AJOMS Vol One 2024
Australasian Journal of
ORAL AND MAXILLOFACIAL SURGERY Official journal of the Australian and New Zealand Association of
Editor
Oral and Maxillofacial Surgeons and the Oceania Region
Professor A Goss editorajoms@anzaoms.org Deputy Editors Professor A Heggie AM Professor D Wiesenfeld
+61 2 8091 0535 ISSN: 2982-0065
ajoms@anzaoms.org
Level 13, 37 York Street, Sydney NSW 2000
The Australasian Journal of Oral & Maxillofacial Surgery is the official scientific journal of the Australia & New Zealand Association of Oral &
F O U N D AT I O N E D I T O R
EDITORIAL BOARD
Alastair Goss
Business Manager Dieter Gebauer
• Emeritus Professor of Oral & Maxillofacial Surgery, The University of Adelaide • Emeritus Consultant Surgeon, The Royal Adelaide Hospital Adelaide, Australia
Perth, Australia
Maxillofacial Surgeons. DEPUTY EDITORS Aim & Scope The Australasian Journal of Oral & Maxillofacial Surgery is the premier forum for the exchange of information for new and significant research in oral and maxillofacial surgery, promoting the surgical discipline in the Oceanic region.
Oceania comprises 19 countries, spread over one sixth of the globe, but with Australia and New Zealand being the dominant developed countries.
The Journal comprises peer reviewed scientific reports, reviews, case reports of rare of unusual conditions, and perspective all of value for continuing professional development. Information for prospective authors, including author guidelines, publication ethics, malpractice statements and patient consent forms are available for download from the Australian & New Zealand Association Oral & Maxillofacial Surgery homepage. All correspondence with the Editor is via editorajoms@anzaoms.org.
Andrew Heggie, AM
• Clinical Professor, Department of Paediatrics, The University of Melbourne • Senior Consultant Oral & Maxillofacial Surgeon, Royal Children’s Hospital of Melbourne Melbourne, Australia
David Wiesenfeld
• Honorary Clinical Professor, The University of Melbourne • Lead in Head & Neck Research & Education, The Victorian Comprehensive Cancer Centre Melbourne, Australia
PRODUCTION MANAGEMENT Website and Distribution Belinda Mellowes • Executive Officer, Australian and New Zealand Association of Oral and Maxillofacial Surgeons Sydney, Australia
Production Editor Jac Taylor • Foundation Managing Director, Crucible Content Sydney, Australia
The Australasian Journal of Oral & Maxillofacial Surgery accepts paid advertisements from companies involved with the surgical discipline.
Graphic Design Daniel Sim • Managing Director, Daniel Sim Design (DSD)
For information on advertising guidelines and rates contact Ms Belinda Mellowes, Executive Officer, The Australian & New Zealand Association of Oral & Maxillofacial Surgeons: eo@anzaoms.org
Brisbane, Australia
Submit advertisements to ajoms@anzaoms.org
Catherine Offler
A D M I N I S T R AT I O N • Administrative Assistant to the Editor Adelaide, Australia
The Australasian Journal of Oral & Maxillofacial Surgery Editors and Editorial Board cannot be held responsible for error or consequence arising from the information contained in the Journal. The views and opinions expressed there do not necessarily reflect those of the Australian & New Zealand Association of Oral & Maxillofacial Surgeons, AJOMS Editor or Editorial Board. Neither does publication of advertisements constitute any endorsement of the products advertised. © Copyright 2024 ANZAOMS
Electronic Promotion Arun Chandu • Senior Consultant in Oral & Maxillofacial Surgery, Royal Dental Hospital of Melbourne • Clinical Associate Professor of Oral & Maxillofacial Surgery, The University of Melbourne Melbourne, Australia
Members Alexander Bobinskas • Consultant Oral & Maxillofacial Surgeon, The Canberra Hospital • Research Fellow, The John Curtin School of Medical Research Canberra, Australia
Advertising Information
Disclaimer
• Senior Consultant in Oral & Maxillofacial Surgery, Royal Perth Hospital • Clinical Associate Professor in Oral & Maxillofacial Surgery, The University of Western Australia
Kathryn Steward • Advertising Sales and Administration - Membership and Administration Coordinator, Australian & New Zealand Association of Oral & Maxillofacial Surgeons Sydney, Australia
Nigel Johnson • Consultant Oral & Maxillofacial Surgeon, Princess Alexandra Hospital • Senior Lecturer in Oral & Maxillofacial Surgery, The University of Queensland Brisbane, Australia
Darryl Tong • Professor of Oral & Maxillofacial Surgery, The University of Otago • Senior Consultant in Oral & Maxillofacial Surgery, Dunedin Public Hospital Dunedin, New Zealand
Ex Officio Members Jasvir Singh • President, Australian & New Zealand Association of Oral and Maxillofacial Surgeons • Consultant in Oral & Maxillofacial Surgery, Prince of Wales Hospital Sydney Australia
Patrishia Bordbar • Immediate Past President, Australian & New New Zealand Association of Oral & Maxillofacial Surgeons • Consultant in Oral & Maxillofacial Surgery, The Royal Children’s Hospital of Melbourne • IAOMS Executive Representative – Oceania Region Melbourne, Australia
John Harrison • Regional Councillor for Oceania, International Association of Oral & Maxillofacial Surgery • Senior Consultant in Oral & Maxillofacial Surgery, Auckland City & Middlemore Hospital Auckland, New Zealand
Jocelyn Shand • Clinical Associate Professor, Department of Paediatrics, The University of Melbourne • Chair, Australian & New Zealand Association of Oral & Maxillofacial Surgeons Research & Education Foundation • Head of Section of Oral & Maxillofacial Surgery, The Royal Children’s Hospital of Melbourne • Vice President Elect, International Association of Oral & Maxillofacial Surgery Melbourne, Australia
C O V I D - 1 9 SCIENTIFIC ARTICLE
TRENDS IN ORAL AND MAXILLOFACIAL SURGERY DURING THE COVID-19 PANDEMIC
The Australian experience Mian M (MD, BDS, MPH)† Subhashaan Sreedharan S (MD, MPH)† Sklavos A (BDS, MD)† Austin S (MBBS, GdipDent, MPhil, FRACDS (OMS))‡ † The Royal Melbourne Hospital, Melbourne, Victoria, Australia
ABSTRACT Objectives: The aim of the study was to investigate the impact of COVID-19 on Medicare rebatable specialist OMS services (consultations and treatment) in Australia during the period January 2020 to December 2020.
‡ Department of Oral & Maxillofacial Surgery, Western Health, Melbourne, Victoria, Australia
Methods: A smoothing model was applied to public datasets between 2016 to
Corresponding author:
2019, in order to predict the number of quarterly consultations and
ANTON SKLAVOS
treatments between January 2020 and July 2021 with 95% confidence
The Royal Melbourne Hospital,
(p<0.05). Predicted and observed consultations and treatments were
Parkville, Victoria, Australia
compared.
Email: antonsklavos@hotmail.com
Results: There was a significant decrease in the number of consultations in the second quarter of 2020 (30.3%, 95% CI: 23.0% to 36.3%). This was followed by subsequent increases in third (13.7%, 95% CI: 2.0% to 28.4%) and fourth quarters of 2020 (16.6%, 95% CI: 0.8% to 38.4%). Telehealth consultations made up only 5.1% of total consultations during the pandemic. There was a significant decrease in the number of OMS treatments in the second quarter of 2020 for both dualqualified (33.8%, 95% CI: 27.9% to 38.9%) and single qualified surgeons (42.2%, 95% CI: 35.4% to 47.7%). Total treatments for dual-qualified rebounded in the third (7.9%, 95% CI: 0.2% to 16.9%) and fourth quarters of 2020 (9.5%, 95% CI: 1.7 to 18.6%). This was associated with a change in treatment types, including sustained reductions in orthognathic surgery and an increase in preprosthetic and implant surgery. Conclusion: These findings confirm that the most significant impact of COVID-19 Keywords:
on OMS services in Australia occurred early in the pandemic. Total
coronavirus | healthcare delivery |
services recovered during the second half of 2020 to reach pre-
healthcare systems | maxillofacial surgery |
pandemic levels. The relative proportion of treatments subtypes is
SARS-CoV-2
changing.
148 | AJOMS Volume 1 2024
INTRODUCTION
Coronavirus disease 2019 (COVID-19) continues to have a profound impact on healthcare systems and economies worldwide. In the international context, Australia has fared relatively well, with 115,802 cases of COVID-19 resulting in 1,357 deaths as of October 6th, 2021.1 However, aggressive suppression strategies and lockdowns across the country have had significant impacts on healthcare delivery, including surgical services. Throughout the pandemic, oral and maxillofacial surgery (OMS) has been particularly affected, in part due to the perceived risk of COVID-19 transmission associated with instrumentation of the upper aerodigestive tract.2 As part of the response to the COVID-19 pandemic, national and state governments implemented a range of measures aimed to reduce the risk of transmission in healthcare settings and to ensure adequate hospital capacity and personal protective equipment (PPE). Restrictions were placed on non-urgent elective surgery and dental services, first beginning nationally in March 2020, and implemented at state and local government levels during subsequent waves. Surgical consultations in public outpatient and private practice settings were also limited. In this context, the Australian Government also funded temporary COVID-19 telehealth services. 3 In Australia, OMS services are provided predominately through the private healthcare system.4 Government rebates for specified services are available through the national universal healthcare scheme (Medicare). This study used an interrupted time series model to analyse publicly available Medicare Benefits Schedule (MBS) data for OMS consultations and treatments. 5 The aim of this study was to investigate the impact of COVID-19 on rebatable specialist OMS services (consultations and treatments) in Australia during the period January 2020 to July 2021.
AJOMS Volume 1 2024 |
149
METHODS Data Source Statistical Analysis Category 3 and 4 of the Australian Medicare Benefits Schedule (MBS) outline the range of coded surgical services
Triple exponential smoothing (TES) is a commonly used
utilised by OMS surgeons that attract a Medicare rebate.
forecasting method used to model and predict interrupted
Category 3 services are used by most OMS clinicians
time series data. TES uses weighted averages of past
(dentally and medically qualified) and are shared with
observations, with weights decreasing exponentially as
other medical specialists. Category 4 applies exclusively
observations get older. TES modelling decomposes the
to clinicians who obtained their FRACDS (OMS) or
data series into a level component, a trend component and
equivalent qualifications prior to 1 November 2004
a seasonal component, thus accounting for long term trend
(dentally qualified). This study utilised data from both
and seasonal or holiday related changes.7
6
the OMS section of Category 3 of the MBS as well as all Category 4 data. Category 3 services are divided into
In the present study, additive TES was used to model the
orthognathic surgery, TMJ surgery, oral and maxillofacial
quarterly number of (1) consultations, (2) total treatments
pathology surgery, preprosthetic and dental implants
and (3) each OMS treatment subtype between January
and treatment of facial fractures. Category 4 services are
2016 and December 2019. Models were used to predict
divided into face-to-face consultations, general surgery
consultations and treatments between January 2020 and
(including oral and maxillofacial infections and pathology
July 2021. Observed and predicted number of quarterly
surgery), plastic and reconstructive surgery (including
consultations and treatments between January 2020 to
orthognathic surgery), preprosthetic surgery and dental
July 2021 were compared to calculate residual differences.
implants, neurosurgical surgery, ear-nose-throat surgery,
A 95% confidence interval for predictions was also
temporomandibular joint surgery and treatment of facial
calculated in order to determine statistically significant
fractures. Quarterly MBS data for rebatable OMS services
residual differences (p<0.05). All statistical analyses were
provided between January 2016 to December 2019 was
performed using SPSS version 22 (IBM SPSS, Amronk,
extracted from MBS datasets and grouped into face-to-
NY, USA) and LKS-CHART Forecasting Tool (St. Michael’s
face consultations or treatments. In addition, the number
Hospital, Toronto, ON, Canada).
5
of telehealth consultations, using the temporary COVID-19 telehealth item numbers for OMS (Category 4), was extracted and included in consultation data. This analysis was Human Research Ethics exempt as only publicly available, de-identified, composite statistical data was considered.
RESULTS Consultations There was no significant difference between the number
There was no significant difference between the number of
of observed and predicted consultations in the first quarter
observed and predicted total quarterly consultations during
of 2020. There was a significant decrease in the number
2021 (Figure 1, Table 1). There were 3,519 telehealth
of consultations in the second quarter of 2020 (4247,
consultations (Category 4) between January 2020 and
30.3%, 95% CI: 23.0% to 36.3%). This was followed by
July 2021 making up 5.1% of total consultations during the
a significant increase in consultations in the third (1893,
period implemented.
13.7%, 95% CI: 2.0% to 28.4%) and fourth quarter of 2020 (2082, 16.6%, 95% CI: 0.8% to 38.4%).
150 | AJOMS Volume 1 2024
Figure 1 Total oral and maxillofacial surgery consultations (Category 4) performed in Australia during COVID-19. Panel A shows observed consultations between January 2017 and June 2020, modelled consultations between January 2017 and December 2019 and predicted (with 95% CI) consultations between January 2020 and June 2020. Panel B shows observed and predicted (with 95% CI) consultations between January 2020 and June 2020.
Jan-Mar 2020
Apr-Jun 2020
Jul-Sep 2020
Oct-Dec 2020
Jan-Mar 2021
Apr-Jun 2021
-1.6 (-9.6, 7.9)
-33.8* (-38.9, -27.9)
7.9* (0.2, 16.9)
9.5* (1.7, 18.6)
0.4 (-6.6, 8.5)
2.4 (-4.5, 10.4)
Orthognathic
-15.6* (-24.0, -5.2,)
-46.8* (-53.8, -37.4)
-10.5 (-25.0, 11.1)
-27.0* (-41.2, -3.9)
-33.3* (-48.3, -5.7)
-41.7* (-57.4, -7.8)
TMJ
5.9 (-21.0, 60.3)
-37.8* (-51.8, -12.6)
30.6* (2.8, 79.3)
12.6 (-9.5, 49.0)
13.4 (-11.2, 57.1)
-11.4 (-28.7, 17.0)
Pathology
-6.3 (-12.7, 1.1)
-32.7* (-37.0, -27.8)
-3.4 (-2.9, 10.5)
5.6 (-0.9, 13.1)
-4.6 (-10.4, 2.0)
-7.2* (-12.5, -1.1)
Preprosthetic and Implant
0.0 (-8.4, 10.0)
-37.0* (-41.9, -31.2)
7.3 (-0.5, 16.5)
8.4* (1.1, 16.9)
9.9* (1.8, 19.3)
16.8* (8.7, 26.1)
Fractures
-20.3 (-44.9, 44.1)
-35.7 (-53.5, 4.0)
-24.4 (-47.3, 27.4)
-20.1 (-46.6, 58.5)
6.1 (-29.6, 115.5)
-5.5 (-34.0, 66.4)
Total Treatments Treatment Subtypes
* indicates statistical significance Table 1 Percentage differences between observed and predicted oral and maxillofacial treatments (Category 3)
AJOMS Volume 1 2024 |
151
Figure 2 Oral and maxillofacial surgery treatments (Category 3) performed in Australia during COVID-19. Panel A shows observed treatments between January 2017 and June 2020, modelled treatments between January 2017 and December 2019 and predicted (with 95% CI) treatments between January 2020 and June 2020. Panel B shows observed and predicted (with 95% CI) treatments between January 2020 and June 2020.
Treatments There was no significant difference between the number of
There were significant changes to the relative proportions
observed and predicted total treatments in the first quarter of
of Category 3 treatment subtypes in 2021. There was a
2020 for either Category 3 or 4 items. There was a significant
sustained reduction in orthognathic surgery during the first
decrease in the number of OMS treatments in the second
(734, 33.3%, 95% CI: 5.7% to 48.3%) and second quarters of
quarter of 2020 for both Category 3 (1761, 33.8%, 95% CI:
2021 (931, 41.7%, 95% CI: 7.8% to 57.4%). There was also a
27.9% to 38.9%) and Category 4 (1971, 42.2%, 95% CI:
reduction in treatment for head and neck pathology in 2021,
35.4% to 47.7%). This was followed by significant increases
which reached statistical significance in the second quarter
in total treatments for Category 3 in the third (440, 7.9%, 95%
of 2021 (335, 7.2%, 95% CI: 1.1% to 12.5%). In contrast,
CI: 0.2% to 16.9%) and fourth quarters of 2020 (532, 9.5%,
Category 3 preprosthetic and implant surgery increased in the
95% CI: 1.7 to 18.6%), (Figure 2). In contrast, there was no
first (213, 9.9%, 95% CI: 1.8% to 19.3%) and second quarters
significant difference in observed and predicted treatment
of 2021 (389, 16.8%, 95% CI: 8.7% to 26.1%).
levels in the third and fourth quarters of 2020 for Category 4 treatments (Figure 3). Decreases were observed across most OMS treatment subtypes during the second quarter of 2020 (Table 1, Table 2).
152 | AJOMS Volume 1 2024
Figure 3 Oral and maxillofacial surgery treatments (Category 4) performed in Australia during COVID-19. Panel A shows observed treatments between January 2017 and June 2020, modelled treatments between January 2017 and December 2019 and predicted (with 95% CI) treatments between January 2020 and June 2020. Panel B shows observed and predicted (with 95% CI) treatments between January 2020 and June 2020.
Jan-Mar 2020
Apr-Jun 2020
Jul-Sep 2020
Oct-Dec 2020
Jan-Mar 2021
Apr-Jun 2021
Total Consultations
-7.5 (-14.6, 0.8)
-30.3* (-36.3, -23.0)
13.7* (2.0, 28.4)
16.6* (0.8, 38.4)
12.8 (-5.4, 39.6)
14.7 (-7.8, 51.8)
Total Treatments
-5.6 (-14.8, 5.8)
-42.2* (-47.7, -35.4)
8.7 (-1.4, 21.2)
-0.1 (-9.2, 11.0)
8.2 (-2.2, 20.9)
1.3 (-8.2, 13.0)
-8.5 (-20.2, 7.2)
-33.6* (-41.7, -22.8)
1.4 (-10.7, 17.3)
-0.3 (-12.9, 16.6)
8.4 (-5.7, 27.6)
2.3 (-10.5, 19.3)
- Infection†
-2.1 (-20.2, 26.5))
-25.6 (-42.5, 5.3)
6.6 (-18.9, 55.7)
-9.8 (-34.0, 42.7)
-1.3 (-29.5, 64.4)
0.1 (-31.6, 86.5))
- Pathology†
-10.5 (-22.5, 6.0)
-43.9* (-50.9, -34.6)
-12.8 (-23.5, 1.4))
-11.3 (-22.9, 4.2))
-3.1 (-16.3, 15.1)
-12.9 (-23.9, 1.8)
-5.0 (-14.6, 6.9)
-34.3* (-40.8, -26.2))
24.9* (13.0, 39.4)
4.4 (-5.3, 16.1)
12.5* (1.8, 25.8)
8.0 (-2.1, 20.5)
-0.7 (-20.4, 31.9))
-53.8* (-64.8, -32.9)
-21.8 (-38.8, 8.5)
3.1 (-17.5, 37.5)
-0.1 (-20.3, 33.8))
-4.4 (-27.7, 41.0))
Preprosthetic and Implant
2.1 (-15.3, 28.6)
-40.5* (-51.6, -22.6)
26.9 (-2.0, 80.0)
23.7 (-9.0, 93.0)
50.5 (-2.0, 224.0)
55.5 (-6.3, 357.3)
Neurosurgical
-4.3 (-41.0, 152.1)
-45.7 (-65.8, 30.9)
4.6 (-39.0, 266.8)
6.8 (>-46.5)
47.4 (>-34.7)
17.7 (>44.5)
Ear, Nose and Throat
14.9 (-4.3, 43.8)
-37.6* (-47.3, -23.6)
13.3 (-4.2, 38.6)
1.1 (-14.2, 23.2)
26.4* (4.8, 59.3)
-2.9 (-18.3, 19.6)
Temporomandibular Joint
5.1 (-24.3, 71.9)
-35.6 (-53.2, 3.5)
-14.7 (-36.5, 29.8)
15.9 (-15.7, 85.6)
12.5 (-20.2, 90.7)
12.2 (-19.8, 86.4)
Fractures
-4.3 (-46.1, 328.5)
-42.7 (-63.5, 32.8)
-45.4 (-62.5, 0.6)
64.0 >-22.9
10.1 >-47.4
37.3 (-20.2, 391.9)
Treatment Subtypes
General
Plastic and Reconstructive - Orthognathic‡
* indicates statistical significance † treatments related to infections and pathology are a subgroup of general treatments ‡ treatments related to orthognathic surgery are a subgroup of plastic and reconstructive treatments
Table 2 Percentage differences between observed and predicted oral and maxillofacial consultations and treatments (Category 4)
AJOMS Volume 1 2024 |
153
DISCUSSION This study aimed to investigate changes in government
orthognathic surgery. In summary, the most significant
subsidised OMS consultations and surgical treatment
impact of COVID-19 on OMS services occurred during the
during the COVID-19 pandemic in Australia. There was a
first wave of the pandemic. Total services recovered during
30% reduction in consultations during the second quarter
the second half of 2020 to reach pre-pandemic levels,
of 2020. This corresponded to the peak of the first wave
however the relative proportion of treatments subtypes is
of the pandemic and national lockdown (Figure 4), with
changing.
patients avoiding face-to-face attendances with all medical personnel. 8 Non-emergency dental treatment was also
There was limited uptake of telehealth services by oral
heavily restricted during this period. Given that dentists
and maxillofacial surgeons, making up only 5.1% of total
and dental specialists represent the source of 80% of OMS
consultations since implementation. In contrast, telehealth
referrals in Australia, dental service restrictions likely had
consultations made up 35.6% of total consultations for
a direct effect in further reducing OMS consultations.4
general practitioners and 38.5% of total consultations
Consultations rebounded in the second half of 2020, with
for non-GP specialists in Australia. 8 A limitation of this
increases of 14% and 17% in the third and fourth quarters
report is that it did not break down into surgical and non-
respectively, before stabilising to pre-pandemic levels in
surgical non-GP specialist services, therefore the impact
2021. Similarly, OMS treatments were reduced by over
on surgical specialists is not clearly defined. 8 There are
one third during the second quarter of 2020. Category
obvious barriers to the use of telehealth services specific to
3 treatments (dual-qualified surgeons) rebounded with
OMS, such as difficulties in adequate intraoral examination,
increases of 8% and 10% in the third and fourth quarters
inability to palpate important structures, as well as
of 2020, respectively. This was associated with a change
inadequate staffing and facilities at the patient’s location
in the type of treatments delivered, including an increase
to assist in examination. 9-10 Despite this, there is evidence
in pre-prosthetic and implant surgery and a decrease in
to suggest a high level of concordance between face-to-
Figure 4 Cases of COVID-19 in Australia. Daily (left axis) and cumulative (right axis) COVID-19 cases diagnosed in Australia are shown with key time points for elective surgery procedures indicated.
154 | AJOMS Volume 1 2024
Figure 5 Patient information sheet in preparation for a telemedicine consultation. Reprinted with permission from Prasad et al, 2020.14
face and telehealth consultations for triage and treatment
and to prepare patients for the encounter. Patients may be
planning in OMS.
advised to organise a flashlight and retraction device to
10-12
Indeed, acceptance of telehealth by
oral and maxillofacial surgeons during COVID-19 has been
assist in examination. Providing written information may
high elsewhere.13 In this study, OMS consultation data
also help in optimising the consultation (Figure 5).15
was only available for clinicians utilising Category 4 of the MBS. They are likely to be older and may be less inclined
Following service restrictions on non-urgent elective
to use telehealth services, which may help to explain the
surgery and dental treatment the Australian and New
low uptake of telehealth. Telehealth services are likely to
Zealand Association of Oral and Maxillofacial Surgeons
have an expanding role in oral and maxillofacial surgery in
(ANZAOMS) provided guidelines for appropriate procedure
the future. In particular for patient populations who reside
categorisation to reduce the impact of COVID-19 on
in regional and rural areas who face the burden of travel
time-sensitive surgery. This included management of
distance when seeking OMS services. Increased travel
suspected or existing head and neck cancers, craniofacial
distance has been found to be associated with more severe
and dentoalveolar trauma and infections not responding to
odontogenic infections, and higher rates of loco-regional
non-surgical measures.16 Despite this, this study showed
failure from oral tongue squamous cell carcinoma.
a large reduction in the treatment of oral and maxillofacial
Telehealth consultations could play an important role for
pathology which persisted even when total treatment
regional and rural patients in accessing timely care and oral
volume returned to pre-pandemic levels. Concerningly, there
cancer screening. A number of strategies are important
is emerging international evidence of delayed diagnoses of
to help increase uptake and effectiveness of telehealth
head and neck cancers resulting from system-wide health
services. This can include administrative staff contacting
service disruptions due to COVID-19.18-20 It is likely that this
patients prior to the consultation to test video technology
is also the case in Australia, where 430 cases of head and
14,15
AJOMS Volume 1 2024 |
155
neck cancer are diagnosed per month, with one third of
knowledge of the infectious disease; during the COVID-19
these cases referred to oral and maxillofacial surgeons.21,22
pandemic this was directed toward minimising non-
For example, in Victoria, from April 2020 to October 2020,
essential contact with patients, and minimisation of
there was a 15% reduction in head and neck cancer
aerosol producing procedures, and utilisation of telehealth
notifications, representing 105 undiagnosed tumours.23 The
consultations where appropriate27.
delayed diagnosis and management of these patients may result in a higher tumour burden associated with greater
This study demonstrated significant differences between
morbidity and mortality. Ongoing monitoring of service
single qualified and dual qualified OMS surgeons in
levels, in particular of diagnosis and treatment of important
Australia. Over the five-year study period, item numbers
oral and maxillofacial pathology, should inform evidence-
used by single qualified surgeons remained stable or
based strategies to reduce the detrimental secondary
decreased, while those for dual qualified surgeons has
public health impacts of COVID-19.
steadily increased, reflecting the professional requirements of new OMS surgeons in Australia since 2004 to be
The reduction in services during the peak of the pandemic
qualified in both medicine and dentistry. Following the
has a number of secondary implications for the speciality.
first wave of the pandemic, treatment levels for dual-
This includes disruption of surgical education for OMS
qualified surgeons rebounded with significant increases
trainees, which is similar to the experience from trainees
in the third and fourth quarter of 2020. A similar rebound
around the world.24,25 The impacts of government
was not observed for single qualified surgeons. This may
restriction and reduction in patient volume on private OMFS
reflect differences in the scope of practice between these
surgeons also warrants further investigation. This will
groups.28
allow practices to better predict and prepare for ongoing disruptions related to staff employment, pre-emptive
This study quantified the effect of COVID-19 on OMS
purchase of equipment, and planning for access to private
services at a national level using robust modelling methods,
general anaesthetic facilities for future pandemics.
however these findings should be interpreted in the context of a number of limitations. OMS specific consultation data
Reductions in orthognathic surgery persisted in 2021,
was only available from Category 4 of the MBS. These
when total services returned to pre-pandemic levels. This is
clinicians will be registered as dental practitioners only.
likely to be due to the elective nature of most orthognathic
They will also be older and have worked for longer.27 This
procedures, as well as intermittent restrictions on dental
may affect the pattern of consultations and the proportion
services which deferred or extended essentially all
of consultations delivered via telehealth. Finally, data
orthodontic treatment during the pandemic. Delays in
presented here does not represent all oral and maxillofacial
orthodontic treatment during the pandemic have already
surgery services in Australia. The MBS does not include
been noted elsewhere.26 In contrast, there were increases
services provided to inpatients at public hospitals or
in Medicare-subsidised preprosthetic and implant surgery
services that are entirely private and do not attract a
following the national lockdown in early 2020. The specific
Medicare rebate, this includes most dentoalveolar surgery
drivers of this change are unclear. One explanation is that
(including most dental implants and third molar surgery).
clinicians may be shifting practice to facilitate the oral
These procedures are classified as aerosol generating and
rehabilitation of existing patients who have previously
therefore are likely to also have been significantly affected.
undergone head and neck cancer resection. Ongoing
Despite these limitations, these findings are still largely
monitoring of service levels will be important to better
reflective of the overall impact of the of COVID-19 on oral
understand how the pandemic is changing the type of
and maxillofacial surgery services in Australia.
treatments being provided by OMS surgeons and prepare the speciality to meet these demands. The current study has demonstrated that there were significant changes in the practice of OMS during the COVID-19 pandemic period between January 2020 to December 2020. Significant decreases in elective surgical output were demonstrated early in the pandemic response, and the uptake of telehealth consultations was noted throughout this period. Preparation for future pandemics can be divided into general and specific preparedness.27 General preparation is based on principles of minimising risk, appropriate training of staff, and minimising nonessential services until specific knowledge of the disease threat is known.27 Specific preparation is guided by 156 | AJOMS Volume 1 2024
CONCLUSIONS The most significant impact of COVID-19 on OMS services
treatment subtypes is changing. The surgical needs of the
in Australia occurred during the first wave of the pandemic.
public should be balanced against the risk of COVID-19
Reduction in OMS services during this time likely had
transmission and the need to protect hospital capacity.
significant implications for patients, especially those
Ongoing surveillance of service levels is important to
requiring non-emergency surgery. Despite the profession’s
respond to and reduce the impact of the pandemic on OMS
attempt to protect access to care for patients requiring
patients, trainees and surgeons.
time sensitive treatment, system-wide reductions in services may have resulted in a delay of diagnosis and treatment of significant pathologies such as head and neck malignancies. While total services recovered to reach pre-pandemic levels in 2021, the relative proportion of
Conflict of interest statement No conflict of interest or funding sources are declared. Ethics approval was not required for this study.
Trends in Oral and Maxillofacial Surgery during the COVID-19 pandemic: The Australian Experience
Refe re n ce s 1.
World Health Organization. WHO Coronavirus Disease (COVID-19) Dashboard (2020). https://covid19.who.int
2.
Givi B, Schiff BA, Chinn SB, et al. Safety recommendations for evaluation and surgery of the head and neck during the COVID-19 pandemic. JAMA Otolaryngol Head Neck Surg 2020;146:579-584.
3.
Australian Government Department of Health. COVID-19 Temporary MBS Telehealth Services (2020). http://www.mbsonline.gov.au/internet/ mbsonline/publishing.nsf/Content/Factsheet-TempBB
4.
Singh KA BD, Spencer AJ, Goss AN. Practice patterns of oral and maxillofacial surgeons in Australia. Australian Institute of Health and Welfare (Population Oral Health Series No 3; 2004). https://www.aihw.gov.au/reports/dental-oral-health/practice-patterns-oral-maxillofacial-surgeons/ contents/table-of-contents
5.
Services Australia. Medicare Item Reports (2020). http://medicarestatistics.humanservices.gov.au/statistics/mbs_item.jsp
6.
Australian Government Department of Health. Medicare Benefits Schedule Book: Category 4. Canberra. 2020.
7.
Coghlan A. A Little Book of R For Time Series (2018). https://buildmedia.readthedocs.org/media/pdf/a-little-book-of-r-for-time-series/latest/a-littlebook-of-r-for-time-series.pdf
8.
Scott A. The impact of COVID-19 on GPs and non-GP specialists in private practice (2020). https://melbourneinstitute.unimelb.edu.au/__data/ assets/pdf_file/0003/3436014/UoM-MI-ANZ_Brochure-FV.pdf
9.
Wood EW, Strauss RA, Janus C, Carrico CK. The use of telemedicine in oral and maxillofacial surgery. J Oral Maxillofac Surg 2016;74:719-728.
10.
Wood EW, Strauss RA, Janus C, Carrico CK. Telemedicine consultations in oral and maxillofacial surgery: A follow-up study. J Oral Maxillofac Surg 2016;74:262-268.
11.
Brownrigg P, Lowry JC, Edmondson MJ, Langton SG. Telemedicine in oral surgery and maxillofacial trauma: A descriptive account. Telemed J E Health 2004;10:27-31.
12.
Rollert MK, Strauss RA, Abubaker AO, Hampton C. Telemedicine consultations in oral and maxillofacial surgery. J Oral Maxillofac Surg 1999;57:136138.
13.
Al-Izzi T, Breeze J, Elledge R. Following COVID-19 clinicians now overwhelmingly accept virtual clinics in Oral and Maxillofacial Surgery. Br J Oral Maxillofac Surg 2020;10:290-295.
14.
Daniell JR, Dolja-Gore X, McDowell L, et al. The impact of travel distance to treatment centre on oral tongue squamous cell carcinoma survival and recurrence. Int J Oral Maxillofac Surg. 2022;51:854-861.
15.
Sklavos A, Lee K, Masood M. The association of travel distance and severity of odontogenic infections. Oral Maxillofac Surg. 2022. doi: 10.1007/ s10006-022-01135-1. Online ahead of print.
16.
Prasad A, Brewster R, Newman JG, Rajasekaran K. Optimizing your telemedicine visit during the COVID-19 pandemic: practice guidelines for patients with head and neck cancer. Head Neck. 2020;42:1317-1321.
17.
Australian and New Zealand Association of Oral and Maxillofacial Surgeons. ANZAOMS Guidelines for Elective Procedure Categorisation – Oral
AJOMS Volume 1 2024 |
157
and Maxillofacial Surgery. https://www.anzaoms.org/documents/item/523. 2020. 18.
Arduino PG, Conrotto D, Broccoletti R. The outbreak of Novel Coronavirus disease (COVID-19) caused a worrying delay in the diagnosis of oral cancer in north-west Italy: The Turin Metropolitan Area experience. Oral Dis 2021;27 (Suppl 3):742-743.
19.
Gilligan G, Lazos J, Piemonte E, Criado E, Pánico R. Delays in the diagnosis of oral cancer due to the quarantine of COVID-19 in Córdoba, Argentina. Spec Care Dentist 2020;40:618-620.
20.
Sud A, Torr B, Jones ME, et al. Effect of delays in the 2-week-wait cancer referral pathway during the COVID-19 pandemic on cancer survival in the UK: A modelling study. Lancet Oncol 2020;21:1035-1044.
21.
Australian Institute of Health and Wellbeing. Cancer data in Australia (2020). https://www.aihw.gov.au/reports/cancer/cancer-data-in-australia/ contents/summary
22.
Kaing L, Manchella S, Love C, Nastri A, Wiesenfeld D. Referral patterns for oral squamous cell carcinoma in Australia: 20 years progress. Aust Dent J 2016;61:29-34.
23.
Te Marvelde L, Wolfe R, McArthur G, Blake LA, Evans SM. Decline in cancer pathology notifications during the 2020 COVID-19-related restrictions in Victoria. Med J Aust. 2021;214:281-283.
24.
Brar B, Bayoumy M, Salama A, Henry A, Chigurupati R. A survey assessing the early effects of COVID-19 pandemic on oral and maxillofacial surgery training programs. Oral Surg Oral Med Oral Pathol Oral Radiol 2021;131:27-42.
25.
Huntley RE, Ludwig DC, Dillon JK. Early effects of COVID-19 on oral and maxillofacial surgery residency training—Results from a national survey. J Oral Maxillofac Surg 2020;78:1257-1267.
26.
Abed Al Jawad F, Alhashimi N. Orthodontic treatment pause during COVID-19 outbreak: Are we overlooking potential harms to our patients and their treatment outcomes? Dental Press J Orthod. 2021;26:e21ins2.
27.
Nesbitt I. Pandemic planning and its relevance to surgeons. Surgery (Oxf). 2021;39:444-448.
28.
Ricciardo P, Bobinskas A, Vujcich N, Nastri A, Goss A. Survey of Australasian oral and maxillofacial surgeons 2011 - scope and workforce issues. Int J Oral Maxillofac 2015;44:1569-1573.
158 | AJOMS Volume 1 2024
2024 APRIL Volume 1 | Issue 1
+61 2 8091 0535
ajoms@anzaoms.org
Level 13, 37 York Street, Sydney NSW 2000