The Bridge Between Medicine and Dentistry
How oral and maxillofacial surgery helps make the connection between oral and systemic health
Dentists, physicians and the public at large are all making the connection between oral health and systemic health. But if there is one ADA-recognized dental specialty that embodies that connection, it is oral and maxillofacial surgery. And the buying habits of these practitioners reflect this fact.
Oral and maxillofacial surgery, as defined by the American Association of Oral and Maxillofacial Surgeons (AAOMS), is the specialty that includes the diagnosis and treatment of diseases, injuries and defects involving both the functional and aesthetic aspects of the hard and soft tissues of the oral and maxillofacial region.
An oral and maxillofacial surgeon is a graduate of an accredited dental school who has completed an additional four or more years of training in an accredited, hospital-based oral and maxillofacial surgery residency program.
Many oral and maxillofacial surgeons, in fact, are MDs. What’s more, many dually qualified oral and maxillofacial surgeons are obtaining fellowships with the American College of Surgeons. Some pursue fellowships in head and neck oncology, craniofacial surgery, cosmetic facial surgery or cranio-maxillofacial trauma.
Becoming board-certified in oral and maxillofacial surgery is optional, but "it does indicate a certain level of training and understanding," says Ira Cheifetz, DMD, president of the American Association of Oral and Maxillofacial Surgeons and a private practitioner in Mercerville and Princeton Junction, N.J. There’s another benefit to board certification: Certain hospitals will allow only board-certified members to hold chair or officer positions. Board certification is time-limited. Oral and maxillofacial surgeons must maintain certain levels of continuing education and must be recertified every 10 years.
Broad span of practice
Oral and maxillofacial surgeons are trained in a broad number of treatments and procedures, according to the AAOMS. They include:
- Corrective jaw surgery, or orthognathic surgery, which is designed to correct minor and major skeletal and dental irregularities, including the misalignment of jaws and teeth. In some cases, bone may be added, taken away or reshaped, according to the AAOMS. Surgical plates, screws, wires and rubber bands may be used to hold the jaws in their new positions. Incisions are usually made inside the mouth to reduce visible scarring; however, some cases do require small incisions outside the mouth.
- Dental implants to replace a single tooth, several teeth or a mouthful of teeth.
- Diagnosis and treatment of infections in the maxillofacial region.
- Treatment and repair of injuries to the face, jaws, mouth and teeth caused by trauma. Fractures can involve the lower jaw, upper jaw, palate, cheekbones or eye sockets. The principles for treating facial fractures are the same as those for a broken arm or leg, according to the association. The parts of the bone must be lined up and held in position long enough to permit them time to heal. Complex or extensive fractures may require a combination of wiring and plating.
- Surgical correction of oral and facial deformities caused by differences in skeletal growth between the upper and lower jaws, as well as congenital deformities, such as cleft lip and palate, which occur when all or a portion of the oral-nasal cavity fails to grow together during fetal development.
- Facial cosmetic surgery, to correct physical malformations resulting from aging, disease, injury and birth defects. Examples include cheekbone implants; chin surgery, to increase or reduce the length and projection of the chin; ear surgery, usually to set prominent ears back closer to the head; eyelid surgery, to remove fat and excess skin from the upper and lower eyelids; facelifts, to provide a more youthful appearance by tightening facial skin, muscles and removing excess skin; facial and neck liposuction; forehead/brow lift, to improve brow positioning, minimize frown lines and reduce forehead wrinkles; lip enhancement; and nasal reconstruction, to reduce or increase the size of the nose, change the shape of the tip or the bridge, narrow the span of the nostrils, or change the angle between the nose and upper lip.
In addition, oral and maxillofacial surgeons treat skin that is wrinkled, scarred or otherwise damaged through such procedures as Botox® injections, chemical peels, dermabrasion and laser.
Where the twain meet
The crossover into what is traditionally called "cosmetic surgery" is a natural for oral and maxillofacial surgeons, says Cheifetz. "If we do reconstructive surgery for a facial deformity, sometimes it is for the entire face," he says. For example, while repositioning the jawbone, the oral and maxillofacial surgeon might also treat the nose, so it conforms aesthetically to the rest of the facial work.
At that point, the oral and maxillofacial surgeon may proceed to do some cosmetic work. "These patients might feel, ‘I have a nice facial profile; now I need something done with my wrinkles.’"
In fact, oral and maxillofacial surgeons have been doing cosmetic work, including Botox® injections, for years, says Cheifetz. Part of their training is in maxillofacial trauma, including orbital trauma. "The incisions to treat a fracture of the orbit [eye socket] are the same as those for eyelid surgery," he points out. "So it’s an extension of things we’ve always done."
This thin line between reconstructive and cosmetic surgery has been the source of some headaches for oral and maxillofacial surgeons, particularly when it comes to collecting payment from third-party payers. "If you have a patient who has a developmental or skeletal deformity requiring reconstruction and repositioning of bony segments, the end result will show cosmetic improvement as well, but the true purpose of [the procedure] is to help the patient speak better or eat better," says Cheifetz.
Unfortunately for practitioners, insurers may choose to consider the work "cosmetic," and hence, ineligible for coverage.
This issue has been bubbling up for some time. In June 2009, the AAOMS issued a statement applauding Senator Mary Landrieu (D-La.) for introducing legislation that would require insurers to cover reconstructive surgeries for children with congenital deformities, including craniofacial anomalies.
Oral and maxillofacial surgeons donate thousands of hours each year performing corrective surgery on such children, points out the association. Indeed, adds Cheifetz, he and his colleagues donate services to financially compromised patients through such efforts as the Donated Dental Services program of the National Foundation of Dentistry for the Handicapped.
However, thousands of children currently covered under health insurance plans are not able to receive corrective surgery because insurers deem the procedures "cosmetic" and deny the claims, according to AAOMS. "While craniofacial anomalies may affect appearance, they often impede a child’s ability to chew food, speak normally and perform other quality of life functions," said the association in a statement following the introduction of Landrieu’s bill. "This legislation will put an end to the practice that has misclassified thousands of legitimate healthcare claims and will ultimately provide children the coverage for the surgical procedures they need to grow and thrive."
Where is it practiced?
Given the wide variety of procedures in which oral and maxillofacial surgeons are trained, it stands to reason that they practice their craft in a number of settings. More complicated procedures, particularly those associated with trauma, are performed in the hospital. In fact, the American College of Surgeons requires that all Level 1 trauma centers – those that treat the most serious and complex facial trauma patients – have oral and maxillofacial surgeons on call at all times.
But because of the sophistication of today’s technology, most oral and maxillofacial procedures are performed in the office setting. "Our procedures have become more refined, and anesthetic techniques are more amenable to the outpatient setting," says Cheifetz. "Our instruments have become smaller, particularly endoscopic instrumentation. And there are some things we can do in the office – due to changes in radiology, such as cone beam technology – that can help us localize pathology and identify areas that need to be treated. In the past, patients might have had to go to the hospital for extensive CT scan procedures.
Some [temporomandibular joint disease] procedures may also be performed in the office, whereas in the past, they were always done in the hospital, continues Cheifetz. "And most cosmetic procedures are now done in the office."
Oral and maxillofacial surgeons can do these procedures in the office because, as residents, they rotate through the anesthesia department for a minimum of four months. Throughout their four years of residency, they are involved in significant outpatient anesthesia training, says Cheifetz. According to the American Association of Oral and Maxillofacial Surgeons, the training includes local anesthesia, nitrous oxide, intravenous moderate and deep sedation, and general anesthesia.
Challenges and opportunities
In addition to the reimbursement challenges mentioned above, oral and maxillofacial surgeons face a number of others, including the effects of the current economic downturn. "The office-based surgery practice is primarily referral-based," points out Cheifetz, with referrals coming from other dental groups or satisfied patients. "But the economic environment affects everyone," he adds. Naturally, some procedures, such as those to treat infections, certain pathologies or trauma incidents, can’t wait. But a good portion of what the oral and maxillofacial surgeon does is elective. "If somebody needs reconstructive surgery or an implant, they might put it off until next year," says Cheifetz.
That said, the outlook for the specialty is bright. "Our greatest opportunity is to get word of the scope of our practice out to the public and appropriate insurance industry and regulatory officials, so we can continue to provide these services to our patients at cost-savings to them," says Cheifetz.
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