Wagner Oral Surgeon & Dental Implant Specialists
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.
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.
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
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
Should I take a dose of ibuprofen prior to my wisdom tooth treatment? There have been many studies through the years showing that taking an NSAID, such as ibuprofen, prior to extraction of wisdom teeth reduces post-treatment pain and swelling. (J Oral Maxillofac Surg 77:1990-1997, 2019). I believe this is true for most dental procedures performed under local anesthesia, and I would advise that therapeutic measure.
In our practice, nearly all of our third molar (wisdom tooth) extraction cases are performed under IV anesthesia (the patient is asleep for the treatment) and, as part of that treatment, we often use an intravenous steroid, which is a more potent drug, to reduce inflammation, swelling, and pain. Patients receiving IV anesthesia are asked to fast (no food or liquids) for six to eight hours prior to treatment, so they would not take in a medication like this. I do feel that a preemptive dose the night before treatment is fine, but I do not feel that it makes a difference in outcomes. In fact, over the years we have tried a number of different pretreatment and intraoperative regimens such as oral rinses, IV NSAIDs, and oral steroids. My results with these are anecdotal, but have been consistent with what has been shown in the literature. These do not make significant difference. Truth-be-told: I do prescribe additional oral steroid, mouth rinses, and/or prescription NSAIDs, for certain specific cases where I feel that the extent of surgery warrants, but for the routine case I do not feel they make any difference.
The final point that has been shown over and over is that the skill of the operator, reduced surgical time, careful techniques, early age of the patient, minimal access, and proper debridement and cleaning of the surgical site are the big factors that give better outcomes when removing third molar teeth.
I (Dr. Wagner) have been removing impacted wisdom teeth for over 30 years. I regularly have to treat very difficult cases, including cases where there is a significant risk to the neurovascular bundle in the jaw (inferior alveolar nerve), jaw cysts (odontogenic cysts), infections, and complicated/difficult extractions. I am an expert in this treatment and have treated thousands of patients, and I rarely have complications. Having said that, I have had complications including injury to the nerve in the jaw, but our complication rate is well below what is reported in the literature as average. We use proper imaging (I recommend cone beam imaging when there are advanced risks to the adjacent structures), we have and practice high surgical skills, and we are careful and gentle in our treatment technique (we genuinely care about our patients’ wellbeing and success with treatment).
I must interject here that the point of using other methods for removal of third molars only becomes an issue when there is inappropriate delay in removal of the teeth. Get them evaluated early (14-15 years old) and remove them early (typically about age 15), before root formation. All of these other risk concerns are generally avoided with that practice.
There are a number of techniques that have been put forward to aid in the treatment of difficult lower third molar (wisdom tooth) extractions. (J Oral Maxillofac Surg 79:1422.e1-1422.e8, 2021) These techniques include coronectomy (which I have blogged on before — and I am generally against) and orthodontic extrusion of third-molar teeth (which I feel is a reasonable treatment, but both expensive and uncomfortable). The cited article references the orthodontic eruption model. This technique historically was used to upright unusually angled impacted second- and third-molar teeth that we wished to save. In this present application, the idea is to use this technique to bring an impacted third-molar tooth into a more favorable position for its removal by first forcibly erupting it to a point where the roots are no longer in proximity to the sensory nerve in the lower jaw.
This technique requires a surgical procedure to attach a tether, such as an orthodontic wire or chain, to the impacted tooth. You must uncover and access the tooth surgically, bond (glue) or screw an attachment to the tooth and extend that attachment to the mouth, where orthodontic traction can be applied to the tooth to change its position. There are quite a few variables including surgical risks to the adjacent teeth and tissues, infection, and risks that the impacted molar will actually be caused to become ankylosed. In spite of these risks, I feel this technique is reasonable and effective for an individual who can afford the treatment time, general risks, and expense, and I do feel this treatment can reduce the risk of nerve injury.
Now having said all of that, I still feel that for me personally — I would trust my experienced, careful oral and maxillofacial surgeon, who has proper imaging and technique, to just remove the tooth surgically and comfortably under IV anesthesia.
Another way to phrase the question would be, “Does the presence of diabetes cause problems with dental implant care?” The quick answer to the question is “no”. (JADA 2021:152(3):189-201). Over the years, we have looked at the presence of diseases and the effect of these diseases on dental implant care. This can be looked at from a number of different angles. I will address two of them here — that is the effect of the development of diabetes on existing dental implants, and the impact of the presence of diabetes on dental implants being placed. For this discussion, we will assume the affected patient in both cases is being followed medically and that the diabetes is under control medically, either through medications or other interventions.
First, the effect of the development of diabetes. Once an implant has integrated properly in the bone, it is almost “difficult” to cause problems. The key is proper care and treatment at the time of placement, with allowance for adequate time for integration before loading the implant. I have seen properly placed implants survive significant disease as well as significant medical insults, such as chemotherapy and even radiation therapy.
The second is the effect of the presence of diabetes on the placement of dental implants. Again, with proper care and placement, you should expect a high rate of success. One difference, in my hands, is that patients with disease states such as diabetes, are much less likely to be treated with immediate-therapy protocols such as immediate implant placement. I will discuss and advise my patients about this, and my general advice is for patients who may have “immune-compromised states” to first get the bone “right” — that means first get a nice, well-healed bone and soft tissue site — and then place the dental implant. This type of care reduces the variables with healing and will give the highest success rate.
The cone beam scan is by far the better of the two if you are just basing the question off which gives you more information (J Oral Maxillofac Surg 77:1968, 2019). The panoramic is a two-dimensional x-ray picture of the jaw structure, and the cone beam imaging is a three-dimensional reconstruction of multiple scans, and the computer can create multiple planes of view of the same area, giving us much more information and 3-D “views” of a given area of the jaws and teeth.
The cone beam scan (CBS) uses a higher dose of radiation, and the equipment is much more expensive, so the cost per scan is typically more. The skill of the practitioner should also be taken into account. A cone beam scan read by a head and neck radiologist versus an oral and maxillofacial surgeon versus a general practitioner may well yield different levels of information.
At the time of his writing, the CBS has not yet been recognized as the standard of care for evaluation of impacted third-molar teeth (wisdom teeth). In my practice, I will generally insist on a CBS if there are significant questions about the relationships of the adjacent vital structures, such as the neurovascular bundles to the impacted third-molar teeth, or if there are lesions associated where we would benefit from quantification of the lesional extent. This process usually involves a discussion and explanation and a reasonable decision process with the patient and/or their guardians or their advocates.
The cone beam imaging gives us a much better visualization, pretreatment, which helps to make better surgical decisions. This is especially true if there is associated pathology and/or proximity to vital structures.
As a trained and educated scientist, I have always approached literature, especially scientific literature, with skepticism. What I have observed in the COVID-19 pandemic is a proof of something I have felt as I have read our scientific literature and attended many courses and symposia through the years — that is: There is a considerable amount of bad information, and in many cases purposefully promulgated false and/or misleading information, put out by people who have taken the roles of “leaders” in our medical and surgical professions.
Much of this is understandable but not excusable — that is: Much of it is just plain greed. A good example is the false manufacturing of “evidence” or support information for a surgical procedure or medication with a financial goal or benefit for the individual making the claim. In many other cases it is just plain arrogance that gets in the way of good science. An example is where data is manipulated or misinterpreted by an author to support their hypothesis. We see this often if we read medical and surgical literature critically. This type of critique should be the job of the editors.
As the end users of this type of information, and because of this, I continue to approach scientific information with appropriate skepticism. One certain tool is to find leaders, teachers, mentors, collaborators, and innovators who have proved themselves to be trustworthy, and seeking them out to discuss and evaluate the information and new ideas as they come along. I have been fortunate to find a number of these groups, and I continue to bring my experience and ideas to these groups as well as seeking them out for solid evidence-based information. Most of us are just striving to be the best practitioners who provide excellence in care for our patients. Unfortunately, in the COVID era everyone must sift through the information and “facts” that are given and look for consistencies and truths. When you find the truth, follow it.
Dr. Richard Wagner
Mar 24th, 2022
Posted in Blog | Comments Off on Has the COVID-19 Pandemic had an Effect on the Oral and Maxillofacial Surgery Literature?
First, I will give you a good reason not to get it — that is if your faith in God is based on a theology that vaccinations are in some way evil or represent a sin against God. After that, as a scientist and as an individual with considerable education and knowledge (not an immunologist) in immunology and oral disease states, I feel that the possible benefits of the vaccines so outweigh the risks that it becomes quite silly to not get this vaccine. (JADA 2021:152(8):596-603)
It is of significance that the vaccines have been given to tens of millions of people worldwide, with a safety profile well above that of other vaccines and well below the risk/complication rate for many medicines that we think nothing about taking, such as antibiotics. Consult with your doctor and make an informed decision.
Please note, to paint you a picture of me, that I come from a strong medical/surgical background — but on a philosophical background, I am a skeptic, I am a conservative-thinker, and I have a strong Christian faith — I love and genuinely care about the success and wellbeing of all people.
COVID-19 is a dangerous topic to blog about because it is so polarizing and people have such strong opinions. The key is to respect everyone’s opinion, and I encourage everyone to respect others’ rights to make their own medical decisions. In the end, that seems to be what has been borne out as true and correct as it relates to this pandemic.
Dr. Richard Wagner
Mar 24th, 2022
Posted in Blog | Comments Off on Give Me a Good Reason to get the COVID-19 Vaccination!