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.
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.
Another confusing topic for patients is the training and background that Oral and Maxillofacial Surgery entails. Prior to starting the residency portion of our education all oral surgery residents will have completed nationally accredited dental school and obtained their doctorate. A very small percentage of new dentists or experienced practitioners will then apply to a residency program in Oral and Maxillofacial Surgery across the country. An Oral and Maxillofacial Surgery residency is a hospital based training program of either four or six years, in the surgery and treatment of pathology of the head and neck region. This includes dentoalveolar surgery (tooth extractions,dental implants, gum surgery, etc.), facial trauma (fractures, lacerations, etc.), orthognathic jaw surgery, Temporomandibular Joint surgery (TMJ), oral pathology (cysts, tumors and cancerous lesions of the jaw,head and neck), facial cosmetic surgery, cleft lip and palate surgery, obstructive sleep apnea surgery, reconstructive surgery, and the administration of general anesthesia. All training programs will have their own strengths and weaknesses in terms of how much exposure the resident has in each of these aspects. It is up the individual physician to determine their own level of comfort and decide which procedures they will perform and which they would refer.
During the four to six years of training the residents will assist in and perform a large number or a wide variety of surgeries under the supervision of an experienced attending. The supervising doctors instruct and examine the residents in the performance of surgery as well as impart their didactic knowledge of anatomy, physiology, pharmacology and physics. Some of the time during the residency program will be spent cross-training with other medical students and hospital residents. Typically this time is broken up over the four year period but includes training in anesthesiology, medicine, general surgery, neurology, plastic surgery and ENT surgery. The final year of the training process is referred to as the “chief” resident year. During this year the focus of the resident is primarily on oral and maxillofacial surgery procedures, aiding in the training and improvement of the less experienced residents, and preparing for the board certification process.
Once the residency program is completed a certificate is awarded allowing the former resident to specialize in the performance of oral and maxillofacial surgery under their dental license. In addition to the certificate many oral surgeons will also attempt to become board certified. This is a separate, independent examination process involving all potential aspects of the oral and maxillofacial surgery specialty as mentioned previously. This exam is a two year process involving a written and oral examination. We are proud at Pottstown Oral and Maxillofacial Surgery Associates that all of our physicians are board certified. Every year as part of the maintenance of both the board certification and dental license our physicians undertake more than the required amount of continuing education. All of our physicians are also certified in Advanced Cardiac Life Support, Pediatric Advanced Life Support and Basic Life Support. This extensive level of training that all of our physicians undergo allow us to provide expert level care across the full scope of our practice.
Many of our patients will get very nervous about the after effects of the upcoming surgery. During the consultation appointment we go over the routine expectations and try to estimate how you will be feeling and what activities you will be able to do afterwards. The vast majority of our patients have little to no unexpected problems after their procedures but there are a few key points that are the most common questions after the surgery.
- Swelling- The level and degree of swelling varies significantly with the procedure type and location of the surgery. For example, getting front teeth removed typically will not cause as much swelling as back teeth, and lower teeth tend to cause more swelling than upper teeth. Two procedures in particular tend to create more swelling in general; wisdom tooth removal and bone grafting procedures. The reason behind this has to do with the location of the wisdom teeth in the corners of the mouth, underneath a major muscle attachment, and the incisions that are necessary during both the bone grafting procedure and wisdom tooth removal surgeries. Typically swelling will increase over the first 48 to 72 hours and will begin to subside slowly over the next 7-10 days. Swelling that does not begin to subside after 5 -7 days is cause for concern.
- Pain- Everyone experiences and tolerates pain at different levels. As with any surgery we expect some level of pain after any oral and maxillofacial surgery. Some more major or difficult procedures are often accompanied by more severe levels of pain. We will typically prescribe narcotic pain medications after your procedure to help minimize your pain. Pain medications cannot fully eliminate the experience of pain. They are designed and used to reduce the amount of pain. All narcotic pain medications come with a variety of negative side effects including: nausea and vomiting, insomnia, hyperactivity, dry mouth, constipation, and numbness/tingling feelings in the extremities. Non-narcotic medications such as Motrin can be substituted for the narcotic pain medications and typically do not have the severe side effects. Patients should also be careful when taking narcotic pain medications as many of them contain Tylenol and taking additional Tylenol containing medications can cause liver damage.
- Bleeding- Almost all of our surgical procedures will cause some degree of minor bleeding. Typically this bleeding is minimal and will subside over the first 24-48 hours. Occasionally even later in the healing process some bleeding may occur but typically stops within 15-30 minutes. The typical treatment for this minor bleeding is to bite down on a roll of gauze. This gauze can be moistened for comfort and is designed to apply direct pressure over the source of bleeding. It is the pressure, not the gauze itself that stops the bleeding. If the bleeding is not severe the gauze is not necessary. Often the constant changing out of the gauze packs will disturb the blood clot that is forming in these areas and will cause continued bleeding. Another similar tactic to stop bleeding involves substituting moistened tea bags for the gauze. The tea contains a chemical that can aid in stopping bleeding. If these simple home solutions do not stop the bleeding over 30-60 minutes it may be necessary to return to the office for the doctor to assess the situation. Occasionally a procedure may be done to stop the bleeding under local anesthesia in emergencies.
- Fever- After anesthesia or dental surgery a low grade fever is common and is typically no cause for alarm. Temperatures greater than 101F after surgery can indicate a possible infection. This is typically treated with antibiotics if it occurs but you may be asked to return to the office to have the surgical area evaluated to determine if infection is present. When your body is recovering from surgery of any kind it often becomes more susceptible to viruses or other illnesses that may cause similar symptoms.
With any surgery there will always be occasional unexpected side effects or outcomes and we understand that questions will arise. Our doctors and staff are available to handle these questions and concerns for our surgical patients every day.
As an oral and maxillofacial surgery practice we are fully trained to offer patients general anesthesia for their surgical procedure in our outpatient office. People often have misconceptions about the kinds of anesthesia that is offered due to the many terms and phrases used to describe outpatient anesthesia procedures. People often use the term “twilight” or “sedated” to describe their expectations or fears. To help clarify what will happen during the surgery I will attempt to give easy to understand definitions.
General anesthesia as defined by the American Society of Anesthesiologists is defined as the level of sedation where a painful stimulus will not elicit a response. In common terms that would mean that the patient will not be able to verbally communicate during the procedure. Many times the misconception is that general anesthesia is not being performed without a breathing tube being inserted. Hospital based general anesthesia often uses this technique due to the longer time of anesthesia and the patient being flat on the operating table. General anesthesia in its true definition does not require a breathing tube. Due to the shorter duration of our procedures we can safely perform this level of anesthesia on healthy patients in our outpatient clinic.
IV sedation or “twilight” anesthesia allows the patient to have a sedative such as valium or other similar medication to ease the anxiety of the procedure. Although the patient may not have a clear memory of the procedure they are awake enough to respond to questions and follow directions during the procedure. This is helpful in some procedures but does often have the patient remember or experience some of what is happening during their procedure. This level of anesthesia also varies in the surgeon or provider’s administration of medications. Some providers will prescribe a sedative medication to be taken prior to coming to the office while others will give these medications through an IV.
Finally, nitrous oxide analgesia or “laughing gas” is an even lighter form of sedation designed to ease the anxiety of the procedure. Patients typically have full memory of the procedure but find it easier to undergo the treatment with the help of the gas. This is inhaled through a mask placed over the nose and can be adjusted to some degree to the patient’s tolerance level. It should be noted that nitrous oxide does not allow us to avoid the administration of local anesthesia. Patients under the “laughing gas” will continue to feel the pressure and manipulation being done throughout the treatment.
All forms of anesthesia are subject to a review of the patient’s medical history. It is sometimes impossible for us to provide the level of anesthesia requested due to significant medical problems. Also, some procedures that require more time or appear to be more difficult are scheduled at the hospital for safety reasons. It is important to discuss these issues or any questions you may have about anesthesia with our staff at the time of your consultation appointment. At Pottstown Oral and Maxillofacial Surgery our doctors are fully trained in the administration of anesthesia and the management of complications, advanced life support techniques for adults and children and CPR. At our office we employ a wide range of skilled assistants, including registered nurses, who in conjunction with our doctors will manage our patients during the entirety of their stay.