Wagner Oral Surgeon & Dental Implant Specialists

Variations of this question are common and the quick answer is no, but teeth that are injured in this way require dental follow up. The second answer is that if a tooth is knocked completely loose it is a different story. The more unstable or loose in its socket, the poorer the prognosis and greater the need for immediate care. (JADA 2019:150(8):649-655)  Another best answer is that, if this happens to you or a family member, get into your dentist on an urgent basis and have the situation evaluated right away. Time in these cases is critical. The existence of cone beam imaging by most endodontists and oral surgeons can also be helpful in determining the long term prognosis for a tooth that has been significantly injured or displaced. Often it is early stabilization of the tooth and early root canal therapy that will be the determining factor as to whether such a tooth will survive in the long run.

Often, injured teeth are in the cosmetic zone (front teeth) which also increases the importance of early evaluation and treatment. Again, the extent of injury is very important and what you do in the early stages of such an injury can make all of the difference.

This question was presented to the group at a recent meeting that I was at and it really started me thinking. There were some internet references and I looked them up and found that there is quite a bit of material on core values for corporations and such. I was in Taekwondo for many years and I was always impressed by their tenets which are “honesty, integrity, perseverance, self-control, and indominable spirit.” I have always felt that these were great basic values to live by. I think the first time that I ever remember encountering the idea of core values was in the Boy Scout Pledge. The idea of these is helping to form a balanced and disciplined person.

Specific organizations with specific missions may use certain values to reflect their goals such as “greatest service” or “never stop pushing forward.” I am particularly motivated by challenge phrases that challenge me physically or mentally. “Go beyond your apparent abilities” or “attaining greatness” these seem self-serving, but ultimately as we bring our organization to new heights we serve our customers better when we have those types of values. After studying a list of core values from top organizations I have selected mine.

• “Integrity” – This embodies both honesty and an intentional caring for the best interests of others.
• “Excellence/Unequaled service” – Servanthood is a biblical trait that suggests both a sacrificial love for people, but also a humility in placing others interests above your own. Excellence in service to me requires that we do everything in our ability and skillset to have a great outcome.
• “Always Improving” – A commitment to keep growing, continually updating and teaching/learning new concepts that keep us at the forefront of surgical care and anesthesia.
• “Love what you do” – Just what it says. Love and relationships are a lot of work and require active input and communication from all parties. It also requires a commitment to be honest about your position, growth, and results. We are a God-oriented group who are performing surgical procedures at a high level. This is very satisfying and gives one a feeling of reaching the summit each time.
• “Compassion and caring” – People who are having a problem and are undergoing a procedure are vulnerable, uncertain, and often afraid. We have to be empathic and focus on the special needs of each individual – meeting those needs in a gentle, caring way. We respect our patients and care about them as our own.
• “Communication” – Effectively sharing information is a great calling and challenge. We all learn differently and we go to great lengths to explain our procedures and instructions well and also making sure our correspondence between health care providers is beyond complete.
• “We are the best” – It speaks for itself.

You can look up on the internet under “core values” to see various companies and their core values. Have some fun and pick out those values that appeal to you the most. Think about why. Reflect on how you can change your life to better embody those values.

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.

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.

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.

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.

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.

 

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

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.

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.