In addition to routine surgical procedures that are performed by our practice on a daily basis we also treat pathology of the mouth and jaws. Often times during a routine dental evaluation dark or bright white spots will appear on dental x-rays. Impacted teeth such as third molars or wisdom teeth can lead to the formation of cysts and tumors. Impacted teeth can also result from the presence of a mass or growth preventing the tooth from taking its place in the mouth. Any growth that is not a normal part of the anatomy is considered a tumor. These tumors can be either benign or malignant and may or may not be give the patient symptoms such as pain, swelling or numbness. Your general dentist will then refer you to a specialist for evaluation of these areas or lesions on the x-ray. And while most often these areas are nothing to be concerned over, being vigilant and fully investigating the possible issues is certainly warranted.
When you arrive at our practice our doctors and staff will review all the relevant medical information and discuss these issues with you. The initial step in treatment of these possible jaw tumors is confirming that they exist with a three dimensional image or CT scan. Our office is equipped with a Cone Beam 3D scanner and panoramic x-ray which can be used to distinguish radiographic anomalies from true cysts and tumors. Repeating the x-ray from your dentist can help distinguish shadows or other positional issues from true problems. The doctors at our practice will then review these images with you and explain what is found and then discuss recommendations for treatment. While the x-rays help confirm the presence of a cyst or tumor there is no definitive way to tell what type of tumor it is by x-ray alone.
Most dark lesions on an x-ray are cystic in nature and should be surgically treated with biopsy. Removal of the cyst and evaluation microscopically will determine if further intervention is necessary. The reasoning behind these recommendations is that while statistically most cysts are benign, (not cancerous) most will continue to grow over time and be destructive to the surrounding bone and teeth. Leaving a benign cyst untreated can lead to significant deformity, fractures of the jaw bone, loss of teeth and gums, and malocclusion. Some larger or more aggressive tumors may need to be treated more radically with a procedure called resection. This entails removing a large section of the jaw involved to prevent the tumor from reoccurring. This is only necessary in a small fraction of cysts and will be discussed and planned out well after the initial diagnosis is made.
White or bright areas on the x-rays are less often associated with a need for surgical intervention. The vast majority of these lesions are simple areas of rapid bone growth called condensing osteitis. This is a benign condition and surgical treatment is not required. What makes the white lesions more concerning is that a small number of these areas may be a form of bone cancer. This is usually easy to distinguish on early images and CT scans but as with all forms of cancer, the treatment is more urgent.
If your general dentist or primary care physician has recommended a consultation with a specialist for a growth or tumor the doctors and staff of Pottstown Oral and Maxillofacial Surgery can help guide you through this process. Please contact our office for a consultation appointment for assistance.
Recently new laws were passed in Pennsylvania and other states further regulating the prescriptions our patients receive from our practice. I wanted to use this opportunity to help clear some misconceptions and explain our new office policies as they relate to these changes. We have been and always will be concerned with the growing epidemic of prescription drug use. As a group we feel that the new laws are frightening and impeding interactions with our patients. The doctor-patient relationship is an important aspect of our practice and these new laws limit our ability to have an open discussion regarding pain management. Limiting our ability to care for certain patients in a way we felt was appropriate in some cases and putting undo pressure on patients and their families who may now be afraid to even use pain medication despite their recent surgery.
The laws themselves require that, in addition to our normal history and examination that all patients receiving narcotic or sedative medications be investigated for all prior prescriptions through an online database. Recent or excessive prescription medication usage may result in no prescriptions being issued from our office. In addition to the law our office policy reflects these rising concerns. We do not routinely issue narcotic or sedative medications to patients prior to surgery. As a surgical office we feel comfortable and required to manage your post-operative discomfort. Many studies done on the use of narcotic pain medications point to the long term use of these medications as highly addictive but the short term usage for severe pain control, especially in a surgical situation, does not typically lead to these issues.
The law also requires minors and their guardians to sign consent forms showing the risks, complications and concerns regarding these medications. We feel as a group that all patients should be aware of these risks and will therefore be asking all patients having a surgery to review and sign the consent form if the use of strong pain medications is a possibility. Please keep in mind that signing the form or leaving with the prescription does not require you to take them. The written prescription given to our patients just makes these medications available if needed. Different people will experience different levels of pain after any procedure. Previous law makes it impossible for us to “phone in” these same prescriptions. We still have a level of trust with our patients that they will use these medications only when necessary. As the patient you are ultimately responsible for what goes into your own body.
The spirit of the new legislation is in the right place. We want everyone to be safe and we certainly don’t want to see prescription drug abuse worsen in our community. This is a difficult subject for some people as the pharmaceutical industry has advocated for years to make these medications, which are now so reviled, the treatment of choice for chronic and acute pain management. These new laws will affect the way patients with pain are treated. With a dire shortage in access to dental and medical services for patients across the country it won’t be easy. We encourage people to engage in preventative management to prevent conditions from deteriorating to the point where pain becomes an issue. See your doctor and dentist on a regular basis to prevent small issues from becoming painful ones and we can stop many prescriptions before they are even needed.
We often hear from patients that they were told they are not able to get dental implants. That is typically not the case. There are few patients who cannot receive dental implants. Those patients are typically very ill with poorly controlled disease, active bone diseases or cancer and severely immunocompromised patients. The reason patients are sometimes told that they are not a candidate is a lack of boney support or bone loss. This problem does not have to be permanent. With the new advances in bone graft procedures and technology various types of bone grafting can be done to augment the previously lost bone. These are often difficult procedures that may take more than one surgery to achieve our goals but there are options available to improve the quality and quantity of available bone for implant placement. The question that becomes more accurate for patients is, “are you willing to go through these procedures?” and “are you willing to wait the amount of time necessary to achieve success with implants?”
The seriousness and invasiveness of these procedures is very case specific. Depending on whether the implants are needed in the upper jaw or lower jaw, front or back teeth may make a huge difference in the technique chosen and recovery time. It is important to discuss your treatment options with your general dentist or one of the oral surgeons here at Pottstown Oral and Maxillofacial Surgery to create a clear picture of your needs as a patient and the options for your specific case. During your consultation you will get a clear picture of your surgical needs, the recovery process and the financial implications which will allow you to make an informed decision about your dental implant options.
Whether it is an accident or surgery, cuts or lacerations to the facial regions can be a difficult thing to manage for doctors and patient’s alike. As oral and maxillofacial surgeons, all of the doctors in our practice are trained in the cosmetic repair of lacerations and treatment of all varieties of facial trauma. We also do surgical procedures which require us to make incisions on or around the face. The main goal of the treatment of cuts and lacerations to any part of the body is the control of bleeding and closure of the wound. The cosmetic outcome is a secondary concern to the treatment of the actual injury. The techniques we use during the repair are designed to minimize the appearance of scars but are not guaranteed to hide all marks related to the injury. We cannot make the injury not happen but we can help make it look less noticeable.
Several things can be done at home to help the skin heal will and minimize scarring after the sutures are placed. The main thing is to keep the area clean, which means cleaning the area with soap and water at least once per day. The use of antibiotic ointment during this initial healing time also helps minimize the appearance of scars. The use of petroleum based antibiotic ointment helps to keep the inflammation to a minimum and prevents scabs from forming which allows the area to heal more rapidly and fully. The area does not require coverage with a bandage but if you choose to cover it you should remember to change the bandage twice a day. Depending on the area the sutures should be removed in 5-10 days. Once the sutures are removed several OTC products can help soften the skin and improve the healing time. These “scar reducing” creams and oils have been shown to decrease scar appearance and improve redness more quickly but the long term appearance (2+ years) after the injury is typically unaffected. It is very important to protect the newly repaired skin from sun exposure as the area will be hypersensitive to sunburn for the first few months. Sunblock or sunscreen or coverage is important during the first few weeks after sutures are removed to prevent prolonged discoloration and scarring.
If, despite the appropriate repair of the injured tissue, a significant cosmetic deformity remains after allowing full healing for 4-6 months, additional options for improvement of the scar are possible. Laser scar revision is usually the least invasive way to surgically improve the appearance of scars. This involves using a laser to resurface the skin in the area of the scar to improve the appearance. This mostly helps with discoloration and raised scars. Another surgical option is a procedure called dermabrasion. This procedure removes the surface layer of the scar tissue and surrounding skin allowing it to heal at the same level and is therefore used mainly for raised scars. Finally, a scar revision procedure can be performed which excises the scar tissue and repairs the skin defect. This procedure can be done using many techniques which allow for reorientation and improvement of the overall appearance but does require placement of additional sutures and is more invasive than the other procedures. If you have questions or concerns about a scar or previously repaired laceration a consultation with one of our doctors at Pottstown Oral and Maxillofacial surgery may give you additional information and insight on your options to improve the problem.
Bone grafting is a generic term meant to refer to a group of procedures that are utilized to add additional bone to an area where bone is either absent or deficient to correct a defect in the existing bone structure. There are many types of bone graft materials and many different methods of bone grafting. There have been entire textbooks written to describe these techniques and the materials commonly used so to try and explain all there is to know about bone grafting would be too great a task to tackle here. We will however attempt to answer some basic questions regarding the most common materials and techniques used in our practice.
What bone graft materials are available?
There are four basic types of bone used in bone grafting. Autogenous bone is bone taken from the same person and can be harvested from several different areas depending on the amount needed and the procedure being performed. Allograft bone is bone taken from the same species (human cadaver bone). This material is processed by the manufacturer to prevent transmission of disease or rejection of the material and is generally easy to use for small defects. Xenograft bone is bone taken from a different species. The processing of this material is very similar to cadaver bone and can also be used in small defect. Alloplastic graft material is synthetic chemicals or materials utilized to fill the boney defect. These materials vary widely in their composition and the amount of time necessary for the human body to process them.
What kinds of bone grafting techniques are available?
There are many techniques that can be used to replace or restore lost or missing bone. Block grafting utilizes a solid piece of bone and an attachment system of screws or tacks to secure it into position to fill a defect. It is most often used to increase both the height and width of a severely deficient area. The benefit of block grafting is that it is difficult for the body to resorb or dissolve the solid bone rapidly which allows it to be more stable in areas that will be under significant tension. Particulate grafting uses small particles of bone graft material to provide additional bone into an area of deficit. Particulate grafting is generally used in areas that requires minimal to moderate amounts of bone or in cases where a hollow defect is present. The main benefit of this material is the decreased healing time. The most common type of particulate grafting is socket preservation grafting where a tooth is removed and particulate graft material is used to fill the residual socket to prevent collapse in preparation for or during placement of a dental implant. Sinus lift bone grafts involve the placement of bone graft material into the maxillary sinus to vertically increase the amount of bone present. This is most common in the posterior maxilla (upper molar and premolar areas) where the sinus tends to invade the areas around the teeth. Other techniques which are less frequently used include distraction osteogenesis, ridge split bone grafting, and ridge split grafting.
Is bone grafting medically necessary?
Bone grafting of the upper and lower jaw is typically only necessary for the placement of dental implants. There are ways to avoid bone grafting in order to replace teeth such as crown and bridgework, zygomatic implants, short implants and nerve lateralization. None of these procedure themselves are without significant drawback including the damage to existing teeth, numbness, higher failure rates and permanent numbness. In most cases the risks of the more involved procedures will outweigh the issues involved with the bone graft placement option. To determine if bone grafting is required a consultation with one of our specialists will be required to fully evaluate the options. The utilization of bone grafting techniques is common in dentistry and our practice and has provided our patients and the general public with options that were not available in the past.
One of the significant problems that the healthcare industry faces is access to care. Access to care has many aspects but primarily involves the ability of a patient to get an appointment for treatment with a doctor. Everyone has had the experience of calling a doctor’s office and being told that the earliest appointment available isn’t for months. At a surgical office the matter is compounded by the two types of appointments, the consultation appointment where the surgery is first discussed and the actual surgical appointment. Depending on the level of difficulty of the procedure and the patient’s medical history occasionally those appointments can be one and the same. The time of year and the surgical schedule will vary by office and often appointments may be available but are not convenient to a patient’s own schedule.
We at Pottstown Oral Surgery pride ourselves on our patient care and the ability to take care of not only routine issues but patient emergencies. One thing to keep in mind is that we see thousands of patients every month, all of whom expect their treatment to be done in a timely fashion. A huge bottleneck exists where these thousands of patients need to be seen by our four doctors. The fact that appointments are available often within a two to three week period is a testimony to our desire to provide our patients with quality care and timely service. The common misconception is that if the appointment time or day of the week that a patient requests is not available for a month or two that “I can’t get in to see them” when the real statement is “They can’t see me when I want to be seen”. Certain days of the week and times of year like Fridays and Holidays will tend to fill all available open appointments very rapidly.
Patient safety also plays a role in the timeliness of care. Prior to a patient’s arrival at our office we cannot fully assess medical problems or the difficulty of the surgery to be performed. Patients with significant medical problems often require management of their medical conditions through alteration of medications or consultation with their treating physician. Although this may slow the overall process it is a very important step in ensuring the safety of the patient for all procedures. Although patients may think, “it’s only a tooth”, we take our responsibility for your safety very seriously and will treat you accordingly. You would never think of going to the heart surgeon’s office and demanding to have surgery before it was safe, all we ask a similar courtesy. Our main concern is your overall health and safety.
Another rate limiting factor in obtaining appointments is the insurance process. Certain procedures and insurance companies require authorization prior to a procedure being performed. Please keep in mind that this is an issue between the patient and their chosen insurance provider and not with our ability to see or treat you as soon as possible. The alternative always exists for you to be financially responsible for your treatment and process the insurance on your own. Following the insurance parameters to minimize your out of pocket expenses is a choice that you as the patient will make. We understand that this can be very frustrating for patients and we do everything in our power to minimize any and all delays and be available for our patients.
Virtually every dentist out there will go to any length possible to try and repair or “save” a bad tooth. Certain situations however may arise where a tooth cannot be repaired and must be extracted. In other cases the degree of difficulty of the procedures necessary to repair a broken tooth may not lead to a high likelihood of success. Although these procedures can be done you have to ask yourself whether or not you are willing to go through the time, energy and money of a procedure that may not last for very long.
When a tooth has a large cavity often the general dentist will recommend root canal treatment of that tooth. A root canal goes into the tooth to remove the extensive decay and also to remove the nerve and blood vessel tissues inside to remove the infected material from the tooth without extraction. It is possible that after the root canal is attempted, that the infection persists or that the tooth remains painful requiring extraction or reattempt at root canal treatment. In addition a procedure called an apicoectomy may be recommended to remove additional infected material from above the tooth in the bone. These procedures in general are successful but that success rate tends to decline the more involved the tooth repair becomes. If the initial attempts to salvage the tooth were unsuccessful but had the best chances then each additional procedure that is performed has increasingly less likelihood of being successful. On other occasions the root canal itself is successful but the general dentist cannot complete the repair of the tooth through a large filling or crown due to the proximity of the cavity to the bone and gum tissues. An additional procedure called crown lengthening (which removes surrounding bone from the tooth) can be done but again; the question is, should it be?
Fractured or cracked teeth are also very difficult to manage. First and foremost fractured teeth are very difficult to diagnose. They often do not show up on routine dental x-rays and are diagnosed almost entirely by symptoms. If the fractured area of the tooth stays above the gum line the dentist may be able to repair it with a root canal or crown. If the fracture extends underneath the gum and into the bone area often the tooth cannot be repaired and must be extracted.
Finally, one of the most difficult things to deal with is when a significant problem is visible on an x-ray requiring tooth removal but the patient isn’t experiencing any problems. In those cases most dentists will recommend removal of the tooth prior to any symptoms arising. However, no one knows how long that tooth will remain calm with no symptoms and having it removed
Recently there have been some concerns amongst our patients with regard to the management of pain through medications post-operatively. These concerns fall on both sides of the argument where some people feel they haven’t been given enough pain medication and others don’t want pain medications at all. This is a very tricky subject, not just for our patient’s but for us as physicians. All of the doctors here at Pottstown Oral and Maxillofacial Surgery have faced situations where the management of pain either before or after surgery has been difficult. One of the main reasons that we as a practice are concerned is the high abuse and addiction potential of these medications. The statistics compiled by the National Institute of Drug Abuse are staggering. Over 58 million people over the age of 12 have used prescription drugs non-medically at some point in their lives. The United States in particular comprises only 5% of the world population but consumes over 75% of prescription drugs. In Pennsylvania where our practice is located 4-5% of the population is abusing or has abused prescription drugs.
With these well researched statistics it concerns us as physicians when patients come to the office requesting pain medications. One in twenty of these patients statistically is or could become addicted to the medications we are prescribing. As a surgical office specifically we know our patients can have pain after surgery and we routinely write medications to help people manage their discomfort. It should be said however that when you undergo surgery you should expect to feel some level of discomfort. Pain medications are designed to help with your pain management, they do not improve your body’s ability to heal and they do not remove the underlying cause of the pain. Only time and your body’s healing capacity will improve the situation. You as a patient should also be doing everything in your power to optimize your body’s healing capacity. Smoking and poor oral hygiene after the procedure cause delayed healing that can dramatically impact the pain you are experiencing.
Every case and every patient has a different pain tolerance and we try our best as physicians to determine what medication will be necessary based on the level of difficulty of the procedure and the patient’s history. We know that pain and surgery are difficult things to deal with as patients and it can be frustrating if the pain continues for long periods of time or is more severe than expected. In most but not all circumstances we will give you pain medication to manage your postoperative discomfort. As with all medications it is important to take these as prescribed and not excessively to minimize the abuse potential and side effects. Please know that none of our doctors are actually trying to keep you in discomfort or not be helpful. What we are trying to do is help you without contributing to the level of addiction and prescription narcotic abuse that are a significant concern in our society.
With the advancements in dental technology and treatment methods, patients faced with losing all of their teeth are no longer limited to traditional dentures. One of the main concerns for these patients is that they will have to go without teeth for an extended period of time. Several methods now exist to allow patients to go from having their teeth removed to having a functional, non-removable appliance in a short period of time. Several options for these cases exist and are being done here at Pottstown Oral and Maxillofacial Surgery.
The situation that the patient initially presents with will determine the possibilities. And the initial planning stage for these patients is very important. The first appointments allow for coordination between the surgeon, general dentist and dental laboratory as well as to discuss the various options available. Three main options exist that vary in terms of speed, restoration and price. The three main options are:
- Implant supported overdenture- In this case the patient’s existing teeth are removed and 2-4 implants are placed at the same time. A denture is worn over the healing tissue and implants for several months. After the healing phase is completed the denture is either attached to the implants or a new denture is fabricated with attachments to the implants. These implants are used to prevent the denture from being easily dislodged, improving overall chewing and function and in some cases allows for a smaller, more easily tolerated denture.
- Fixed hybrid prosthesis- In these cases the patient’s existing teeth are removed and 4-6 implants are placed. The option then exists to attach a modified denture directly to the implants on the day of surgery. This is done through the coordinated efforts of the patient’s general dentist and the dental laboratory. The implants totally support the new teeth and are not removable by the patient. The patient is instructed to eat a soft food diet during the healing phase and the area will be monitored by the surgeon and general dentist. Once the healing is completed the teeth do not rest on the gum tissue and are fully functional.
- Traditional fixed bridge- Once again the teeth are removed and implants are placed the same day as above and an attached temporary prosthesis is inserted. Once full healing is completed as in option two a final restoration is fabricated utilizing traditional crown material and attachment system to the implants. The biggest difference here is that the teeth are made of stronger material that is more resistant to wear over the long term function.
Although traditional dentures are still an option, patients are becoming more and more aware of the advancements in dentistry and are achieving a highly satisfying result in a shorter amount of time. If you are interested in discussing any of these options a consultation with Pottstown Oral Surgery will help explain the intricacies of these procedures and help you on your way to a new smile.
Part of the consultation process for any surgical procedure is obtaining informed consent. Informed consent is the process by which the surgeon explains the procedure being done and the risks, benefits and potential complications which can occur from undergoing a procedure. Additionally the consent process implies that with full knowledge of what can occur as a result of the procedure that the patient wishes to proceed with the planned treatment. Most informed consent documents contain many sections including the type of anesthesia to be used, the name of the procedure, the permission to correct any unforeseen complications at the time of surgery and most importantly the potential risks for the procedure itself.
Our most common procedures (third molar removal, tooth extraction, bone grafting and the placement of dental implants) have similar risks. The most concerning of these are related to the anatomy in the areas that the surgery will be performed. In the lower jaw the anatomical concern is for damage to the nerves that run in and around the jaws. These supply the lips, chin, gums, tongue, teeth, cheek and lips. All procedures create inflammation and swelling which can put pressure on these nerves resulting in temporary or permanent numbness to these areas. Typically this numbness or altered sensation will resolve as the area heals over several weeks or months. The nerve tissue that is involved will take much longer to heal than the surrounding bone and gum tissues. The potential for permanent numbness or altered sensation does exist and can be related to several factors including the difficulty of the surgery, the proximity to the nerve, and the patient’s ability to heal.
In the upper jaws the risk of nerve involvement is lower but the back teeth may be close to or in the maxillary sinus. The sinus is an air filled space in the facial bones that allows for normal air circulation. This structure when close to the area of surgery may lead to a post-operative complication known as an oral-antral fistula. This means that the sinus tissue invades the extraction socket area to create a passage from the sinus into the mouth. Many of these will heal on their own over several months. Occasionally however, a fistula may become permanent and require additional surgical procedures to attempt to remove the fistula and close the opening in the gum tissue.
One of the more common complications is the damage to adjacent teeth or dental work. Fillings may become damaged by the movement of teeth during extraction. Crowns may be dislodged or removed. Teeth may become cracked or chipped during extraction. Most of these issues can be resolved with repair of the teeth by the general dentist. Although every effort is made to avoid the involvement of adjacent teeth, damage is sometimes unavoidable. If the damage is significant enough or the tooth that has been damaged is obviously unrepairable the tooth that has been damaged may be removed to prevent the patient from having to return for additional surgery.
It is important for patients, and us as surgeons, to take these risks seriously and fully understand the potential issues that may arise from any and all surgery. Often patients who have complications will say that they didn’t expect this to happen. The truth is that we don’t expect them to happen either. But the potential for complications is the reason that the procedure is discussed in detail at the time of consultation. All questions regarding the possibility of these issues should be asked and addressed before proceeding with planned treatment. All surgery is scary, and luckily complications of any kind are rare. We strive to prevent all unfortunate outcomes or correct problems that may arise. Don’t be afraid to ask questions during the consultation. It is your right as a patient to be fully informed before you agree to have surgery.