Wagner Oral Surgeon & Dental Implant Specialists

I read with interest this article on the use of injectable Hyaluronic Acid to help with areas where the gums might be deficient around the teeth. (J Oral Maxillofac Surg 77:2467-2474, 2019). Oral surgeons have been using injectables for facial rejuvenative treatments ever since these products came out. They work great and result in a more youthful appearance and even help with certain types of injuries and deformities such as scars.

Using these same principles on gums seems very logical and this article supports that. I suppose the main problem is cost and the likely need to regularly replenish the areas. Typically with facial rejuvenation this has to be done every 6 months to a year depending on the defect. Because of the regenerative capacity of oral keratinized mucosa (your tooth supporting gums), it will be interesting to see if these treatments can actively result in change in the actual tissues. I would guess that, as this develops as a technology, the manufacturers will simply add some type of fibrin-stimulating matrix to enhance the body’s own tissue growth essentially creating some scar which would not be tolerated on the facial skin, but could result in plumping of the gums which would be desirable.

On its own merit, especially for better cosmetics and health around the teeth, this use of this injectable seems to be a great idea. We will plan to apply it!

This blog entry is based on an article with the title “Standing on the Shoulders of Giants” (J Oral Maxillofac Surg 78: 12-17, 2020). The implication is that those who have gone before us are “giants” and are due a certain amount of awe. I guess there is a great deal of truth in that for me and that I feel very privileged to have been trained and mentored by some great minds and great technical surgeons who cared enough about me to want to impart their knowledge and skills to me. I guess I really do believe in and have great confidence in my skills and knowledge – I might hope that most people who work in areas where they have people’s lives in their hands such as surgeons and pilots for example would feel that way.

Now I am entering into a final area in my professional life where I have a greater opportunity to pass my own knowledge and skills on to a successor, Dr. Paul Pamula. That prospect is actually quite exciting to me. I have always loved teaching and sharing knowledge – and I also feel that I have learned much over time relating to techniques and ideas which fine tune the art and science of what we do.

I have four children who are all successful in their own regard and I can only hope that they feel that I have contributed significantly to their growth as men and women. I hope the same for those for whom I have had the opportunity to mentor in my specialty. I am no “giant,” but I am a good learner and I have always enjoyed sharing. I look forward to this next step of mentoring the next generation of oral and maxillofacial surgeons.

Talk about misinfodemics! (J Oral Maxillofac Surg 77:2466.e1-2466.e7, 2019). Ok, now please do not berate me and bombard me with all kinds of opine-blasts. I understand how sensitive many of you are about your essential oils and the proclaimed medical benefits of these. I do recognize that there are certainly many essential oils, especially aromatics, which have been studied appropriately and have been shown to have therapeutic effects. It is just that the fact that if an individual derives a therapeutic effect from an essential oil (or for that matter snake oil) does not make it true for all people – or even for a few people.

Home remedies are great and the use of home remedies has its place in both the lexicon of medical care and the day-to-day treatment of disease. It is just that we should never confuse the difference between “state of the art – peer reviewed” practices and those practices which are just conjecture and even incorrect or dangerous. I am the first to see the historical truth that as medicine progresses we find that some of the same practices we felt were “true” and “well studied” became archaic and replaced by “new” breakthroughs in medical care.

You are likely reading this blog on the internet which has been one of the greatest advancements in medicine. We all have ready access to the knowledge base on most all problems, diseases, and treatments. Unfortunately, as much information that is out there is disinfodemics and may guide us toward incorrect or even bad decisions.

That gets me back to the article I am blogging about. The article tells about the use of lavender oil inhalation on reducing presurgical anxiety. Now truly, I am sure there is a subset of individuals who may benefit from this. The article refutes this and concludes that it did not have that anxiolytic effect. What mainly disturbed me is that the authors as well as this medical journal found it fit to report on this subject at all. It shows me that we have regressed in the pages of our medical and surgical journals to the evaluation of things that should be taking place in research and development settings.

Dentin hypersensitivity may present as anything from a mild discomfort, ache, or “electrical” sensation, to being overtly painful. It is typically transient and can be initiated by the same types of things as toothache type pain such as temperature variation or irritating foods. Any exposure of the dentin such as wear, abrasion, bone loss, periodontal problems, and tooth brush abrasions (to name a few), can cause this.

I read with interest an article from 2019 in a general dental journal claiming that it was a thorough discussion on dental hypersensitivity (Compendium of Continuing Education in Dentistry Vol 40 Number 10 Pgs. 653-657). I have written on this subject in the past from several different points of view. This article in my opinion represents “fake news in dentistry.” The authors seem to be trying to put forward a scientific article with recommendations and conclusions that seem well supported and logical, but they fall way short in my opinion and frankly do not even address the main point – thus “fake news.”

The story-behind-the-story is that as a science, dentistry is influenced by politics and culture. And where this intersects here is where the politics of fluoride use and fluorination of community water supplies. There is a strong movement here in the United States and frankly around the world to demonize fluoride use. I understand how an ill-informed person might be able to take basic information out there and think that ions such as potassium or fluoride (for example) may be dangerous things. They certainly can be and they are poisonous in larger quantities. The plain truth is that fluoride in appropriate amounts is one of the most thoroughly studied initiatives in the world. The use of fluorination in water and topical fluoride dental treatments to reduce dental disease is well established. Some in the “fringe medicine” or “anti-medicine” press put forward untrue or frankly harmful information trying to guide people and communities away from using fluoride.

As it relates to this article, fluoride application in my experience is the one easiest and best, most effective, and most cost effective ways to decrease dental sensitivity, especially sensitivity due to dentin exposure and gum disease.

I recommend the use of topical gels such as Gel-Kam®. I do not have any relationship with Colgate, but I just happen to use their product. Use it once or twice a month at nighttime after brushing your teeth.  Apply like toothpaste with a toothbrush. Do not rinse and go to bed. If you are just starting treatment, you repeat it for four days straight. Using it too often or too much is not helpful. I expect your sensitivity will go away.

With the use of seatbelt restraints, airbags, and protective equipment such as helmets, we have seen a significant reduction in the number of multiple trauma incidents and facial fractures associated with traumatic brain injury. High speed automobile accidents and multiple trauma incidents such as plane or train crashes often bring in much more complicated cases, especially to our regional trauma centers. (J Oral Maxillofac Surg 65:1693-1699, 2007).

Very often we are considering care with multiple specialties, usually directed by an intensivist or general surgery team. Even with injuries that seem to be confined to the face it is a collaboration with general medical, anesthesia, and surgeon that leads to the best decision process for care.

For the most part, facial injuries can be initially stabilized and definitive treatment can be delayed, even for several weeks to allow for proper stabilization of general medical, cardiopulmonary, and neurological problems as they are prioritized. We can perform excellent repairs and treatments in a proper, sequential manner, in the best interests of a patient’s overall health needs. In many cases the best treatment is methodical and not rushed. Even though it looks grim at the time, I have seen many wonderful and successful outcomes with cooperative, collaborative care.

Complete implant supported teeth (All-On-Four, Teeth In A Day, Immediate Teeth, Implant Prosthetics, etc.) is wonderful treatment that we are able to provide with a high degree of success when it is done correctly. I do have concerns that every dental clinic is offering some variation of this and it is not “easy” treatment to do well. The less bone you have, the poorer the support – the greater the chances of developing problems over time. The best care is to have good bone support for your implants as a starting point.

A proper work up should be driven by the dental needs. We call this “prosthetic driven implant care”. That is; planning the initial treatment with the end in mind. This may sound intuitive, but it is not the “rule” for much of the implant care provided. There are wonderful technologies available to improve the aging jaw. The best options often take time and may take some more complex techniques, but the results can be excellent and long term.

In most cases it is straightforward and we can take advantage of the bone that is present and place implants to support teeth. Bone grafting techniques and orthognathic surgery are techniques that we are experienced in and appropriate recommendations are given where this care is needed.

Reference: J Oral Maxillofac Surg 65:1764-1771, 2007

To an experienced OMS the idea of complexity of surgery for any problem is a relative thought. All surgery is at the same time complex and, if prepared, trained and experienced – all is straightforward. The way we approach any surgical procedure involves planning and carrying out the plan while being prepared to deal with variables and possibilities along the way (J Oral Maxillofac Surg 75:1591-1600, 2017). The term “complex third molar extraction” usually describes a situation or case that falls outside of what we are used to as normal. We enter into any surgical case prepared to face unknowns, but you can never guarantee that all variables can be covered so we prepare with the best methods possible.

The cone beam scanner has been a quantum leap for us in evaluation and preparation for third molar extractions. This is particularly true with the cases where we see greater risks or concerns for adjacent vital structures such as the neurovascular bundle in the lower jaw.

I feel that you should get the scan for any case where the risks are accelerated by unusual positioning or development of the third molar teeth. We offer it to our patients and get the study if they agree. Planning with or without the scan takes into account the risks and concerns, and with careful planning we have a very high success rate with very few complications.

Many women will give a history of developing problems with their teeth and gums during pregnancy. There are certain types of problems that we see that have been studied such as progression of gum disease during pregnancy, but these are not consistent nor universal. There does appear to be a certain genetic predisposition to this but clearly, hormonal changes cause tissue fragility leading to increased risks of viral concerns (such as aphthous sores) and general periodontal inflammation (such as sore, red gums and bacterial infections). This is even noted during menses for certain individuals.

The article that I am reviewing (J Oral Maxillofac Surg 65:1739-1745, 2007) showed that there were increased periodontal problems around wisdom teeth during pregnancy. There are a combination of factors here. Wisdom teeth by themselves, especially if there is a continuity defect at the site (an opening or gap along the gum line on the adjacent tooth to the third molar area) often have an inflammatory reaction taking place. This is a normal way that teeth erupt into the mouth if there is space. The sack around the impacted tooth undergoes a reaction with increased fluid production (expansion of the sack) and then an opening of the sack to the oral cavity allowing the tooth to come through. When there is not enough space as is often the case with third molars, this exists as just an opening or tract into which germs and debris can enter into the site and cause related problems.

Pregnancy appears to enhance this process. It is likely a combination of factors (general health, nutrition, hormonal affects, stress, fragility of the tissues, as well as dental concerns) which lead to the increase in gum problems around these sites.

For me it goes back to basic dental care for wisdom teeth. Get them out at an early age before all of these problems can occur. By the way, I can treat the pregnant patient. It is safer the later in the term of pregnancy and we work with your obstetrician for the best and safest care.

Many of the cells in our bodies contain packets of substances that they release when given a chemical command. A good example is the release of histamines from cells in response to chemical mediators in an allergic reaction. The histamines are released from the affected cells to the surrounding tissues and into the blood stream where they themselves act as mediators or activators of other processes seen in the allergic-type reaction such as red skin, watery eyes, swelling, etc. Many cells in our bodies can be induced to produce other chemicals and hold them in “packages” in the cell where they may be released in specific circumstances when the genetic machinery of the cells (DNA) are induced or stimulated to do so.

This is a process which not only occurs in regular life processes but also occurs in many types of cancer. This is part of what makes some cancers more aggressive. Put simply, cancer can be due to a malfunctioning of the tissue cells causing them to reproduce abnormally. Along with this the cells may be able to produce “packages” of chemicals such as enzymes which tend to dissolve tissue and tissue barriers, allowing the spread of the cancer from one tissue space to another. When the spread goes into the lymphatic system or blood vessel system it more easily passes to other areas of the body. If those new areas are susceptible the cancer can start growing there (metastasis).

As researchers discover and learn more and more about these processes we get closer to finding ways to treat, counter, and even cure diseases such as cancer. Research is the key. We regularly support research activities through our organizations and other donations. Small things, like supporting a cancer run or donating to someone’s care, help to keep the fight going.

Reference: J Oral Maxillofac Surg 65:1725-1733, 2007.

I have found that atypical facial pain in the upper jaw is often related to a bone defect in the sinus wall which has healed with tissue ingrowth. This typically occurs as the result of dental trauma or a surgical defect after tooth extraction or orthognathic surgery, as examples. (J Oral Maxillofac Surg 72:2453.e1-2453.e5, 2014). Patients will have point tenderness to pressure or touch and in some cases overt pain. Organic pain can usually be differentiated from neurologic pain (brain origin-or central origin) by use of diagnostic local anesthetic blocks. Pain caused by local organic factors will typically be relieved for a short time by the local anesthetic blocking.

Historically, I have found satisfactory treatment with local bone grafting or connective tissue grafts after debridement of the areas. Guided bone regeneration (use of membranes) has also been helpful. With the advent of bone grafting techniques with alloplastic grafts such as human bone product plus LPRF/PRGF has seen good success in healing such defects and relieving these types of pain problems. Again, these would not be effective techniques to use for a condition such as trigeminal neuralgia.