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.
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.
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.
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.
This is probably the most common question asked by our patients during the consultation process and as a result is the first subject for our blog. The answer to this question is not so simple. There are a small percentage of people who will never need their wisdom teeth (or third molars) removed. The underlying question is really; “why should I get my wisdom teeth out NOW?” That is an easier question to answer. The age at which someone will have their wisdom teeth removed varies from very young (12-13 years old) to adulthood. The most common time to have the procedure performed is between the ages of 16 and 20. The range varies so greatly due to the many reasons that someone will require wisdom teeth removal. The wisdom teeth may negatively affect the eruption or movement of other teeth for someone getting or about to get braces (orthodontics). The wisdom teeth attempting to erupt may also cause pain and or swelling of the gum tissue requiring their removal.
If your wisdom teeth are not currently causing issues for you specifically, there are still reasons to have your wisdom teeth electively removed. For years the oral surgery community has advocated for the early removal of wisdom teeth prior to adulthood when possible. Only recently however, have the studies to support this view been performed. The general result of the studies confirmed that the vast majority of people will develop more significant problems with their wisdom teeth in place (periodontal disease, cavities, cysts, etc.) compared to patients who have had their wisdom teeth electively removed. These results were the same for people with impacted wisdom teeth and for those whose wisdom teeth actually had enough room to erupt.
Given these results (that most people will have their wisdom teeth removed at some point in their life), having your wisdom teeth out as a young adult (16-20 years old) is recommended at our office. Statistically you are less likely to develop a significant complication from your wisdom tooth surgery (infection, numbness to lip, chin or tongue, sinus problems, etc.) at a younger age. As you get older the risks for these complications as well as the rate at which your body will recover from the surgery itself gets progressively worse. Also, it may be more convenient as a patient to have the surgery scheduled electively when it fits best into your schedule that to wait for an emergency situation that would be more disruptive to activities our patients are involved in (school, sports, extracurricular activities, etc.).
Discussing these issues and how they relate specifically to you is what occurs during our consultation process. Coming to our office to discuss the procedure does not commit you to undergoing any procedures but it does give you all the information you need to make an informed decision for yourself or your child.