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.
Many children these days will at some point during their development are recommended for orthodontic treatment or braces. Most of these patients will be routine cases for any orthodontist to handle. A small percentage of these patients however will be evaluated for a significant malocclusion. Occlusion is the way that your teeth come together. People with significant malocclusion will be either one of two types. Type 2 patients have a significant overbite, having the lower teeth positioned well behind the upper teeth. Type 3 patients have a significant underbite which has the lower teeth positioned forward of the upper teeth. Both of these conditions can be caused by overgrowth or undergrowth of either the upper jaw, lower jaw or both. This condition is referred to as a skeletal malocclusion. If these conditions are caught early by the orthodontist initial attempts to guide the bone growth of the face and jaws with appliances such as braces, headgear, retainers etc., can be attempted. Once the majority of the skeletal growth is completed in the teenage years correction of the misalignment of the jaws may require surgery.
Surgery to reposition the facial bones, teeth and jaws is called orthognathic surgery. This can be a life altering surgery for patients who cannot chew food properly or are concerned about their facial esthetics due to abnormal jaw position. Many types of cosmetic smile and facial profile issues can be aided through orthognathic surgery. Patients that show an excessive amount of gum tissue when smiling often suffer from a condition called vertical maxillary excess which can be surgically corrected. Patients whose lower jaw and chin are pronounced may suffer from mandibular hyperplasia or maxillary hypoplasia which will cause a very flat or concave appearance to the face. Patients with a weak chin may suffer from maxillary hyperplasia, mandibular hypoplasia or geniohypoplasia causing a convex appearance to the facial profile. Finally patients with a significant asymmetry to the facial appearance can suffer from one of several developmental syndromes or conditions that limit the growth of one side of the jaws or may have significant overgrowth of one area of the jaw requiring recontouring or orthognathic surgery to correct.
All of these conditions can be managed through a joint effort between the oral surgeon and the orthodontist. Several months of planning and workup of the conditions, planned procedures, diagnosis are done prior to any surgical intervention. The surgery can be very involved and there is a significant recovery period after the surgery but for those patients that require the surgery the functional and esthetic outcomes are tremendous. If you suspect a problem with you or your child, or if your orthodontist has discussed the possible need for surgery it may be a good idea to discuss your treatment with one of our surgeons here in Pottstown Oral and Maxillofacial Surgery Associates.
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.
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.
Every six months, usually during your dental hygiene appointment, your dentist and hygienist will perform an intraoral examination. They’re not just looking for cavities; they are also looking for any pathology that may have developed in your mouth since your previous visits. They may also be checking to make sure that certain areas that they are monitoring have not gotten larger or have gone away since your last visit. This process is called an Oral Cancer Screening (OCS) and is a vital component in the prevention and early detection of oral cancer. If your dentist sees something unusual, they typically refer you to an oral and maxillofacial surgeon or more rarely an oral pathologist or otolaryngologist.
When you arrive at the oral surgeon’s office, the examination will be repeated. We are looking for anything that your dentist may have missed on their exam and more importantly to identify and diagnose the area of concern. The vast majority of lesions, cysts, tumors and other abnormal findings in the mouth are totally and completely benign (non-cancerous). Most often, however, if we can confirm the presence of something abnormal in the mouth a biopsy is recommended. This does not mean that something bad is going on. It is extremely difficult and sometimes impossible to visually tell the difference between certain variations and similar looking pathologic conditions. The only way to obtain a definitive diagnosis of your problem is to have the tissue examined under a high powered microscope at a pathology lab. Your surgeon is trying to make an accurate diagnosis so that we can accurately treat the condition. Once our suspicions are confirmed or an accurate diagnosis is obtained you will have the diagnosis reviewed at your reevaluation appointment, typically one week later.
As with all the procedures in our office, the biopsy procedure can be performed either with local or general anesthesia. Some larger conditions due to the size or location of the lesion are best removed under sedation or general anesthesia for our patient’s comfort and/or safety. Talk with your surgeon about your treatment options. You may choose to have the area reevaluated and defer the biopsy procedure until a later date. As with everything there are positive and negative aspects of having or not having the biopsy performed. Rarely a biopsy result will be reviewed with some variety of oral cancer. The treatment in these cases all depend on the size of the area, location of the lesion and progression of the disease. By recommending biopsy in most cases we are trying to detect an issue as early as possible to prevent spread or progression of the disease. All of these issues should be discussed with your treating surgeon at the consultation appointment. The goal of the entire team involved in the care of our patients is the detection, prevention and appropriate treatment of all oral pathology.
“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.
Once you and your general dentist have decided that a restoration with a dental implant is the treatment option for you, you are left with an often confusing decision. Questions like “Should I see a specialist?”, “How much does it cost?”, and “Can I be asleep for the procedure?” often come up. The answers are somewhat controversial depending on who is giving the answer. Technically, any dental professional can place dental implants. However, the degree to which the practitioner is trained in the placement of implants varies greatly among dentists, periodontists, prosthodontists, endodontists and oral and maxillofacial surgeons. One of the key differences amongst all the specialties is the management of complications that inevitably arise from these surgical procedures. An oral and maxillofacial surgeon should be capable of managing any and all complications that could arise.
The question of cost can often be deceiving. Lots of money is spent advertising low prices for dental implants, but that is not always the end of the story. Many practitioners will break down the price of the dental implant procedure, so that while the dental implant itself only costs 800-1000 dollars the additional parts and pieces are charged separately raising the total overall cost for the procedure. There are also different types of dental implants and many different manufacturers that sell cheaper products that a dentist or specialist may choose to use. The use of “top of the line” implant products has an impact on your overall treatment. A similar issue is the reputation and guarantee of the product being placed. If something does go wrong with your implant it is a good idea to know upfront if you will be refunded your money for the implant, or if the replacement of the implant will be done at no cost to you. That is the standard policy here at our office. We are able to offer this policy because of the documented high success rates of our dental implants. Anyone who places dental implants will run into complications from time to time, but it should be reassuring that not only will that complication be managed appropriately but that you will not incur any additional costs. Make sure you get an estimated cost for the planned treatment from your doctors’ office prior to the undertaking of the procedure. All of your possible costs and potential treatment needs should be discussed in full during a consultation appointment.
An oral and maxillofacial surgeon is also capable of providing sedation and anesthesia for you during your procedure. People with anxiety about replacing missing teeth with implants can typically undergo the procedure with deep sedation or general anesthesia. This requires a thorough review of medical history during the consultation appointment but is a very safe and less stressful way to undergo surgical procedures for some patients. Make sure to tell your referring dentist that you would like sedation or anesthesia for your procedure. The placement of implants can and is also easily accomplished with local anesthesia (novocaine) as well if you would prefer. It should be noted that the placement of dental implants and the treatment plans they may be used for also vary greatly. Certain cases require the use of multiple implants, bone grafting procedures, and lengthy recovery periods. Implants are utilized on a case by case basis and there is no one system that works in every situation. A thorough evaluation and discussion of the options for you should be done during the consultation phase. Feel free to contact our office for a consultation appointment if you are interested in dental implants or any other of our surgical services.