-year period, but the treatment group had a significantly lower proportion of patients still reporting dysfunction.
Clinical Significance.—Laboratory and animal research has shown that sensory retraining helps the CNS reorganize so that it can make sense of the disordered signals from injured nerves. The reorganization of the CNS and response property changes in individual cortical neurons suggest that signals from the injury site are more accurately perceived and translated into functionally correct motor function. The simple, noninvasive exercise program proved useful in achieving this reorganization and permitting patients to recover sensation.
Fig 1.—Estimated likelihood of a patient reporting the presence of altered sensations after BSSO for patients who were less than 20 years of age at the surgery, between 20 and 30, and older than 30 after controlling for the effects of psychological distress and exercise group. (Courtesy of Phillips C, Kim SH, Essick G, et al: Sensory retraining after orthognathic surgery: Effect on patient report of altered sensations. Am J Orthod Dentofacial Orthop 136:788-794, 2009.)
Phillips C, Kim SH, Essick G, et al: Sensory retraining after orthognathic surgery: Effect on patient report of altered sensations. Am J Orthod Dentofacial Orthop 136:788-794, 2009 Reprints available from C Phillips, Dept of Orthodontics, CB 7450, Univ of North Carolina, Chapel Hill, NC 27599; e-mail: [email protected]
Volume 55
Issue 3
2010
159