Wagner Oral Surgeon & Dental Implant Specialists

DOES USING A CONE BEAM SCAN BEFORE WISDOM TOOTH EXTRACTION CHANGE THE TREATMENT PLANNING?

This question is put forth in an article in the JAAOMS in 2020. (J Oral Maxillofac Surg 78: 1071-1077, 2020). The process is actually the other way around, at least in our practice. We first diagnose the third molar condition using a panoramic scan which is a lower radiation dose and less costly than a cone beam scan. If appropriate, such as when we discover anatomy as risks that suggest it – we recommend the cone beam scan.

In my practice, the most common need in third molar cases is when the third molars are well formed and have roots that are overlapping or otherwise close to the sensory nerve in the lower jaw (inferior, alveolar nerve) and putting it at risk. The cone beam scan is a wonderful, relatively new, technology. I am able to trace out the nerve bundle and “see” the surgical site virtually before I ever make an incision. This allows me to better avoid problems and lower the surgical risks.

SHOULD WE BONE GRAFT JAW CYSTS AT THE TIME OF REMOVAL?

We have treated extensive jaw cysts and tumors, some that involve an entire segment of the jaw. If you have an otherwise healthy individual without associated pathology (such as jaw fracture) cleaning out the cyst and maintaining the bone architecture as you can along with closing of the tissues gives the best result. The body has an incredible ability to regenerate bone through what we call primary healing. Blood fills a defect. The blood turns into a clot. The clot becomes the architecture for new bone formation. This is not a perfect system and there may be areas that need secondary attention such as grafting, but overall we have good results with this. I have found that platelet concentrates such as PRGF can enhance this process and we often use these. I have also found that the use of bone graft materials do not seem to enhance this process and in some cases end up causing greater concerns. The most common concern would be infection since the graft material can act as foreign body. If your oral surgeon is recommending a bone graft, I would assume that they would have your best interest in mind and I would follow their recommendation.

Again, we have been performing bone graft procedures in the jaw for many years and we have tried just about everything. Based on that experience, I tend to try to keep things simple when dealing with cysts or tumors of the jaw.

CAN SURGICAL MANAGEMENT IMPROVE RESOLUTION OF MEDICATION-RELATED OSTEONECROSIS OF THE JAW AT EARLY STAGES?

We are still seeing patients with medication-related osteonecrosis of the jaw (MRONJ) although it is becoming much less common as the dosage regimens for the use of antiresorptive and antiangiogenic drugs have improved dramatically over the past 20 years. (J Oral Maxillofac Surg 78: 1986-1999, 2020). We do, however still see these patients in our practice with these types of bone problems. Most of our patients who are on these medications are taking them as part of a chemotherapy for neoplastic disease (cancer treatment), but we also still see patients who are on these drugs for osteoporosis (decreased bone density problems). The use of injectable forms of these drugs seem to be the most common cause of the jawbone problems, specifically the “dead bone disease” problem. There are multiple factors that seem to lead to these problems such as poor general health, nutrition, and immune status.

Early treatment of these bone problems with local debridement and flap closure have been very effective. I have only used other adjunctive treatments such as HBO therapy (hyperbaric oxygen) in rare cases. These are difficult cases as there are other problems (comorbidities) that we have to deal with at the same time. Also, it often takes several surgical procedures depending on the condition of the supporting tissues and bone. This additional time often negatively affects the psychological aspects of care. If you have these types of bone problems I would recommend addressing them early, and a team approach to care is the best. We would typically team up with the other treating doctors to work toward the best outcome.

USE OF PRF AND PRGF FOR THIRD MOLAR EXTRACTION SOCKETS

We have been using the PRF, L-PRF, and PRGF technologies now for many years. This technology uses concentrated platelets processed at the time of surgery, as a graft material either alone or in combination with bone graft material (autologous, allograph, and/or xenograft). A recent study looked at outcomes when this is used as a socket treatment at the time of wisdom tooth extractions. (J Oral Maxillofac Surg 75:2497-2506, 2017). The idea is to try to enhance the healing process. In the study they found that it provided a significant reduction in pain, swelling, and incidence of alveolar osteitis (dry socket). They go on to suggest its use for “more complicated” third molar extraction cases.

We in our practice have a lot of experience with this and that we have used this material extensively for grafting procedures, but we have also used it regularly to help with the healing process for bone defects. The results have been great. We have seen greatly enhanced healing, especially noticeable in cases where there is a larger surgical site such as defects left by lesions (such as odontogenic cysts), with large extraction defects, or with bone reconstruction procedures such as osteotomies, to name a few. If we had to look for a downside it would be additional cost of treatment and some added treatment time with processing the platelets.

We will generally offer this and recommend it for larger procedures, but not for routine procedures. This is a little arbitrary, but we do not feel that the improvement of outcomes is significant enough for the smaller procedures to warrant the expense which is typically not covered by third party carriers.

Most procedures we perform, both hard and soft tissue, could benefit from the use of platelet concentrates in their various forms to enhance healing.

ANTIBIOTIC PRESCRIBING PATTERNS. HOW MUCH IS TOO MUCH ANTIBIOTICS?

We routinely prescribe antibiotics following oral surgery procedures such as removal of wisdom teeth or placement of dental implants. (JADA 2017:148(12):878-886). The mouth is a naturally dirty place and it is not possible to “sterilize” it prior to treatment. In fact, it is common that the structures that we are treating are infected such as abscessed teeth or gum disease. Our patient population is by in large intolerant of complicating factors such as infections that can be avoided.

The studied infection rates without antibiotics are low, but still too high for patient expectations. Because of this, as I present the alternatives and risks to patients, they will select taking the antibiotics as long as they tolerate them well physically. Anecdotally, when we do not use antibiotics due to allergy or personal patient preference, we see a higher rate than I might expect. You might suggest that it is our technique or contamination, but believe me – we are psycho in our approach to this. The fact remains that the mouth is a dirty place with a lot of naturally occurring germs. And these are naturally contaminating our surgical sites.

Because of the concerns with resistance and over prescribing, we continue to fine tune our therapies and techniques to look for ways to reduce antibiotic prescribing. But for now we continue to prescribe for most of our procedures.

 

HOW EFFECTIVE ARE PLATELET CONCENTRATES FOR HARD- AND SOFT-TISSUE GRAFTING?

If you have seen my blogs before you have heard of our experience – but I feel it is of very important note and I will comment that we have been performing bone and soft tissue grafting procedures for over 35 years. I have watched the evolution of these procedures and have been on the cutting edge of these procedures. I have been fortunate to have trained under and received continuing education from providers and developers of these techniques through the years. We have been using platelet concentrates, plasma rich fibrin (PRF), PRGF and LPRF as well as synthetic bone promoters such as BMP ever since their inception. These have been quantum leaps for bone grafting and bone regeneration techniques. (Compendium Vol 42, #5: 212-227, May 2021). In my hands, the best of these is PRGF (plasm rich in growth factors). It promotes and speeds bone and soft tissue regeneration and specifically increases the acceptance and “take” of a graft. The science and techniques are not perfect, but they work well consistently.

A point of caution, many people advertise the use of these techniques, but few are actually using the proper protocols and materials.

 

Richard M. Wagner DDS

CAN MICROSURGICAL REPAIR OF INFERIOR ALVEOLAR NERVE INJURIES IMPROVE SENSORY FUNCTION AND RELIEF OF PAIN?  

The nerve bundle that runs through the mandible provides sensory perception (feeling) to the lower lip and chin, the teeth and gums, and there is a branch that goes to the side of the tongue. The nerve enters the bone on the inside surface at the back of the jaw and then runs forward from there through the bone and branches to those areas. The roots of the teeth, especially the roots of the third molar teeth (wisdom teeth) in the adult often approximate or overlap the nerve bundle putting it at risk in various types of dental treatments such as extractions and root canal therapy. (J Oral Maxillofac Surg 79:1434-1446, 2021). Fortunately, this is a rare occurrence with specialists, but it can occur and I have had it happen. Nerve injury, and the need for repair, is much more common after trauma such as jaw fractures.

When it does occur, the typical problem is decreased sensory (partial or complete loss of feeling in a spot, region, or area). In rare instances, there can be pain along with this which is more likely to prompt us to consider attempting a procedure to decompress or repair the nerve. This type of microsurgical repair is so rare, that there really are no “specialists” to perform this – but our training in this and our experience with the structures and anatomy, along with similarity to other procedures, makes this a treatment that a board certified OMFS with experience in orthognathics and fracture treatment should be able to provide. If you are near a regional center where advanced training may exist, a referral may be made.

These are low-yield procedures and so frankly it is not a desirable surgical treatment to provide. “Low-yield” means that the results are rarely excellent. The cited article indicates that the procedure to effect a repair or decompression of the nerve resulted in some improvement in pain sensation, but little improvement in the return of feeling.

In the few patients that I have treated, surgical findings were typically not significant – that means that we usually did not see a significant injury or bone problem. When we did, and when corrected – we saw great improvement in symptoms. This may seem obvious, but there are also cases where you do not see issues surgically, but the patients show improvement after the procedure. I do feel that our bodies have a significant ability to heal themselves. Sometimes it is useful to help that along through decompression.

Is IV anesthesia needed and appropriate for my oral surgery treatment?

Sometimes we are questioned about the need for IV Anesthesia for treatment.  The typical concerns are for the appropriateness of care, risks of treatment, and cost of treatment.  This most often comes up when there is an urgent care need.  The patient is of course under some stress in that they have to see another doctor and they share these concerns.  We have a lot of experience in helping them in this process so that their experience is the best experience.

We work hard to schedule urgent care and emergency care patients in right away and take care of them along with our regularly scheduled patients.  We slot them in, many times in places in our schedule where “there aren’t really places”.  We do that because we want to serve you and serve you expediently.  To manage your care effectively we cannot in many circumstances manage a difficult extraction, on an anxious patient, with local anesthesia.

We have years of experience with this.  Also many cases with good intentions turn out to be more difficult than expected. Please let us do our job effectively and expediently.  That means allowing us to have you prepared for the possible need for anesthesia for the treatment. If I feel it can be done under local, we have the time in our schedule, and you wish that; we will do it. But if in my judgment the procedure warrants, I’m going to provide the care appropriately with intravenous anesthesia. This is what we are trained to do for proper, comfortable, quick and safe treatment.

This serves all of us.  We are able to perform the treatment expediently. You get treatment in a comfortable environment quickly and without pain. Patients are typically very happy to have received proper care comfortably.  This discussion did not even touch on the fact that most patients, who come here for care, when given the options choose to be sedated for care.

I hope that this discussion helps with the understanding of how we as oral surgeons practice. We want to serve you and your needs. We want to do it with excellence and with proper care and comfort.

HOW SAFE IS OUTPATIENT SEDATION ADMINISTERED BY ORAL AND MAXILLOFACIAL SURGEONS?

The typical techniques used by Oral and Maxillofacial Surgeons (OMFS’s) have evolved over my years in practice, but the overall safety has remained the same. It is very safe. (J Oral Maxillofac Surg 79: 990-999, 2021). Anesthesia administered by OMFS’s has one of the highest safety records in medicine. There is a very good reason for this. Not only are OMFS’s highly trained in anesthesia, but along with state and national standards and regulations, we are also self-regulated by our association who performs regular updates, continuing education, and in-office on-site evaluation. This is a good reason to have a surgeon who is board certified and a member of the AAOMS performing your oral surgery procedures. Remember, there are many “dental surgeons” out there performing the same procedures. Make sure your surgeon is properly credentialed.

Lastly, ask questions. Make sure your surgeon uses a “titrated dose technique.” Make sure they have proper resuscitation equipment with drugs for anesthesia emergencies. Ask if they are ACLS certified.

The truth is that any of us can have an anesthetic emergency at any time. The key is to be properly trained, equipped, and aware. Prevention is the key.

 

Richard M. Wagner DDS

SHOULD ORAL DEXAMETHASONE BE TAKEN PRIOR TO MANDIBULAR THIRD MOLAR SURGERIES?

In my practice, we anesthetize almost all of our third molar surgery (wisdom tooth surgery) patients and we also give a steroid – typically IV dexamethasone – to those patients when indicated. The use of oral dexamethasone for these patients would not be indicated as a premedication as we want the patient to be fasting (NPO) prior to surgery. (J Oral Maxillofac Surg 79: 981-988, 2021).

I agree with the authors of the indicated article that the use of an oral steroid as a premedication would be useful in reducing postoperative pain and swelling. We also see improved results with preoperative usage of anti-inflammatory drugs such as NSAIDS.

The bottom line is my preference is to have you most comfortable during your third molar surgery, so let me give you intravenous anesthesia and as part of that anesthesia I will give you an intravenous steroid if indicated for a better outcome.

 

Richard M. Wagner DDS