LETTERS TO THE EDITOR

J Oral Maxillofac Surg

69:2483-2487, 2011

FAMILIARITY DOES NOT BREED COMPETENCE

To the Editor:—Your recent editorial in the June 2011issue1 regarding the problems of providing adequate train-ing to produce clinical competence is at the essence of thecurrent dilemma faced by those who must accredit trainingprograms in oral and maxillofacial surgery (OMS).

For far too long, it has been accepted that all OMS resi-dents must be trained to an acceptable level of clinicalcompetence in all aspects of our specialty, even now in theera of “expanded scope.” In a surgical field as broad andcomprehensive as OMS, no one surgeon can be expected tobe, or in fact is, “clinically competent” in all areas of surgicalexpertise. We should look to other surgical specialties forguidance. In otolaryngology/head and neck surgery (ear,nose, and throat), clinical competence is provided for basicotolaryngology/head and neck surgery within the tradi-tional residency. Additional fellowship training is availablefor those who wish to gain expertise (ie, “clinical compe-tence”) in areas such as otologic surgery, head and neckoncologic surgery, or facial esthetic surgery. In plastic sur-gery, fellowship training is offered to those who are seekingadditional certification in hand surgery, microsurgery, cos-metic surgery, oncologic surgery, and craniomaxillofacialsurgery.

Residents in OMS should be trained to clinical competencein physical evaluation and care of the medically compromisedpatient who requires surgery in the office or the hospital, oraland maxillofacial pathology, oral and maxillofacial radiology,anesthesiology in the outpatient setting, dentoalveolar surgery,implantology, and maxillofacial trauma. Residents must beexposed to clinical experience, either as an assistant surgeonor as the operating surgeon, as well as either on the OMSservice or on off-service rotations, in temporomandibular jointopen and arthroscopic surgery, craniomaxillofacial/orthog-nathic surgery, oral and head/neck oncologic/reconstructivesurgery, facial esthetic/cosmetic surgery, and microsurgery.However, the resident should not be expected to acquireenough surgical cases to achieve clinical competence in allthese areas, although in some programs that may be possiblein some of these areas and should be recognized. Most oral andmaxillofacial surgeons will elect to practice the basic scope ofsurgery learned during residency. After completion of resi-dency training, the graduate who wishes to pursue fellowshiptraining in 1 of the previously listed subspecialties will then beable to acquire the additional experience he or she needs topractice with “clinical competence.” Development of clinicalcompetence requires a large volume of cases and the associ-ated experience to acquire judgment and patient manage-ment, as well as technical skill. There is simply not enoughclinical material to adequately train (to clinical competence) allOMS residents in all aspects of surgical practice. In many

instances fellowship training is currently made available only

Letters to the Editor must be in reference to a specific article omust be submitted within 6 weeks of the article’s print publicatioit first appeared online. Letters must be submitted electronically vjoms. Letters are subject to editing and those exceeding 500 wophotograph may accompany the letter if it is essential to undermaterial or material published elsewhere. There is no guarantee tnot be provided. Submitting a Letter to the Editor constitutes tedition of the journal, in any form or medium.

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to those with a medical degree and general surgery training,2,3

which may influence a prospective applicant in his or herselection of a particular residency program.

The day is long past when a surgeon in any specialty canbe considered simply a technician performing a technicalservice. Familiarity with all aspects of our specialty is anecessary part of basic residency training, but familiaritydoes not breed clinical competence. However, familiaritydoes create an interest that may stimulate the resident topursue the additional training in a fellowship to provide himor her with the clinical competence necessary to provideexemplary surgical care in a specific subspecialty. Thosewho wish to practice in a subspecialty beyond basic resi-dency training should acquire the necessary skills in fellow-ship training. This may require some adjustment in theexamination of the American Board of Oral and Maxillofa-cial Surgery, but such adjustment, if it adds an additionalcertification for fellowship training, will do much to im-prove the quality of practice across the entire expandedscope of our specialty.

ROGER A. MEYER, DDS, MS, MDGreensboro, GA

SHAHROKH C. BAGHERI, DMD, MDMarietta, GA

References1. Hupp JR: Surgical training: Is dabbling enough? J Oral Maxillofac

Surg 69:1535, 20112. Meyer RA, Bagheri SC: Double degree training supported. J Oral

Maxillofac Surg 68:1703, 20103. Meyer RA, Bagheri SC: Single degree and dual degree: We are all

oral and maxillofacial surgeons. J Oral Maxillofac Surg 68:2926,2010

doi:10.1016/j.joms.2011.06.220

TCR OR NOT TCR?

To the Editor:—With great interest, we read the article ofBohluli et al,1 which nicely presents their results on theincidence of the trigeminocardiac reflex (TCR) during bilat-eral sagittal split ramus osteotomy and the potential preven-tive and protective role of the Gow-Gates block in attenu-ating the reflex response. Currently, TCR is defined as asudden decrease in the heart rate (HR) and the mean arterialblood pressure (MABP) by more than 20% after manipula-tion at or around any branches of the trigeminal nerve.2,3

Indeed, TCR has received little attention from the oral andmaxillofacial surgery profession, and only a few studies

have been conducted to elucidate its incidence, its compli-

r editorial that has been published by the Journal. Lettersn or, for an online-only article, within 8 weeks of the dateia the Elsevier Editorial System at http://ees.elsevier.com/

rds may be shortened or not accepted due to length. Onestanding the subject. Letters should not duplicate similarhat any letter will be published. Prepublication proofs willhe author’s permission for its publication in any issue or

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2484 LETTERS TO THE EDITOR

cating effects, and its clinical and surgical management.Therefore the current work by Bohluli et al seems morethan timely to sensitize oral and maxillofacial surgeons toTCR. Furthermore, similar to the research on oculocardiacreflex, which constitutes a peripheral subform of TCR, suchas the maxillary and mandibular variants, research on themaxillary and mandibular branches delivers vivid insightsinto the differences between peripheral and central TCR.On the basis of the 20% threshold, peripheral TCR, at leastoculocardiac reflex, in contrast to central TCR, is not con-sidered to be accompanied by hypotension.4 Unfortunately,MABP values are often missing in such reports, as is the casein the study by Bohluli et al. In a previous study, Bohluli etal5 first reported decreased MABP values (9.7%), in additionto decreased HR values (6.5%), during Le Fort I osteotomy,considering those values to indicate TCR and disregardingthe rather arbitrary 20% threshold. In their latest study onbilateral sagittal split ramus osteotomy, however, MABP hasnot been monitored, thus limiting this study’s comparabilityto other studies for elucidating differences between periph-eral and central TCR. Moreover, the TCR definition has beeninconsistently applied for the HR decreases. Patients withanesthetic block before surgical manipulation showed amean decrease of up to 6.8%. In contrast to the Le Fort Iosteotomy study, this value was not considered to indicateTCR. On the other hand, mean HR decreases by 17.6%(during splitting osteotomy) and 21.5% (during setback ma-nipulation) in this study were both considered to indicateTCR. This reflects a common problem in TCR researchresulting in heterogeneous reports on the occurrence ofTCR, thus blurring the real incidence of TCR. It seems morereasonable to include every decrease in HR and MABP,disregarding any threshold, coinciding with the manipula-tion of any of the trigeminal branches into the TCR conceptand to solely differentiate between severities of the auto-nomic response by measuring the mean decrease in values.

Because, according to the literature, the administration ofanesthetics has been associated with failure rates, and giventhe fact that the significant difference in pulse rate decreasebetween the 2 study sites is not likely to be of any otherorigin but local anesthesia, the results of the present studymay reflect the minimum average efficiency of local nerveblockade. However, it should not be forgotten that theadministration of anesthetics before general anesthesiawould have provided a more reliable outcome. Finally, wewould like to express our hope for further research to helpdepict the different aspects of this relatively unknownreflex.

AMR ABDULAZIM

NORA PROCHNOW, PhDBochum, Germany

TARA TAEIHAGH

Tehran, Iran

References1. Bohluli B, Schaller BJ, Khorshidi-Khiavi R, et al: Trigeminocar-

diac reflex, bilateral sagittal split ramus osteotomy, Gow-Gatesblock: A randomized controlled clinical trial. J Oral MaxillofacSurg 69:2316, 2011

2. Schaller B: Trigemino-cardiac reflex during transsphenoidal sur-gery for pituitary adenomas. Clin Neurol Neurosurg 107:468,2005

3. Schaller BJ, Weigel D, Filis A, et al: Trigemino-cardiac reflex

during transsphenoidal surgery for pituitary adenomas: Method-

ological description of a prospective skull base study protocol.Brain Res 1149:69, 2007

4. Schaller B, Probst R, Strebel S, et al: Trigeminocardiac reflexduring surgery in the cerebellopontine angle. J Neurosurg 90:215, 1999

5. Bohluli B, Bayat M, Sarkarat F, et al: Trigeminocardiac reflexduring Le Fort I osteotomy: A case-crossover study. Oral SurgOral Med Oral Pathol Oral Radiol Endod 110:178, 2010

doi:10.1016/j.joms.2011.05.028

In Reply:—We read with great interest the noteworthycomments of Abdulazim et al on our recent publication. Asmentioned in the letter, unlike occulocardiac reflex and thecentral subtypes faced in the neurosurgery field, the tri-geminocardiac reflex (TCR) has been less studied in thefield of craniomaxillofacial surgery. The studies of Bohluli etal,1-3 which to the best of our knowledge stand among theew to have systematically assessed the reflex, have greatlyontributed to the understanding of some crucial aspects ofCR. From our personal experience, cardiac responses to

he manipulative procedures of Le Fort and orthognathicurgeries, as well as other maxillofacial procedures, areuite common. However, the intensity of these bradycar-iac responses seems to be totally dependent on the inten-ity of the manipulation. Therefore, we decided to recordny pulse rate and mean arterial blood pressure alterations.e then came to the conclusion that the original valuable

escription of the TCR by Schaller et al,4 which reported a20% decrease in the pulse rate and mean arterial bloodpressure, might reflect the neurosurgical experience of thereflex, the central TCR, or might simply reflect the clinicallynotable intensity of TCR. We have now prepared a criticalreview through which, in consultation with Dr Schaller, weintend to introduce TCR as “any bradycardia triggered bythe stimulation anywhere along the course of cranial nerveV or its midbrain nuclei, which is self-eliminated uponcessation of the stimulant.” This modified descriptionmakes sense, especially considering that the mean arterialblood pressure has largely been neglected in the reports ofthe reflex and the name of the reflex implies a cardiaccomponent, rather than a vagal or cardiovascular compo-nent (which might be best described as a trigeminovagalreflex).

The administration of Gow-Gates before the main courseof surgery would ensure maximum anesthesia during surgi-cal manipulation. It might also be possible to inject long-acting local anesthetics before general anesthesia. However,there are potential problems even with the application oflow doses of these agents. For instance, bupivacaine cancause significant bradycardia and dysrhythmia. Etidocainehas been shown to cause less cardiovascular disturbance;however, inadequate control of intraoperative bleeding hasbeen reported as its main disadvantage.5

We are also preparing the report of a case of death due toTCR during the course of maxillofacial surgery. This casenot only delineates the importance of both prevention andproper treatment in high-risk procedures, but also furthernotifies and sensitizes the craniomaxillofacial surgery pro-fession of the abrupt incidence of a potentially life-threat-ening event. Also, the incidence of TCR during simple oralprocedures such as extraction has been studied and thesereports will contain useful discussions regarding the com-parison of TCR and the vasovagal reflex. We hope these

yet-to-be-published findings will improve our understanding