The evolution of oral surgery

March 25, 2019

The questions every general dentist must answer about oral surgery.

Specialists in oral and maxillofacial surgery have extra training and expertise that most general practitioners don’t. GPs refer cases to the specialist when they feel they can’t provide the patient with the best care and a specialist is needed. This relationship has worked well for many decades in dentistry.

However, various factors have changed how GPs practice. Some GPs don’t refer as much oral surgery as they once did, preferring to keep it in their operatory - and in their revenue streams. Some GPs are taking on more complicated cases than in the past and exploring new areas of oral surgery, such as complex extractions and implant dentistry.

In some ways, the relationship between the GP and specialist is evolving. As lines continue to blur between some GPs and specialists, we spoke to clinicians to get a clearer picture of how this critical field is changing.

The driving factors for doctors’ decision to refer or not

Economics is an obvious influence on the decision whether to refer a patient to a specialist. Oral healthcare providers (OHCPs) are trying to find the right treatment mix to combat the low reimbursement levels from insurance companies.

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"The industry’s broken, and people are trying to offer more one-stop shopping to keep more in-house to help with the bottom line,” says Tim Bizga, DDS, FAGD, a private practice general dentist in Cleveland.

Mark E. Hyman, DDS, MAGD, an adjunct full professor at the University of North Carolina School of Dentistry and an international lecturer, explains that a generation ago, the traditional private practice had the benefit of dental insurance that was a decent reimbursement, but it hasn’t kept up.

“A thousand dollars in dental insurance in 1970 is still a thousand dollars in 2019, but the costs a dentist has have increased five times,” Dr. Hyman says.

Dr. Bizga agrees, adding that insurance companies should raise the maximum for the patient from $1,500-$2,000 to $6,000-$8,000. Because reimbursements haven’t kept up with the pace of inflation, Dr. Bizga says sometimes OHCPs have to ask patients to choose between treatments they need. 

“Do you want to do the crown or the root canal this year? That’s a tough thing because now you are not treating what’s best for the patient. You are treating what they can afford right now,” Dr. Bizga says.

Jason Goodchild, DMD, director of clinical affairs for Premier Dental Products Company and an associate clinical professor at Creighton University School of Dentistry, says general dentists can either see and treat more patients or they can integrate procedures they might have otherwise referred to increase revenue. For those who opt to incorporate new areas of surgery, Dr. Goodchild encourages them to invest in training.

“I would always caution dentists who want to do implants and want to do more oral surgery to continue with education to become more proficient in those things. It damages everybody, and most specifically the patient, when we don’t upscale ourselves to deliver the best possible care,” Dr. Goodchild says.

Sarah Jebreil, DDS, AAACD, has a private practice in Newport Beach, California. The patient relationship is sometimes the driving factor for her decision whether or not to refer out. When the oral surgery needed is a straightforward extraction or implant case, she likes to keep those in-house because the patients prefer it.

“You come out the hero because you didn’t have to refer the patient out,” Dr. Jebreil says. “They stay in your office. They didn’t have to go somewhere new. It just makes their life so much easier. So, in those instances the patients value it.”

However, Dr. Jebreil says there’s a flip side to that strategy. With complicated oral surgery cases, things don’t always go according to plan, which can be stressful. The stress is compounded because of the sensitivity of the oral cavity and the emotional environment surrounding surgery in general. In those cases, if you refer it out, you get to be the good guy and avoid the association with unpleasantries the specialist was handling.

“So, I see both sides of it,” Dr. Jebreil says. “I like to refer it out because I want to be the good guy all the time.”

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Dr. Jebreil adds that part of the decision to refer or not is the patient relationship you have. People with whom you have an excellent connection could be the place to start if you’re venturing into new areas of treatment.

“You know they already love you,” Dr. Jebreil says. “With new patients, they are still formulating their opinion of you, and you want them to trust you. You want to have that good rapport before you get started because you want them to come back to you for other things besides oral surgery.”

Patient satisfaction is a primary concern for all dentists, says Jennifer Sanders, DMD, a private practice dentist serving families in rural Montana. People don’t like driving to the other side of town to see an OHCP they don’t know. They would rather have their GP do the oral surgery.

In Dr. Sanders’ case, it’s more than a drive to the other side of town. Her practice is just outside of Missoula, Montana. The specialist is often another 20 miles away, so people sometimes won’t go.

“I have patients who live in very rural areas, and they come to see me, but they don’t want to drive into the city,” Dr. Sanders says. “If it’s a choice between the specialist does the root canal or I pull the tooth if they don’t want to go see somebody else, sometimes the tooth ends up getting pulled.”

Edward Kusek, DDS, is a private practice general dentist in Sioux Falls, South Dakota, with 34 years of experience. He keeps most of his oral surgery in-house. Dr. Kusek says it’s about the comfort level for the patient; they know their dentist but not the specialist.

“Patients don’t like getting bounced around,” Dr. Kusek says. “They like to go to one place and have the treatment done. A specialist they might see once, and it adds a lot of stress for the patient.”

Dr. Bizga says he keeps most of his oral surgery cases in-house too. He loves doing it and even considered at one time specializing in it. He took extra hours in oral surgery training and says he never feels more like a doctor than when he’s suturing a patient.

“For me, it’s a passion area. I feel comfortable. I enjoy doing it. I don’t claim to be an oral surgeon; they have a lot of knowledge and experience with pharmacology, sedation and all sorts of the exotic. However, taking out teeth, I feel very comfortable with that,” Dr. Bizga says.

If a doctor is comfortable doing the case, Dr. Bizga thinks he or she should keep it in his or her operatory. However, he advises doctors to consider their case selection, especially as they’re starting out.

“I believe students get a fair amount of training on taking teeth out in dental school, and if it’s something you enjoy doing, there’s a lot of value for your patients in performing in-house simple extractions and procedures that you feel are within your comfort zone,” Dr. Bizga says.

However, not all general dentists want to do more oral surgery. Dr. Kusek believes the opposite to be true. He says because dental schools train general dentists in so many areas, some of the younger dentists don’t get the training they used to in oral surgery.

“There are a select group of students that are always willing to learn and increase their knowledge, but some of the ones that I’ve worked with or talked to about the major surgery I do as a general dentist are scared to do it,” Dr. Kusek says.

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Technology can help general dentists provide specialty care

Dr. Bizga says technology helps general dentists feel more confident about a procedure they’re considering keeping in their operatory because it takes out the guesswork. Investing in technology could mean more straightforward oral surgery cases can stay in your practice.

“You are going to know what you are getting into before you start,” Dr. Bizga explains. “It demystifies. With our advancement in diagnostic tools and having CT scanning available in your office, it simplifies things. It takes the fear out.”

Dr. Hyman says the two game-changers in technology were first the intraoral camera and then the CBCT scan.  Intraoral cameras on the front end help to diagnose and show patients the problem, so they understand why you recommend the treatment and they accept your plan. CBCT dentistry gives the dentist a 3D image.

“With a quality CBCT, you have a three-dimensional image of the tooth, and you can also anticipate and show the patient in advance when a dilacerated root is wrapped around the entire alveolar nerve, or the root tip is way up into the maxillary sinus, and things like that,” Dr. Hyman says.

When it comes to surgery, Dr. Goodchild says that visualization of the landmarks or the anatomy was always an issue. Now, with CBCT technology and 3D imaging, the doctor can detail the anatomy and treatment plan with more information. For implant surgeries, specifically, Dr. Goodchild says CBCT is probably the standard of care.

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“We still use the same instruments for surgery, the same elevator and forceps, and the same scalpel and drill. All that stuff hasn’t changed,” Dr. Goodchild explains. “But imaging has taken us to another level of being able to appreciate the anatomy and plan our surgeries much better.”

Dr. Kusek agrees, adding that with previous imaging technologies dentists sometimes couldn’t tell the tooth was broken unless there was a lot of bone loss in the area to tip them off. With a CBCT, they can see the fracture and determine if it needs to be extracted and an implant placed. 

Dr. Sanders refers her implants because she doesn’t have a CBCT. Although she has training in implants, she’s not placing them until she has that technology.

“I feel like that’s not as good of care if I don’t get that image to place the implant,” Dr. Sanders says.

To enhance visibility, Dr. Kusek also uses lasers for some of his surgical procedures. He thinks his laser technology improves his outcomes in some cases.

“It might take me a little bit longer to use the laser to cut a flap, but then I have better visibility, which makes me get the procedure done a lot quicker and probably even do a better job,” Dr. Kusek says.

Dr. Kusek says lasers can give you the courage to do a procedure you might’ve sent out before because you were afraid. Biopsies, for example, can be daunting because of bleeding. With a laser, Dr. Kusek says the bleeding isn’t a problem, and things often heal faster.

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Successful specialty-level care requires continuing education

Dr. Hyman describes continuing education as “paying your dues.” When he’s lecturing, Dr. Hyman encourages his audiences to join dental societies and to set a goal of doing 100 hours of education per year. He says it makes for a fruitful career. Plus, you meet other dentists who are excited about dentistry. 

“I don’t think it’s appropriate and fair to the general public to do a specialty procedure if you haven’t had extra training,” Dr. Hyman says. “In today’s world, there’s so much exquisite continuing education available. If you’ve committed to becoming an exceptional general dentist, then it makes it a different discussion.”

Dr. Hyman advises the OHCP not to take on the complicated specialty procedure because he or she has open chair time. He asks OHCPs to imagine if it was their loved one in the chair and the doctor was trying something for the first time without sufficient training. Would they still want that doctor to do the procedure?

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“If you are attempting a molar root canal, complicated dental implants, or a full-mouth rehabilitation without proper training, you are cheating the patients, the team and yourself,” he says. “It’s frustrating the entire way around.”

Dr. Hyman says dentistry is “a whole lot of fun” when the doctor and the team are well-trained and on the same page and the patients are highly informed and educated. Patients will accept treatment, pay with appreciation and everybody wins.

“I’m all for professional growth. We all have to learn. We all have a first time for everything. With good CE and trusted mentors, good things happen,” Dr. Hyman says.

Our experts agree that hands-on training has the most benefits over online training. Dr. Hyman says the after-class engagement with the other OHCPs talking about dentistry and their practices was invaluable from the in-person courses he took.

“Online training misses two things: the one-on-one attention from the instructor and the tremendous opportunity to learn from your classmates,” Dr. Hyman says. “I think online education cheats young dentists having the richness of quality education that in-person, hands-on education provides.”

Dr. Sanders says online training is a useful place to get ideas but agrees that it’s not enough on its own. Online training only presents the perfect scenario, she says, and it rarely teaches you what to do if things go wrong. Hands-on training or a good working relationship with a local surgeon who you can shadow is also essential.

“It’s easy to learn the way things should go, the steps to do something. The tough part is knowing what to do if something goes wrong,” Dr. Sanders says. “It’s important to have that hands-on experience and not just watch the perfect online video version.”

Dr. Kusek believes that a mix of didactic learning and hands-on training work best for many continuing education courses.

“Online is good for the didactic part, but you need to have somebody looking over your shoulder and make sure you are doing things correctly,” Dr. Kusek says.

There are numerous ways to get this mix of training. For lasers, the Academy of Laser Dentistry has multiple courses, and some of the laser companies require certification to use them in practice and offer hands-on courses to help dentists learn.  For implants, the American Academy of Implant Dentistry has MaxiCourses® where clinicians can receive didactic training and then have somebody watch them work to ensure they do the procedures correctly.

“It’s extremely important for general dentists to be able to get certifications to show that they are getting to the next level of training,” Dr. Kusek says. “And as far as education, don’t ever stop. You can’t just graduate from dental school and expect your learning is done. Your learning starts when you graduate from dental school.”

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Dr. Goodchild also recommends finding the experts within the area of oral surgery you want to integrate into your practice. Take advantage of the educational opportunities from continuums to symposiums to residency programs.

“There are all kinds of educational opportunities where you can go and you might take one day a month for six months or one weekend a month for six months, or longer educational opportunities in terms of hours that can benefit you and get you ready to start doing these things,” Dr. Goodchild says.

Dr. Goodchild also recommends mentoring through formal and informal venues. Some of the specialties have formal programs where you watch an expert work, and then the expert observes your work to ensure you perform the procedure the way he or she does.

An informal relationship with the specialist also can help you to have a plan for when things go wrong. When Dr. Goodchild wanted to start doing Invisalign in his practice, he worked with an orthodontist with whom he had a great relationship who would step in when he was uncomfortable with the case. He had a similar relationship with an oral surgeon.

“I would cherry-pick the surgeries I wanted to do, and if I felt out of my depth, I would send it to him or go watch him do it or call him to get some pointers,” Dr. Goodchild says. “There’s no downside to that open dialogue between practitioners, all swimming the same direction and seeking the same goal, which is great patient care.”

Dr. Bizga also advises having a preemptive conversation with a specialist to ask if you can call him or her if you run into a problem. He says most surgeons don’t mind having that relationship when there’s an emergency.

“Of course, call the hospital if it’s a medical emergency, but in some tricky cases, when you get stuck, try calling your local surgeon down the road. Those are the kind of situations where having a phone-a-friend is a great thing,” Dr. Bizga says.

Dr. Sanders adds that you can determine if the specialist can take a patient in right away if you have a problem.

“Most of the specialists I work with have been very encouraging for me to take on a few more of the cases on the complicated end of my spectrum but the simpler end of theirs. They know that we have a good relationship. They know I am still going to send them the really interesting stuff and I can take some of the simple stuff off their hands,” Dr. Sanders says.

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Know your limitations

Self-awareness is an essential skill of any medical provider, especially dentists. Dr. Goodchild says self-introspection can help you to identify and appreciate your strengths and weaknesses.

“I can tell you the procedures that I excel in, the things that I can ‘do,’ but they’re not my favorite, and most importantly the procedures I’m not the most comfortable with,” Dr. Goodchild says. “I think every dentist should be able to tell you those things.”

Dr. Hyman was in private practice in North Carolina for 32 years. He says you must have a healthy dose of reality for what you can manage yourself as well as a solid network of specialists.

“You’ve got to be able to have a point where you draw the line and say, ‘This exceeds my talent. I’m going to put a Band-Aid on this and have one of my buddies put the bow on the package,’” Dr. Hyman says. “I was the biggest referral in my hometown to my oral surgeon. So, if I ever stubbed my toe, I could turn to them with confidence and say, ‘I need you to jump in here and bail me out.’”

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Dr. Kusek says that even though surgical skills are learned, some people have better tactile feel with their hands than others. “You need to know your limits on surgery,” Dr. Kusek says.

The decision to refer is yours, but patient care is paramount

\When a general dentist earns his or her DDS or DMD, passes the dental board exam and receives his or her license to practice in the state, he or she can do any procedure he or she is comfortable doing, including oral surgery. In some cases, general dentists are choosing to do quite a bit of it.

Dr. Goodchild says it all comes down to delivering the best possible patient care. Any decision to take on a case or refer it must have the patient’s best interests at heart.

“There’s just no two ways about it in this day and age. The stakes are too high, and you’ve worked too long. It’s too expensive and too many people are depending on you for you to get anything less than excellent patient experience and excellent patient outcomes,” Dr. Goodchild says.

Dr. Hyman believes that just because someone is a general dentist doesn’t mean he or she can’t do an excellent job with an oral surgery case. However, he or she should also be able to deliver the same level of care as a specialist in a similar amount of time and be able to handle post-operative complications, or, in his mind, the dentist shouldn’t do it.

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“The Dale Carnegie organization says there are three magic words: Success leaves clues,” Dr. Hyman says. “What do highly successful men and women in dentistry do? They take a lot of pictures, they take a lot of education, they hire a magnificent team and pay them well, they hire great consultants, and they don’t take themselves quite so seriously. The combination makes for a rich career.”

Specialists don’t get the easy cases; they get all the hard ones. The easy ones stay in the general office.

“There’s a special place for all those providers that spent many more years training for all those bad cases,” Dr. Goodchild says.

Dr. Goodchild says careful case selection is crucial to the general dentist when choosing whether to refer or not. Self-awareness will help doctors know when to refer a difficult case to a specialist who can handle it successfully.

“It’s perfectly reasonable to do specialty care within the generalist’s office, but knowing your strengths and weaknesses and knowing when to punt benefits everybody,” he says.

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