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Oral Surgery: Should I Extract That Tooth? by Jay B. Reznick, DMD, MD

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by Jay B. Reznick, DMD, MD

Should I extract this tooth? This is the thought that frequently goes through the minds of many general dentists when a patient of theirs is in pain with a non-restorable tooth. In the old days, most general dentists were so busy doing crown and bridge, bleaching, veneers and cosmetic dentistry, that doing anything that caused bleeding was not on their clinical radar. But things have changed in the last few years. A major economic downturn affected dentists throughout the country. Those same dentists began looking for ways to maintain the cash fl ow of their practices by expanding their services to include procedures and treatments that have traditionally been done mostly by specialists.

These included orthodontics, endodontic therapy, periodontal procedures, surgical extractions and dental implants. Advances in dental technology and materials helped facilitate these changes by making these procedures simpler and more predictable. Now that the economy seems to be improving slightly, many practitioners are continuing to use their new skills and equipment to boost the profitability of their practices.

The oral surgeon
The typical oral surgeon spent four years of his or her life after dental school learning surgery from senior surgical residents and faculty. The first two years are spent becoming proficient at dentoalveolar surgery and anesthesia. The second two years focus on medical management, advanced surgical techniques and exposure to various medical and surgical specialties. One thus graduates very experienced at every-day office oral surgery before they are allowed to go into private practice. The other thing the surgical resident learns, in addition to the surgical skills, is that which I can simply call surgical judgment. In a nutshell, that is being able to make a surgical diagnosis, know the treatment options, decide on the best treatment option for that particular patient and plan for that option.

The surgical resident is also taught to mentally walk through each procedure, knowing what the steps are, what instruments and materials will be needed, and more importantly, how to avoid trouble and how to get out of trouble if it happens. Having a plan A, plan B, and plan C is crucial, no matter how simple the procedure. The surgical resident is also taught when not to do surgery, and when it is better to refer the patient to a colleague with greater expertise. The welfare and safety of the patient always comes first.

These concepts are not generally taught in the course of undergraduate dental education. So, unfortunately, when faced with a patient who needs specialty treatment, some dentists look at the financial benefits of the case to their practice, look at the patient, and say to themselves "I think I can do that," even when the procedure is beyond their training and experience.

I have devoted a significant portion of my time to educating general dentists in the art and science of oral surgery. My approach is to emphasize proper education and training for each procedure before it is attempted on a live patient. This includes teaching general dentists to "think like an oral surgeon" when contemplating a surgical procedure. As I was taught in my residency, always do what is best for the patient and "above all, do no harm."

I am becoming concerned because, in my private practice, I am managing an ever-increasing number of complications from procedures done by dentists (both GP and other specialties) who were not able to successfully complete the intended surgical procedure. Many times, they have had the patient in their dental chair for an hour or more before they finally throw in the towel and seek assistance. The patient usually arrives in my office in pain, anxious, upset and exhausted. If I decide it is appropriate for me to complete the procedure that day, I usually work more slowly than I usually do, so that I do not make it look too easy and further the patient’s frustration at their dentist’s misadventures. I hate being put into this situation, because nobody wins in the end. I am sure that all specialists feel the same way.

Complications
Here are a couple examples from the past few months. A healthy 19-year-old college student went to his family dentist complaining of pain in the right maxilla. In Fig. 1, you see a periapical radiograph of a bony-impacted tooth #1 which his dentist diagnosed as the source of his pain. Since the patient was in town for a few days, and the procedure looked easy, his dentist decided that he should take the tooth out. About 20 minutes into the procedure, the tooth disappeared. When the patient arrived at my office, he was in pain and had difficulty opening his mouth. A cone beam CT scan (Fig. 2) showed the location of the tooth to be near the infratemporal fossa, against the lateral pterygoid plate. The reason this occurred may be due to inadequate exposure and visibility, lack of appropriate instruments, or lack of surgical strategy. The decision was made to wait a couple weeks for the tooth to become encapsulated in fibrous tissue in order to facilitate removal. It was then easily removed under general anesthesia (Fig. 3). The patient had an uneventful recovery and was glad that he was asleep for the second surgery.



A healthy 59-year-old gentleman was referred by his dentist three months after a difficult extraction of tooth #3, because of recurrent sinus infections, with pain and drainage into the mouth from the extraction socket (Fig. 4). The patient stated that the tooth was pushed into the sinus and the dentist felt it was best to leave it alone and just watch it. A CBCT (Fig. 5) showed the displaced root near the fl oor of the right maxillary sinus, as well as a significant oral-antral communication. This required an open sinusotomy to remove the root tip, close the antral floor and build up sufficient bone to close the bony defect and allow replacement of the tooth with a dental implant (Fig. 6). There were a number of issues in this case. Again, did the dentist have the training and experience to remove this tooth successfully? Did he have the proper instruments? Did he recognize the complications and seek appropriate assistance at the appropriate time? Fortunately, I was able to treat this patient to a positive outcome.

So, I would like to discuss this politically touchy subject from my unique perspective as an educator and a specialist, so that the patient’s best interests always come first. In the new economy, how does the general dental practitioner decide which surgical procedures to do in the office and which ones should still be referred to the oral surgeon? The answer to that question will be different for every doctor. It really comes down to what is your level of training and experience in oral surgery, and what is your resulting comfort level. After all, it may be a slow day in the office, it looks easy and your favorite oral surgeon is on vacation. What may sound like a great idea at the moment may quickly progress to something completely regrettable. As a specialist, I want everything I do in my office to be successful, all my patients to have a great experience, and reflect positively on my practice. As a general practitioner, you should have the same goals.

Preparation The first thing I would like you to do is to assess your surgical training and experience. Are you prepared for the procedure you are about to perform? How many times have you done this, or a similar operation? Are you able to mentally walk through the steps, knowing which instruments and supplies you will likely need in order to successfully complete the task? Can you perform the procedure in a reasonable amount of time? A single tooth extraction should take 15 minutes or less. Most patients can tolerate about 30 minutes worth of surgery under local anesthesia. After that, the experience becomes traumatic. If the patient needs four third molars removed and it will take you an hour, is this a good idea? You may be fine after a 60-minute procedure, but what about your patient? What will you do if a root breaks or you encounter sudden bleeding? Are you comfortable handling those common surgical complications? Do you want to handle them? If you answered no, then the patient is better off being referred to the specialist. If the answer is yes, then go ahead and take care of the patient in your office. Always keep in mind that you will be held to the same standard of care as the specialist if things go wrong. Always have a specialist who will back you up, if necessary. If you have a problem, don’t make things worse. Get help.

As I mentioned earlier, you want everything you do in your office to be a practice builder. A happy patient will tell two friends. An unhappy one will tell 10. Just because you have the time in your schedule, you may not want to take on a surgical procedure that you are not prepared to complete in an efficient and atraumatic fashion. Even if you are comfortable and experienced with the procedure, you still need to consider other factors. Does this patient have medical issues that may complicate things? Is the patient very anxious, and would they be better treated under intravenous anesthesia? Many times, the best thing you can do to help build your practice is to refer certain patients to a specialist, who can take great care of them and return them happily back to your practice.

Conclusion If you enjoy doing surgery in your office, or if you are in a practice situation where you are expected to do more surgical procedures, I would recommend learning as much as you can about medical evaluation, patient management and complications, in addition to surgical skills, so that you can provide the highest quality of care to your patients. Teach yourself to mentally visualize every procedure from start to finish so that you can anticipate what instruments and supplies will be needed, and have them ready to go or readily available. Learn to anticipate complications so you can manage them easily or avoid them all together.

Another thing I strongly recommend is the use of surgical loupes and a headlight. Being able to see what you are doing makes surgery much easier. Plan for success on the first attempt. But, most importantly I recommend invoking the "mother-in-law" test. Would you be comfortable doing the proposed procedure on your mother-in-law, your mother, spouse, or any other family member? Would you want another dentist, with your same level of training and experience, doing the same procedure on your loved one, or would you send them to a specialist? I sleep well at night because I think about these things all the time and as a result, enjoy what I do and take great care of the patients who come to see me. I want the same for you.
                                                               
Dr. Reznick is a diplomate of the American Board of Oral and Maxillofacial Surgery. He received his dental degree from Tufts University, and his MD degree from the University of Southern California, and trained in oral and maxillofacial surgery at L.A. County- USC Medical Center. His special clinical interests are in the areas of facial trauma, jaw and oral pathology, dental implantology, sleep-disorders medicine, laser surgery, and jaw deformities. He also has expertise in the integration of digital photography and 3-D imaging in clinical practice. Dr. Reznick is one of the founders of the site OnlineOralSurgery.com, which educates practicing dentists in basic and advanced oral surgery techniques. He is the director of the Southern California Center for Oral and Facial Surgery in Tarzana, California. He can be reached at jreznick@sccofs.com.
           
                        
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