(36) Assessing Knowledge and Promoting Awareness of Vascular Anomalies Among Oral and Maxillofacial Surgeons

Abstract: A review of the literature demonstrates that the majority of vascular malformations of the jaws are often unrecognized until inappropriate intervention results in severe bleeding. Several fatal, but avoidable, incidents have been reported in dental settings, bringing attention to the alarming gap in knowledge and preparedness of dentists and oral and maxillofacial surgeons (OMS) in these scenarios.

The purpose of this study is to use a clinical vignette to determine the current ability among OMS to detect, diagnose and properly plan for treatment of a vascular malformation in the mandible. An investigator-designed survey constructed as a clinical vignette was sent to a list of 6,126 OMSs practicing in the United States. The case presented a 3-year-old male with an elevated, mobile tooth with a history of intermittent bleeding and discoloration of the mucosa. Open ended questions assessed of 1) information gathering, 2) diagnostic workup, 3) differential diagnosis, 4) treatment plan, and 5) final diagnosis. Intercoder agreement for the scoring of each question was assessed using Cohen's kappa statistic. Once a strong intercoder agreement was confirmed, a single investigator evaluated survey responses for correctness. The data analysis was done by R software v4.1.2 and RStudio v1.372. A p-value of <.05 was considered statistically significant for all analyses. Hypothesis testing was done by Pearson’s Chi-squared test.

13% (70) of respondents described a correct diagnostic work-up, indicating a work-up specific for a vascular lesion. 8.6% (100) respondents answered incorrectly, including a procedure that could have put the patient at harm (given that imaging was not revealed at this point in the survey). 30.1% (157) of respondents indicated correct responses for physical examination, including assessing for a pulse, bruit, or thrill. 35.8% (161) of respondents did not include vascular malformations (or a variant) in their differential diagnosis. 50.7% (228) of respondents indicated an incorrect treatment plan once imaging was provided, putting the patient at risk for a life-threatening hemorrhage in an uncontrollable setting. The only procedure considered acceptable was aspiration or embolization if treated under general anesthesia given the unpredictable nature of this vascular malformation and the age of the patient. Academic OMSs were statistically significantly more likely to have a correct diagnostic work-up (p=0.043) and differential diagnosis (p=0.045). Additionally, this group reported a greater confidence to treat (6.41 (CI: 5.68-7.13) vs 5.03 (CI: 4.73-5.34), p< 0.001) when compared to clinicians in private practice. However, there were no significant differences in correct responses for treatment between these groups. 59.2% (263) of all respondents stated that they believe they received enough training on vascular anomalies during residency training. There were no significant differences in any responses based on geographic areas (urban, rural) and location of practice (Northeast, Southeast, West, Midwest, Southwest) of OMSs. This demonstrates that the knowledge gap encompasses all regions of the nation.

Vascular malformations are rare conditions that demand heightened attention from OMSs. Given the considerable complications in the case of improper treatment and management, it is crucial to augment educational efforts to improve patient care and outcomes. Emphasis must be directed towards focused examination, detection, diagnosis and treatment. Notably, it is critical that OMSs consider contraindications and critically assess reliance on biopsy when presented with these rare, but life-threatening conditions.

References:

1. Mohammadi H., Said-al-Naief N.A., Heffez L.B. Arteriovenous malformation of the mandible: report of a case with a note on the differential diagnosis. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 1997;84(3):286–289.

2. Noreau G., Landry P.P., Morais D. Arteriovenous malformation of the mandible: review of literature and case history. J. Can. Dent. Assoc. 2001;67(11):646–651.