Pasqual Oral & Maxillofacial Surgery

Until the advent of local anesthetics, surgery was a very traumatic and painful experience. The very best surgeons were by no means the gentlest; they were the fastest. General “ether” anesthetics helped alleviate pain, but were very dangerous to administer and unpredictable in the dosing. The advent of local anesthetics truly revolutionized in-the-office surgery, particularly in the dental profession. Our understanding of the anatomy of the head and neck and the efficacy of local anesthetic nerve block has enabled dentistry to be routinely and painlessly performed in an office setting. The advent of safe intravenous sedation and deep sedation/general anesthetic techniques have enabled the oral and maxillofacial surgeon to perform complicated oral and facial surgery procedures in the comfort and convenience of the office surgical suite, thus allowing the patient to return home that day. Intravenous anesthetics in use today are rapid in onset, very potent, and rapid in elimination. This assures that the patient is completely relaxed and unaware for the surgical procedures and allows for a rapid recovery and the ability of the patient to be discharged home.

Our knowledge of local anesthetic techniques coupled with our training in intravenous sedation/deep sedation/general anesthetic techniques allows us to perform procedures of a complexity that too often is taken for granted. The removal of impacted wisdom teeth, for example, is usually more difficult than the removal of tonsils, but due to the fact that it is most often performed in an office surgical suite instead of a hospital, it is deemed by patients and oftentimes referring clinicians to not truly be “surgery”. In fact, many procedures performed in the hospital under general anesthetic could be much more easily, economically, and conveniently performed in an office surgical setting if the physician were trained in local anesthetic and intravenous general anesthetic techniques. Due to the general lack of training among physicians in these techniques, procedures such as the placement of ear tubes in children, digital and extremity amputations, and soft tissue facial plastic procedures requires the use of an anesthesiologist and a general anesthetic or block local anesthetic and, therefore, are performed in a hospital setting.

In the everyday practice of dentistry, extractions are performed. While many of these extractions are simple and can be accomplished with minimal manipulation and quite comfortably under a local anesthetic, a surgical extraction requiring the use of a handpiece and adequate visualization are much more easily accomplished under a monitored deep sedation. Such a sedation produces amnesia for the event, enables the patient to be completely relaxed, not only emotionally, but also from a musculoskeletal standpoint, and allows the safe completion of the procedure. By performing procedures under deep sedations, the procedures are almost always shorter, are almost always performed more gently due to improved access and visualization, and produce a much quicker recovery than when the patient is awake during the procedure and involuntarily tensing and tightening cervical and facial muscles. Briefer procedures produce less postoperative swelling and discomfort and a lower incidence of infection.

These considerations might be kept in mind in evaluating a patient for a potential oral surgical procedure. In private practice, I have rarely had a patient say to me after a surgical procedure that they wished they had been awake for it, but I have had a few wish they had been sedated. Certainly, treating a patient in a fashion in which they are completely relaxed, comfortable, and have an uneventful recovery promotes a happier patient for both the surgeon and the referring clinician.

A successful local dentist referred an elderly male, diabetic patient to me recently for treatment of an acute infection associated with an abscessed, lower premolar tooth. He had been seen in this dentist’s office the previous day with a toothache and was given antibiotics, pain medication, and an appointment for extraction. The infection apparently became much worse that evening and the patient called this dentist’s office the next day asking what he should do. The dentist was out of the office that day so their staff referred him to my office for “emergency” treatment. I examined the patient and found him to have a significant submandibular cellulitis associated with an abscessed lower premolar tooth. While we were obtaining a panoramic radiograph, he told me he was beginning to feel very dizzy so I helped him into a treatment room where I reclined him in the dental chair and brought his wife back to sit with him. A few minutes later, his wife came out into the hall calling for help. I rushed into the room and found the patient sweating profusely, pale, and unresponsive. His breathing was very shallow and his pupils were pinpoint in size. I immediately administered oxygen, started an I.V. and connected him to the monitors we use during I.V. sedation. His heart rate was elevated and his blood pressure and oxygen saturation were low. We checked his blood sugar and found this to be acceptable. I asked his wife if she was aware of any drugs that he may have taken and she pulled a bottle containing approximately 6 demerol / phenergan tablets out of her purse. She said she had given him one pill ”just like the bottle said” one hour before the appointment. She went onto say she thought he had taken one at bedtime the night before and another one earlier that morning for pain. It was becoming apparent to me that we were probably dealing with a narcotic overdose. I immediately administered IV narcan to reverse the demerol and his condition began to improve. At that time my office staff had the referring doctor on the phone and we were able to discuss the patient’s condition. This doctor said that their office computer prints their prescriptions and that they intended to give the patient demerol / phenergan for pain control not for presurgical sedation. However, an employee accidentally printed a presurgical sedation prescription – something that they sometimes give to anxious patients before extensive dental procedures. The patient was told to take it for pain, which he did, but his wife read the bottle which had written instructions for him to “take 1, 1 hour prior to appointment” which he also did. The end result was 100 mg of demerol and 50mg phenergan given to an 82 year old patient within a 2 hour time frame, and a narcotic overdose. Fortunately, for everyone involved, the patient did not drive himself to the appointment, had someone with him who knew what medication he had taken, and was at a facility where there were health care providers capable of treating his overdose. He could have easily died or killed someone while driving his car to the appointment! We observed the patient in our office for several hours. Later that afternoon, we removed the tooth and performed an I & D of his abscess. The patient’s infection resolved uneventfully. Fortunately, for the referring doctor, the patient had a good relationship with the practice and he was not litigious.

In conclusion, I would like to point out several recommendations for anyone using oral sedation.

Administer the drug in your office! There is no rational reason to have the patient sedated before they get there.
Don’t give oral sedation to very young, very old or unhealthy patients.
Know how to provide emergency life support and have your office properly equipped. This is best accompanied by taking an advanced cardiac life support course.
Avoid giving multiple doses of sedatives. If multiple doses “kick-in” at the same time, oversedation and overdose can occur.
Never give a patient a prescription for more than one dose of sedative.
Instruct patients to discontinue all other narcotics and sedatives (including alcohol) for at least 12 hours prior to the appointment.
Keep the sedated patient monitored at your office until they are appropriate for discharge.
If you use computer generated prescriptions, check them before you sign them.
Consider becoming I.V. sedation qualified. I.V. drugs are safer since the doses can be titrated to effect and – usually reversed as the as the IV line is already in place.
Never tell a patient that they will be unconscious during the procedure. Oral sedation techniques can only be safe (in my opinion) when the goal is providing anxiety control / conscious sedation.

The process of selecting a direct digital radiography system can be a daunting task. From the sheer number of options to the disparity of cost it can be an intimidating project. This article will focus on the main factors to consider when selecting a system.

Patient comfort is key when using the sensors. The crucial determining factor of comfort is not as much the thickness of the sensor as its actual design. A number of companies have developed sensors that have rounded edges to improve patient comfort, while others employ an octagonal shape. The holders for these sensors also play an important part. Though RINN style holders might be the most popular, there are a number of variations and other systems to choose from.

Any office that is considering digital radiography should also consider the image management software before choosing a sensor. Take a look at the image software for ease of use and functionality, as some of these systems can be tedious and cumbersome to use, especially if the operator has little or no experience. If your office is already using some type of imaging software you will most likely be able to import any existing images into most of the major image software applications. Digital sensors and their respective imaging software systems are generally compatible with most practice management systems, with the use of a link or bridge to tie them together, so patient demographic data need only be entered once.

Of course cost may be the biggest obstacle to taking the plunge. The estimated costs of direct digital radiography can be anywhere from several thousand to tens of thousands of dollars, depending upon the software tools that are included and the number of sensors you need. Also, consider purchasing the vendors extended warranty program, as the cost of replacing the sensors down the road far exceeds the cost of the warranty. Don’t let the cost of these systems intimidate you. The return on investment usually outweighs the initial cost by increasing staff productivity, increasing chair time availability, and reducing chemical and other equipment expenses.

With the growing popularity of digital radiography there has been an explosion in the number of companies offering sensor systems and the number is still growing. Purchasing a system from a large company or a small company is a matter of personal preference, but do be aware that some companies have gone out of business in the past few years and this is one of the risks of buying lesser-known products. The following is an alphabetical list of some of the companies that provide direct digital sensors:

• Dent-X Corporation USA (www.dent-x.com)
• Dentrix Dental Systems, Inc. (www.dentrix.com)
• Dexis LLC (www.dexray.com)
• KaVo Dental/Gendex Imaging (www.gendex.com)
• Kodak Dental Systems (www.kodakdental.com)
• Progeny Dental (www.progenydental.com)
• Schick Technologies (www.schicktech.com)
• Sirona (www.sirona.com)
• Suni Medical Imaging (www.suni.com)

In summary, the major factors to focus on when selecting a direct digital radiography system should be sensor comfort, imaging software ease of use and functionality, the ability to integrate the system with your current practice management solution, the cost of installing the system and the manufacturer standing behind the system. Once these factors have been considered, you should be in a better position to choose the right digital radiography solution for your practice.

Computed tomography (CT), and the three-dimensional images it provides, was developed in 1973. The technology, while primitive, was amazing to the practitioners involved. Those practitioners where at a loss of how to apply CT, and had no idea of the profound effect it would have on the surgical and medical community. It took several years of development and a new segment of the specialty of radiology, but CT has become an integral part of surgical treatment of the patients of today.

Oral and maxillofacial surgeons utilized CT routinely in the management of trauma and pathology, and are accustomed to the technology. In a dental practice, practitioners depend almost entirely on two-dimensional imaging utilizing plain films. The advantages of CT technology has been unrealized in the dental practice.

Cone beam CT (CBCT) was initially used in angiography. The advantages for head and neck imaging were quickly realized. The first CBCT developed specifically for dentistry was the NewTom 9000 in 1998 (Quantitative Radiology, Verona, Italy). Currently, there are several companies with versions of the CBCT scanner.

Medical CT scanners and CBCT scanners have two main differences. CBCT scanners use a low-energy fixed anode tube, similar to the tube used periapical or panoramic radiographs. CBCT scanners also only rotate around the patient once, exposing the patient to a cone-shaped x-ray beam to capture the images. These two differences result in a less-expensive, smaller device that exposes the patient to approximately 20% of the radiation of a typical helical CT. This is equivalent to the radiation from one full-mouth series of x-rays. The radiation dose from a multidetector row helical CT is 458 mSv, versus 1.19 mSv from a typical CBCT.

The different CBCT scanners are largely identical in their technology. The only major difference among CBCT scanner manufacturers is the type of detector used. All manufacturers use either an amorphous silicon flat-panel detector or a combination of an image intensifier and a charge-coupled device camera. Both provide accurate, reliable, high resolution images adequate for dental medicine.

The introduction of new technology in any field raises many questions. You must first identify the practical applications and benefit to the patient when compared to existing technology. In the end, the most important consideration may be the effect on the standard of care. There are several applications for the CBCT that are encountered daily in an oral and maxillofacial surgery practice: implant dentistry, oral and maxillofacial pathology, temporomandibular joint disorders, impacted teeth, orthognathic surgery, and traumatology.

The advantages of CBCT in implant dentistry are obvious. The ability to accurately visualize the alveolus and surrounding structures of the maxilla and mandible is invaluable. While traditional two-dimensional panoramic radiographs produces approximately 25% of magnification, overlap of vital structures, and an inability to provide information about bone volume, CBCT provides the practitioner with a virtual image of the patient. CBCT images measure one-to-one compared to patient anatomy. CBCT allows volumetric and even qualitative evaluation of the patient’s planned implant site preoperatively. Implant surgery can even be performed virtually preoperatively, and produce a computer aided surgical guide. Abutments and prostheses can even be fabricated preoperatively and placed the day of surgery. Utilizing CBCT, it is far less likely to have to change a surgical plan intraoperatively because of anatomy that was not visualizable preoperatively.

CBCT is indicated in maxillofacial pathology. Traditionally, oral and maxillofacial pathology has been visualized with multidetector helical CT, exposing the patient to a large dose of radiation. CBCT produces higher resolution images and delivers a fraction of the dose of radiation. This allows the surgeon to obtain detailed imaging of cysts and tumors without fear of excessive radiation exposure, allowing more specific preoperative surgical planning for grafting, reconstruction, or stereolithographic model fabrication.

CBCT provides detailed evaluation of the TMJ. Magnetic resonance imaging (MRl) is the gold standard for evaluating the intraarticular soft tissnes of the TMJ. Bony evaluation has been by plain film. CBCT allows more accurate evaluation and diagnosis of the TMJ with radiation exposure equal to plane film.

Orthognathic surgery and orthodontic therapy have relied on plain film lateral cephalometry. Since the landmark studies of the mid-1970’s, evaluation of facial growth and development has been based on standard plain film skeletal landmarks. Lateral cephalometric analysis with plain films is inadequate in severe facial assymetries such as hemifacial microsomia, or skeletal occlusal canting. CBCT skeletal and soft tissue imaging makes all of the data available for complete facial analysis. To date, it is unclear how CBCT can be better utilized in orthognathic surgical planning and orthodontic treatment. With further clinical research, CBCT will become the standard in preoperative surgical orthodontic treatment planning.

Surgical retrieval of impacted teeth is fraught with potential complications. CBCT evaluation allows for more thorough identification, evaluation, and treatment planning with the three-dimensional view. CBCT allows better evaluation or impacted teeth and surrounding vital structures, be it nerves, sinus, cortical border, or other teeth. This results in less invasive and more efficient surgery, resulting in a better outcome.

CBCT is a relatively new but highly applicable technology for dentistry and oral and maxillofacial surgery. Patients are treatment planned more accurately, which provides the ability to operate more accurately and efficiently. The greater diagnostic information will also give the capability for more detailed research in treatment of the head and neck. The lower radiation dose makes this technology more appropriate for imaging in the outpatient setting than traditional helical CT. CBCT will become an invaluable tool in head and neck evaluation.

The use of lasers in periodontal practice has become a desirable alternative to traditional scalpel surgery; however, a deficiency in published evidence supporting the efficacy of such treatment exists. A recent review by Cobb, Low, and Coluzzi (2010) presents the current peer-reviewed evidence on the use of the most commonly used dental lasers over the last decade and explores why the use of such lasers in periodontal therapy remains controversial. The results of this review are summarized below.

Cobb, C., Low, S., Coluzzi, D. (2010). Lasers and the Treatment of Chronic Periodontitis. Dent Clin N AM 54 (35-53).

Nd:YAG Laser (1064 nm) – well-designed and adequately powered studies are severely limited with insufficient evidence to support evidence-based decision making when using this laser. Specifically, the derivation of evidence-based conclusions from the published literature is speculative due to weak and confusing evidence. When laser therapies are compared with conventional open-flap procedures, the conclusions consistently reveal no statistical or clinical significant differences between traditional surgery and laser-mediated periodontal surgery. Although proponents of Nd:YAG have promoted the laser as being effective against pigmented bacteria (i.e., Porphyromonas spp, Prevotella spp), common periodontal diseases exhibit a diverse population of non-pigment producing bacteria.

ER:YAG and ER,CR:YSGG Lasers (2940 nm and 2780 nm, respectively) – erbium lasers are effective in removing calculus and reducing PPD. Several studies have demonstrated safe and effective root substance removal without negative thermal effects. A collective average of 11 clinical trials shows equivalent or slightly greater reductions in PPD (2.29 mm vs 1.93 mm), gains in CAL (1.73 vs 1.26 mm), and decreased BOP (47% vs 43%) when compared to control treatments. Interestingly, of the four studies reporting effects of treatment on subgingival microbial levels, none showed a significant difference between treatment groups.

Diode Laser (809-980 nm) – the purported benefits are based on the premise that subgingival curretage is an effective treatment and significant reduction in subgingival microbial populations are predictably achieved. In the five published clinical trials, none measured all four of the usual clinical parameters (reductions in PPD, BOP, subgingival microbes, or gains in CAL), therefore a meta analysis could not be performed by Cobb et al. Specific trends showed greater reductions in PPD and BOP in laser groups with a nearly equivalent gain in CAL. Two studies reported no significant difference between treatment groups. Despite the equivalency between laser-treated sites vs controls, uncontrolled case studies report successful periodontal therapy when using diode and Nd:YAG lasers as adjuncts to SRP. Although diode lasers are effective for soft-tissue applications, offering excellent incision, hemostasis, and coagulation, when combined with the appropriate choice of parameters can result in soft tissue penetration ranging from 0.5 mm to 3 mm.

CO2 Laser (10,600 nm) – carbon dioxide lasers are effective in removing soft tissue and inflamed pockets while achieving good hemostasis. Only two published clinical trials show the effect on PD and the investigators reported no significant differences between treatment groups for reduced PPD and reduction in BOP. CAL gains were statistically significant in favor of only one of the CO2 treatment groups. The primary caution when using CO2 laser relates to the high absorption by hydroxyapatite and water. Therefore, clinicians are well-advised to carefully direct energy beam and use low energy densities to avoid damage to healthy hard tissues.

Photodynamic Therapy (PDT, 635 nm to 690 nm) – uses a combination of visible light and a photosensitizer; however, as with the diode laser, there are a small number of published clinical trials and the collective differences for measurable clinical parameters are not particularly noteworthy. The main premise for using PDT is to reduce subgingival microbes; however, only one of the five published trials measured this parameter and reported no significant difference between PDT and SRP treatments.

One of the most difficult situations for both the practitioner and the patient is when adequate pain control cannot be accomplished during a procedure. This may be very challenging, especially when the patient is experiencing an infection.

In these cases, the patient may present with pain alone or in conjunction with swelling. It is important to understand the pharmacology of the local anesthetics and the physiology of the infection in order to optimize patient care.

Local anesthetics present in two chemical states, a weak base or a unionized form that penetrates tissue and an impermeable cationic state that does not penetrate tissue very well. When the local anesthetic is administered into an infected environment with a low ph, there will be a greater concentration of the cationic form. (1)

The clinical effect will result in delayed onset and decreased intensity of the local anesthetic. Another theory proposed is that in an infected area there are degenerative and inflammatory changes found in the nerve structures. (2)

These findings support the need for administration of nerve blocks, as opposed to local infiltration. This will allow the local anesthetic to be administered away from the infected site.

When administering the local anesthetic as a block in an infected environment, it is imperative to change the needle. Using the same needle will cause seeding of the tissue into deeper tissue planes.

Never inject directly into tissue that is under pressure from the abscess. You must first establish some form of drainage prior to local infiltration. This will be much more comfortable for the patient and you will not tract the infection into deeper tissue planes.

The local anesthetic that has the closest Pka to the tissue Ph will demonstrate the quickest onset time. Mepivacaine falls into this category and is a great anesthetic to use in an infected patient when the lidocaine is not doing the job. (3)

Mepivicane is best administered in plain form, without the vasoconstrictor in order to help overcome the acidity created by the infection.

Using a larger amount of the local anesthetic (but not exceeding the maximum recommended dose) will allow a greater concentration of the unionized form to penetrate the tissue. Other techniques for increasing the volume of local anesthetic to the infected site include periodontal ligament injection and interseptal injection technique.

Most important of all, you must have patience and allow adequate time for the local anesthetic to take effect. This may take up to 10-15 minutes. During this time, it may be helpful to place the patient in an upright position.

Treating the infected patient has many challenges and satisfactory results may not always be achieved, despite the aforementioned techniques.

At this point, there are two final options available. One is to place the patient on antibiotics and have them return another day or you can refer them for treatment under general anesthesia. Communication plays a major role in these situations, and the patient must be prepared for all possible outcomes.

1. Hersh EV, Condouris GA: Local anesthetics: A review of their pharmacology and clinical use. Compend Contin Educ Dent 1987,8:374-382
2. Brown RD: The future of local anesthesia in acute inflammation: Some recent concepts. Br Dent J 151:47, 1981
3. Jastak JT, Yyagieva JA Donaldson D: Local anesthesia of the oral cavity. Philadelphia WB Saundes 1995

We all treat patients who are taking the vitamin K antagonist Warfarin (coumadin). It only takes one bad experience with a patient on Warfarin for a dentist to respect this drug. I often tell the story of a resident colleague of mine who decided to give a patient who was on high levels of Warfarin an inferior alveolar nerve block for pain. The patient bled so much from the needle puncture wound that he required hospital admission and blood transfusion! While such an incident is fortunately rare, the respect with which we treat a patient on Warfarin should be universal.

There has been some discussion in both the medical and dental literature lately which suggest that we no longer need to be as concerned about the bleeding risk of patients on Warfarin. These authors believe that the risk of medical complication such as stroke is much greater than bleeding risk. They also believe that most oral bleeding can easily be controlled with local measures. This may be true in most cases, but I can assure you that the risk of bleeding is very real, not to mention the risk associated with banked blood products. I would like to share with you my personal protocol for managing the patient on Warfarin.

1. Assess the patient to determine the extent of required surgery and bleeding potential.
2. Consult with the Patient’s physician:

• Why are they on Warfarin?
• What are their most recent Prothrombin Time (PT) & International Normalization Rate (INR) values and when were they obtained.
• Can the patient withdraw Warfarin therapy and what is the medical risk to the patient.

1. Obtain the PT and INR values.
2. If the physician agrees to permit withdrawing Warfarin,use these guidelines:

• Warfarin has a half-life of about 36 hours so it takes 48 – 72 hours for PT & INR to return to normal.
• Most simple surgical procedures can be accomplished with a PT of 1.5 times control (18 or under) and INR levels of 2.5. Local measures such as suturing, gelfoam, surgicel,etc. must be accomplished if the PT or INR is above normal.
• The patient can resume Warfarin when bleeding is controlled.
• The patient should return to their physician 1 week after surgery for new PT & INR levels.

Remember, the dentist and the medical doctor must communicate to determine the risk/benefit level for each situation and the patient must also be informed of such risks. The dentist is not qualified to predict the medical risk of withdrawing Warfarin and the medical doctor is not qualified to predict the bleeding risk of the proposed dental procedure. The medical doctor will not be the one managing the bleeding should it be uncontrollable with local measures, so don’t let the medical doctor force you into a situation that makes you uncomfortable.

If the PT & INR are very high and the medical doctor does not consent to withdrawing or decreasing Warfarin to a surgical acceptable level, the patient can be placed in the hospital, the Warfarin stopped, and heparin started. Heparin stops working in about 3 hours so the medical risk is greatly decreased. Unfortunately, most patients will not be happy with this protocol as Medicare will not pay for the hospital expenses for such services and the patient will have to pay the hospital bill “out of pocket.”

Hopefully, this has given you some insight to this complex issue. If you find anything helpful from this article let it be this: Never, under any circumstances, tell a patient to stop Warfarin without consulting with their medical doctor and documenting this in the patient’s chart.

Dental Implants have an overall success rate of about 95% More and more people are getting dental implants to replace missing teeth. They’re a long-term solution that is imbedded in your jawbone, just like your natural teeth. They even go your natural teeth one better, since they can’t develop cavities. Plus, unlike fixed bridges or removable dentures, dental implants will not affect neighboring healthy teeth or lead to bone loss in the jaw. If properly cared for, dental implants can last a lifetime. Dental implant surgery is, of course, surgery, and is best done by a trained surgeon. Your oral and maxillofacial surgeon (OMS) has the specialized education and training in the complexities of the bone, skin, muscles and nerves involved, to ensure you get the best possible results. Implants are made of titanium metal that “fuses” with the jawbone through a process called “osseointegration.” There’s no short cut to get around that process, and it usually takes several months once the implant is put into your jawbone. Osseointegration, however, is why implants never slip or make embarrassing noises like dentures, and why bone loss is usually not a problem. After more than 20 years of service, the vast majority of dental implants first placed by oral and facial surgeons in the United States continue to function at peak performance. More importantly, the recipients of those early dental implants are still satisfied they made the right choice.