Pain Management

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.

Why do I need a consultation?

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:

  1. 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.
  2. 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.
  3. 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.
  4. 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.

How Do You Become an Oral and Maxillofacial Surgeon?

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.

What to Expect After Surgery

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.

  1. 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.
  2. 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.
  3. 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.
  4. 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.

What is “TMJ”?

“TMJ” stands for Temporo-Mandibular Joint.  This refers to the joint function of your lower jaw (mandible) and it’s attachment at the skull (temporal process).  Must people and some professionals will use the term “TMJ” when referring to problems or symptoms associated with the jaw.  There is no universally agreed upon term for people who suffer jaw problems.  Temporomandibular Joint Disorder (TMD or TMJ Disorder) is commonly used at our practice.  But what does that all really mean?

TMD is actually a title heading for three distinct problem areas.  The first is skeletal or anatomic problems.  This could be related to misalignment of the bones of the jaw due to tumors or overgrowth in certain areas of the jaw, malocclusion or misalignment of the teeth, or skeletal degeneration as is common with arthritic problems.  Anatomic problems can be skeletal or soft tissue based.  The most common soft tissue abnormality is the misalignment or displacement of the cartilaginous “disc” of the joint.  The small area of cartilage is typically situated between the bones of the skull and the bones of the lower jaw to allow for smooth function during movements like chewing, talking and opening wide.  The cartilage being out of position can lead to trauma of the tissue which results in a decrease in range of motion and sometimes pain.

The second distinct problem associated with the TMD title is musculoskeletal disorders of the jaw.  Examples of this type of problem would be muscle spasm or strain, parafunctional habits such as grinding your teeth or clenching, and myofacial pain disorder.  This category is primarily inflammatory in nature and can usually be managed non-surgically.  However, often the underlying cause of this subset of problems may be related to an underlying anatomic issue causing the muscles to be overworked leading to strain.  Most sufferers of TMD will display signs of symptoms that can be a combination of these first two categories.

The third and final problem group that is associated with the TMD title is nerve or sensory problems.  These are very difficult to diagnose by nature but can involve problems such as migraine or other varieties of headaches, atypical facial pain syndromes, neuralgia, or certain tics of the facial region.  These diagnoses are typically made via exclusion.  This means that we try and be sure that one of the other, more likely, causes of pain is not the issue prior to diagnosing a particular nerve disorder.  These are usually handled by referral to a neurologist or facial pain specialist as the treatment and pain management for these conditions is often difficult.  At Pottstown Oral and Maxillofacial we are proud to offer a wide variety of surgical and nonsurgical treatments for TMD sufferers.  Accurate diagnosis of the condition is the first step in finding the right treatment and a consultation with one of our Board Certified Oral and Maxillofacial Surgeons is a good first step.