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.
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.
When making appointments at our practice whether it is for extraction of wisdom teeth, dental implants, TMJ or tooth extractions and other dentoalveolar procedures the front office staff is almost always told/asked “I don’t need a consultation I just need the procedure done.” In the back of my mind I always wonder if the same patient would feel the same if they were having a leg amputated or open heart surgery. To say, “it’s no big deal”, or “it’s just a tooth”, shows a lack of understanding of how an individual’s medical history and the procedure to be done work together. The answer that is typically received with an aggravated sigh is that the timing of the procedure will be determined by the doctor at the time of the procedure. Because this conversation is inherent in our business we know that most people would like their procedure done in a timely fashion if not the same day and we make every effort to accommodate our patient’s wishes. There are, however, many times when we have to have patients come back for their procedure. The following is a list of reasons why we may have to delay dental surgery for another day:
- Anesthesia- this is a very broad category. If the patient had ANYTHING to eat or drink that day surgery would need to be delayed. That’s the most common cause of delay. In addition however, sedation or general anesthesia requires 3-4 devoted staff members and the doctor to safely monitor and recover from the procedure. The schedule that day may limit the number of available personnel and make performing the procedure impossible.
- Difficult procedures- Third molar surgery, bone grafting, TMJ procedures, multiple tooth extractions and many other procedures may not be possible in the allotted time. The time necessary for any particular surgery cannot accurately be determined until the doctor reviews the x-rays and does an examination. I think most patients would agree it would be better to have the surgeon’s undivided attention during any procedure that requires more than just a few minutes.
- Medical problems- some patients have medical issues that interfere with the normal healing process that may cause a delay. Patient’s on blood thinners, steroid medications, bone medications (bisphosphonate medicines) may need adjustments to the medications prior to surgery to prevent complications. In addition patients with uncontrolled blood pressure, diabetes, COPD or other illness may not be able to undergo elective surgeries of any kind due to unnecessary risk.
- Office schedule/emergencies- as a surgical practice and specifically with our practice where we handle emergencies in the hospital and regional area we encounter situations that may be an absolute emergency. These occasional interferences in our normal practice schedule are unable to be planned for and take away time that would have been used to perform elective unscheduled surgery at our office.
Keep in mind that this list of reasons why surgery may be delayed to another day is brief and nowhere near complete. Many other reasons exist for delaying surgery including allowing patients to reasonably consider surgical complications, financial and insurance issues and other daily nuances of our specialty which may not result in everyone getting what they want on any given day. And although we try to provide a place where your needs are always taken care of we appreciate your understanding when things don’t go as expected.
The other day I was watching television when an advertisement came on for mini implants to aid in fitting lower and upper dentures. This advertisement (as most advertisements do) made it seem like these miniature implants cost less than regular implants and do the same job for less money. But the purpose of this post is to try and give everyone the full picture regarding “mini” implants. To start, I do not have any problem using mini implants for our patients. They are a viable treatment option in some cases. In patients with very narrow jawlines or others who simply cannot afford to do traditional implant therapy, mini implants can help those patients obtain their desired outcome. The key point that needs to be stated is the importance of full disclosure.
You see, what these TV and online advertisements don’t tell you is that mini implants are temporary. If you ask the manufacturing companies of these implants they are required during the sale to inform the dentist of the design limitations of their products. The key design limitation for mini-implants is that they never “fuse” to the jaw bone and become permanent structures. This is a result of the narrow design. Because they have significantly less surface area, the bone structure of your body cannot attach or grow into the surface grooves of the smaller implants. The other design limitation is the amount of force and function that a mini-implant can receive without failing. Therefore, in order to do the same work as a regular implant, more mini-implants need to be placed.
There are some patients out there where the mini-implants have been in the jaw for years and as I mentioned earlier the use of mini-implants is common. My biggest problem is with the patients who were never told or didn’t understand that these implants can come out or fail at a significant rate. It is not uncommon for patients with previously placed mini-implants to come to our office for replacement of mini-implants that have been lost or “came out” attached to the denture. It is important to have a full and honest discussion with the treating dental professional about the expectations for dental implant performance and your full treatment options.
Visit our Dental Implants page to learn more about implants.
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.
As an oral and maxillofacial surgeon one of the most common issues that our patient’s find frustrating is the paperwork and resulting battles that ensue from insurance companies. In our field we deal with both medical and dental insurances which compounds the problem. There are hundreds of insurance companies out there that provide insurance to our patients and within each of those companies there are several possible “plans” in which our patients may be enrolled. Most people think they have a basic understanding of their coverage or have even called to check on their coverage status prior to the consultation appointment. One of the overriding factors in the frustration that patients have with the insurance situation is a customer service issue. When patients call to check their own coverage the questions that they ask are often too general to be answered specifically. Questions like “Do I have coverage for oral surgery?” will get a general “Yes” response from your insurance representative when in reality your specific plan may exclude impacted teeth, or implants or several of the other aspects of our practice. The insurance company, unless asked specifically, will not be able to tell you the likely charges or uncovered portions of the procedures. With the recent healthcare changes many insured families are also now subject to larger deductible amounts that must be paid by the patient, further increasing the level of frustration.
With that in mind we, at our practice, employ an entire staff of people solely to deal with the insurance companies on your behalf. We typically call your insurance and do our best to negotiate the pitfalls of the insurance process to save you the stress. A predetermination is sometimes, but not always, necessary to complete this process which can take an additional 4-6 weeks for your insurance company to review x-rays and documentation to determine your coverage. Please keep in mind that both of these processes are NOT guarantees of payment. Ultimately it is the patient’s responsibility to pay the amount due for any procedure performed. Prior to the procedure our office will in almost all cases provide you with a written estimate of our charges and the expected insurance reimbursement BEFORE the treatment is done. In rare instances the insurance company will tell our staff or you that you have coverage for a procedure and then once the claim is submitted, deny or refuse payment on the charges. We as a practice are here to help you try and minimize your out of pocket expenses if possible. Remember that we are in the same situation as you are in these cases. When the insurance company refuses payment our practice is left in the difficult situation of collecting money from our patients who did not expect to be responsible for these fees or in most cases fighting a lengthy battle with the insurance company to receive payment.
The bottom line when it comes to insurance companies, as with any business, is that they are in the business of making money. Your premium that you pay is a mathematically formulated fee to ensure that the insurance company is taking in more money than it will ever pay out. And despite our efforts on your behalf one of the ways that insurance companies hold onto that money is by denying claims. Here at Pottstown Oral and Maxillofacial Surgery our primary concern is providing our patients with the best possible care regardless of insurance coverage. It is, and will always continue to be, the patient’s decision on whether or not to undergo any procedure and it is ultimately the patient’s responsibility for the financial charges of that procedure.