Certificate of Special Competence in Advanced Headand Neck Surgery by ABOMFS.

The Role of Oral and Maxillofacial Surgeryin the Trauma Care Center: OMS PerspectiveR. Bryan Bell, DDS, MD, Portland, OR

Oral and maxillofacial surgeons have made importantadvances in maxillofacial trauma surgery and have a richhistory in the care of injured patients. As surgeons withtraining in both dentistry and medicine, they are uniquelyqualified to manage a wide variety of injuries to the headand neck and, as such, are a critical resource for traumasystems. Since 1988, the OMFS Service at Legacy EmanuelHospital and Health Center has managed all acute head andneck injuries in patients admitted to the Trauma Service,including dental injuries, cranio-maxillofacial trauma, fron-tal sinus fractures, penetrating neck injuries, laryngo-tra-cheal trauma and temporal bone fractures. Occasionally,secondary referrals for additional follow-up or surgery aremade to ophthalmologists, neuro-otologists or laryngolo-gists for the management of globe injuries, intracranialseventh or eighth cranial nerve injuries or secondary vocalcord procedures, respectively. Data from the Trauma Reg-istry at Legacy Emanuel Hospital and Health Center will bepresented that illustrate the need for and scope of servicesrequired, as well as to provide an objective outcomesassessment. With proper training and experience, oral andmaxillofacial surgeons can provide comprehensive, “pleurato dura,” cranio-maxillofacial/head and neck coverage inthe acute setting for a level 1 trauma center.

References

Bell RB, Dierks EJ, Homer L, Potter BE: Management of cerebrospinalfluid leak associated with craniomaxillofacial trauma. J Oral MaxillofacSurg 62:676, 2004

Verschueren DS, Bell RB, Bagheri SC, Dierks EJ, Potter BE: Manage-ment of laryngo-tracheal injuries associated with craniomaxillofacialtrauma. J Oral Maxillofac Surg 64(2):203, 2006

Bagheri SC, Dierks EJ, Kademani D, Holmgren E, Bell RB, Homer L,Potter BE: Application of a facial injury severity scale in craniomaxil-lofacial trauma. J Oral Maxillofac Surg 64(3):408, 2006

Quality Assurance/Quality Improvementin a Maxillofacial Trauma ServiceRodney S. Nichols, DMD, Milwaukie, OR

The delivery of health care services, not unlike any otherconsumer goods and services, requires the continuous eval-uation of the product distribution/delivery and the consum-er/patient satisfaction with the service (outcome).

Consumer dollars expended in health care deliveryduring the past 5 decades continue to grow as a percent-age of the Gross National Product (GNP) at a significantrate. Likewise, trauma services in the United States re-main a major health and social issue that consumeslimited health care dollars.

As a result of the growing consumption of a major portionof the GNP and the need on the part of society to haveaccountability for the dollars spent, the quality of patient care,both trauma and non-trauma, and the outcomes of treatmentin all settings continue to be scrutinized by a variety of gover-nance bodies and organizations. Standards of care for qualityassurance/quality improvement, system process, organiza-tional leadership, and credentialing established by JCAHCOcontinue to provide guidelines for assessment of the Maxillo-facial Trauma Service.

In addition, the American Association of Oral andMaxillofacial Surgeons (AAOMS) has been a leader inthe preparation of clinical practice guidelines neces-sary for evaluation of care delivered in multiple areasof oral and maxillofacial surgery, including maxillofa-cial trauma. “Parameters and Pathways: Clinical Guide-lines for Oral and Maxillofacial Surgery,” provides thedetail needed to meet standards and elements of per-formance dictated by the JCAHCO for the assessmentof facility compliance for the Maxillofacial TraumaService.

References

Comprehensive Accreditation Manual for Hospitals: The OfficialHandbook, CAMH, Refreshed Core, Jan 2005

Parameters of Care for Oral and Maxillofacial Surgery, A Guide forPractice, Monitoring, and Evaluation (AAOMS Parameters of Care-95),Journal of Oral and Maxillofacial Surgery, 53 No. 9, Sept 1995 (suppl 5)

Parameters and Pathways: Clinical Practice Guidelines for Oral andMaxillofacial Surgery (AAOMS ParPath 01), Version 3.0. Supplement tothe Journal of Oral and Maxillofacial Surgery

SYMPOSIUM: PHARMACOLOGY UPDATESaturday, October 7, 2006, 7:30 am—9:30 amModerator: Louis K. Rafetto, DMD, Wilmington, DE

Efficacy of Agents for Pain ManagementKaren Baker, RPh, MS, Iowa City, IA

Optimal ambulatory analgesia may be achieved by avariety of regimens. We will review the comparative

efficacy of NSAIDs, tramadol, narcotics, adjunctiveagents and combination agents in treating acute post-operative pain as well as chronic oro-facial pain. Em-phasis will be placed on advantages and disadvantagesof analgesic regimens and determination of patient-

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16 AAOMS • 2006

specific selection criteria in oral and maxillofacial sur-gery.

Holistic and Herbal Meds: Uses,Mechanisms, and Interactions for the OMSPamela L. Alberto, DMD, Sparta, NJ

In the early 1900’s Herbal Supplements were the hall-mark of the pharmaceutical industry. About 67% of allmedicine listed in the United States Pharmacopeia (USP)were botanicals. Now only 2% of all entries in the USPare botanicals. With the cost of rising health care, and ashift towards self-medicating, the consumer demand for100% natural products has increased dramatically.

Herbal Medicine is an 80 billion dollar per year busi-ness with an annual growth of 10-20%. So with 33% ofAmericans using herbs, one third of the patients you seein your practice will be taking some Herbal Supplement.The World Health Organization defines Herbal Supple-ments as finished labeled medicinal products that con-tain active ingredients, aerial or underground parts ofplants, or other plant material or combinations thereof,whether in the crude state or as plant preparations.During the past 25 yrs, more than half of the modernpharmaceuticals are derived from natural sources. Aspi-rin, Caffeine, Colchicine, Cyclosporine, Digoxin, Qui-nine and Taxol are all plant derived Pharmaceuticals.

Legally, herbs are classified as dietary supplementsregulated by the food service industry. So the quality ofherbs varies from company to company. Even frombatch to batch, there is no consistent, standardized com-position.

Herbs can be used for any disease or human ailment.There are herbs that act as CNS depressants, cardiovas-cular, antimigraine, antiemetic, immunostimulant, andantiulcer agents. Some herbs can alleviate menopausalsymptoms and Benign prostatic Hypertrophy. An impor-tant fact is there are many Herbal/Drug interactions and15 million Americans are at risk. As surgeons it is impor-tant that we include in our medical history herbal sup-plements used. The herbs we must watch out for are theanticoagulant herbs; alfalfa, bilberry, bladder-wrack, cat-claw, celery, Dong Quai, evening primrose, white wil-low, feverfew, garlic, gingko, ginseng, Guggul, horsechestnut, and red clover. There are herbs that can po-tentiate anesthetics we use. For example, Valerian andKava Kava can potentiate barbiturates and benzodiaz-epines. I recommend discontinuing those herbs for 2weeks prior to surgery.

There are many herbs that are unsafe. These includearnica, butterbur, chaparral, coltsfoot, comfey, indiantobacco, jinson weed, pennyroycloil, pokeweed, root,rauwolfia and sassafras. It is important to screen ourpatients for these herbal supplements and inform themof potential interactions.

References

PDR for Herbal Medicines, Third Edition 2005Schultz, Hansel, Tyler: Rational phytotherapy a physicians guide to

herbal medicine, Springer, N.Y. 1998Winn, Merllon, Crosley: Drug Interaction Handbook for Dentistry,

11th Ed. Lexi-Comp, 2005

Substance AbuseKaren Miotto, MD, Los Angeles, CA

The trends and patterns of substance use change overtime. The annual National Survey on Drug Use andHealth (NSDUH), released in September 2004, indicatesthat in 2003 more than 19 million Americans, or 8.2% ofthe population, aged 12 and older reported abusingillegal drugs each month. The most frequently reporteddrug used is marijuana with 14.6 million current users(6.2% of the population). The NSDUH data also estimatesthe percentage of youths who used marijuana for thefirst time within the past 12 months was 5.0 percent in2004.

The average THC content of marijuana has been re-ported to have increased over the past several decades.The psychological concerns about regular marijuana useinclude the risk of psychotic symptoms, subtle memoryimpairment, the risks of developing dependency andimpaired driving. There is conflicting evidence about themedical risks, however, there appears to be a dose-related increase risk of head and neck cancer.

A growing area of concern is the increasing non-medical use of prescription medications among all agegroups but young adults in particular. The 2004 NSDUHshows about 6% of young adults reported non-medicalprescription use in the past month, and 29% had used intheir lifetime. From 2002 to 2004 there was an increasein lifetime prevalence of non-medical use of opiate painrelievers in the 18 to 25 age group, from 22% to 24%.Hydrocodone and oxycodone products showed thegreatest increases in lifetime use.

The rise in prescription opiate use is a public healthconcern that increases the need for dentists prescribingopiates to screen and monitor for addictive disease. It isalso important to be familiar with treatment options forpatients with opiate dependence. Many states have im-plemented Prescription Monitoring Programs to helpidentify individuals who attempt to fill multiple prescrip-tions from numerous providers. Finally, the greatest con-cern about non-medical opiate abuse is the risk of deathdue to overdose and possible progression to intravenousheroin addiction.

There has also been a large increase in the abuse ofmethamphetamine. Most of the methamphetamine useis in the western region of the US, however it is increas-ing in the midwest and in some southern states. Meth-amphetamine addiction is associated with weight loss,dental problems, psychotic symptoms and violence as-

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