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

: 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 in these scenarios. The purpose of this study is to use a clinical vignette to determine the current ability among oral and maxillofacial surgeons 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 oral and maxillofacial surgeons 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. Thirteen percent (70) of respondents described a correct diagnostic work-up, indicating a work-up specific for a vascular lesion. Eight-point-six percent (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). Thirty-point-one percent (157) of respondents indicated correct responses for physical examination, including assessing for a pulse, bruit, or thrill. Thirty-five-point-eight percent (161) of respondents did not include vascular malformations (or a variant) in their differential diagnosis. Fifty-point-seven percent (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 oral and maxillofacial surgeons were statistically significantly more likely to have a correct diagnostic work-up (P = .043) and differential diagnosis (P = .045). Additionally, this group reported a greater confidence to treat (6.41 (CI: 5.68 to 7.13) vs 5.03 (CI: 4.73 to 5.34), P < .001) when compared to clinicians in private practice. However, there were no significant differences in correct responses for treatment between these groups. Fifty-nine-point-two percent (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 oral and maxillofacial surgeons. This demonstrates that the knowledge gap encompasses all regions of the nation. Vascular malformations are rare conditions that demand heightened attention from oral and maxillofacial surgeons. 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 oral and maxillofacial surgeons consider contraindications and critically assess reliance on biopsy when presented with these rare, but life-threatening conditions.