- Email: [email protected]
Response to July 2014 Perspectives Article
2099
LETTERS TO THE EDITOR mandibular ramus and posterior body in the mediolateral and superoinferior planes,4 2) protecting the IAN within the pterygomandibular space while making the horizontal osteotomy cut through cortical bone superior to the mandibular foramen on the medial surface of the mandibular ramus, 3) making the vertical osteotomy cut just barely through the lateral cortical bone of the mandibular body in the molar region to avoid an IAN resting just medial to this area, 4) using inferior and superior border spreaders to begin separation of the proximal and distal mandibular segments until the IAN is visualized and then completing the separation of the segments using osteotomes with the IAN under direct vision and retractor protection, 5) removing irregular bone and enlarging the groove for the inferior alveolar canal on the medial surface of the proximal mandibular segment to lower the risk of compression of the IAN when the segments are fixated, 6) placing a bone graft between the superior portion (above the inferior alveolar canal) of the proximal mandibular segment and the tooth-bearing distal segment to lower the risk of compression of the IAN during the application of internal fixation screws, and 7) using monocortical (rather than bicortical) fixation screws when indicated to lessen the chance of trauma to the underlying IAN. An operation as technically demanding as the SSRO requires the surgeon to exercise dexterity and caution no matter what instruments are chosen to perform the procedure. However, the choice of which type of instrument to use in making the cortical bone cuts (high-speed burs, reciprocating saw, piezosurgery instrument) seems of lesser importance in the risk to the IAN during SSRO compared with the surgical precautions listed earlier. ROGER A. MEYER, DDS, MS, MD SHAHROKH C. BAGHERI, DMD, MD Marietta, GA
References 1. Monnazzi MS, Gabrielli MFR, Passeri LA, et al: Inferior alveolar nerve function after sagittal split osteotomy by reciprocating saw of piezosurgery instrument: Prospective double-blinded study. J Oral Maxillofac Surg 72:1168, 2014 2. Bagheri SC, Meyer RA, Ali Khan H, et al: Microsurgical repair of the peripheral trigeminal nerve after mandibular sagittal split ramus osteotomy. J Oral Maxillofac Surg 68:2770, 2010 3. Meyer RA, Bagheri SC: Etiology and prevention of nerve injuries, in Miloro M (ed). Trigeminal Nerve Injuries. Heidelberg, Germany, Springer, 2013. pp 41–43 4. Yoshioka I, Tanaka T, Khanal, et al: Relationship between inferior alveolar nerve position at mandibular second molar in patients with prognathism and possible occurrence of neurosensory disturbance after sagittal split ramus osteotomy. J Oral Maxillofac Surg 68:3022, 2010
http://dx.doi.org/10.1016/j.joms.2014.06.463
RESPONSE TO JULY 2014 PERSPECTIVES ARTICLE To the Editor:—I am writing in regard to the Perspectives article published in the July 2014 issue of the Journal of Oral and Maxillofacial Surgery ( JOMS). I was excited to see the subject, and the data, because this has been a constant concern of mine. I have experienced this trend for
years in my local practice and at the hospitals that I serve. It is indeed an important issue and needs to be addressed by those who represent our profession and carry the burden of shaping our specialty’s delivery of services. However, I was disappointed by the entire ‘‘Implications for Oral-Maxillofacial Surgeons’’ section. First, although this is a ‘‘perspectives’’ article, it seems to me that the same principles of presentation should apply as to any other learned piece. The authors state 2 problems that they would glean from the data, but the problems are opinion and not necessarily supported by the data at all. Second (and the reason for my response), I am so tired of the hand-wringing over the ‘‘cottage industry.’’ Previous articles in the JOMS have referred to ‘‘teeth and titanium’’ oral surgeons. Fundamental to our profession (and to every other profession) is that we treat the conditions that present to us and the needs of our community. There are certainly those among us who have built reputations important enough that patients seek them out for treatment of the ‘‘full scope’’ of oral surgery. This can be achieved in a variety of ways, but marketing seems to be the primary method. And now we are overrun with our general dental colleagues marketing their way into our scope. Most of us, thankfully, can still keep very busy just serving the needs of the community in which we practice, with little need for billboards or TV spots. Third (and most concerning), the conclusion of the article seems to be that the data trend is the fault of oral surgeons abandoning the hospital. I have been on staff at the same hospital since I finished my residency. I have taken calls and, until recently, I never said no to any request for my care. The alarming trend is not that the oral surgeons have left, but that the hospital gives no incentive to the oral surgeon and is only too happy to keep minor dental infections in-house for days and weeks. On a weekly basis I receive calls for inpatient consultations on patients who have been in-house for days and have had extensive workups. Invariably the patient will be found to have a minor dental abscess that could have been treated in my office and followed as an outpatient. More often than not, the answer I get when I look into it is that the patient was seen in the emergency room previously and ‘ failed to follow-up’’ on discharge. After years of attrition, I am now the only oral surgeon on staff at my hospital (and in fact any hospital in my region). I spoke to the hospital administration about my predicament, in that I was the only oral surgeon left and I was taking all the emergency room calls. I suggested that perhaps it was time that they consider a per diem. They were not interested and I was told that I was responsible for the calls. I decided to go to consulting staff. The story goes on, but you get the picture. This cannot be a unique situation. I am aware that hospitals have a mandate to serve the acute-care patients who arrive at their door. Also, I am aware that they receive governmental compensation that they do not share with the surgeon who actual provides the care. Our system is broken and I do what I can to serve my share of the population. I take public aid and sometimes just treat patients without compensation. However, I choose to do this in my office, where I know that I am more efficient (by an order of magnitude). Whatever absurdity exists in our system that allows the ‘‘self-pay’’ (no-pay) patient to be admitted for a week or more for a vestibular abscess (or less) is unfortunate, but far beyond my ability or interest to correct. It is not a system that I will willingly involve myself in. To the extent that the American Association of Oral and Maxillofacial Surgeons and the JOMS want to force us or guilt
2100
LETTERS TO THE EDITOR
us into being a part of this system is the same extent to which many of us will distance ourselves from the association. The data presented are irrefutable, but the conclusion drawn is contrary to my reality.
PAUL WOLF, DDS
http://dx.doi.org/10.1016/j.joms.2014.07.039
In reply—Please note that the opinions expressed in Perspective essays and Letters to the Editor do not necessarily represent the positions or opinions of the American Association of Oral and Maxillofacial Surgeons. The Journal of Oral and Maxillofacial Surgery ( JOMS) does not have official positions. Opinions offered in the JOMS are those of the author(s). JAMES R. HUPP, DMD, MD, JD Editor-in-Chief Journal of Oral and Maxillofacial Surgery
http://dx.doi.org/10.1016/j.joms.2014.07.040
neck region (ie, otolaryngology and head and neck surgery, plastic surgery). These specialties and others in medicine and surgery have seen the same limitations in private practice versus what was taught in residency programs. Thus, we as OMSs are not alone in this quandary. Factors that might affect the nature of a private practice in oral and maxillofacial surgery (and other specialties) include (but are not necessarily limited to) the need to discharge educational debt, lifestyle considerations, and economics of managed care. One hopes that some sort of role-model influence from faculty members can have an impact on where and how a trainee decides to conduct his or her practice after residency, but such considerations are outside the ability of the academic oral and maxillofacial surgery community to totally control. Certainly, the bottom line is that today’s OMS is better prepared and trained to enter private practice than ever before in the history of our specialty. The credit for that goes to our academic oral and maxillofacial surgery community. How each OMS decides to conduct private practice is a matter for only him or her to decide. If the academic OMS continues to do an excellent job, there will be an adequate supply of well-trained surgeons to handle all patients who require treatment to within the scope of oral and maxillofacial surgery practice. This concern, then, will not be a crisis, but more of a ‘‘tempest in a pot of tea.’’
CRISIS OR CHRONIC COMPLAINT? To the Editor:—Dr Abubaker in his recent letter to the Journal bemoans the apparent discrepancy between what is taught in oral and maxillofacial surgery residency programs and what is actually practiced by oral and maxillofacial surgeons (OMSs) in the community.1 Dr Abubaker refers to the current situation in which many OMSs in private practice no longer take emergency department calls or have staff privileges to perform major operations at hospitals, but instead have office-based practices in which the preponderance of their work is limited to dental alveolar surgery. He labels this ‘‘the mismatch crisis’’ and speculates on whether we should ‘‘be proactive and have a preemptive approach now, rather than facing this issue down the line.’’ His concern is understandable; however, this issue has been addressed many times in the past 50 years as our specialty has progressed (as ‘‘oral surgery’’) from treating dentoalveolar pathology and mandibular fractures to the full-scope surgical specialty of oral and maxillofacial surgery that exists today.2 What is addressed as a ‘‘mismatch’’ is actually the reality of the forces of human nature and economics on the behavior of physicians and dentists in our evolving health care system. These forces are beyond the control of academic OMSs. What should the challenge be for academic training programs? The challenge there is to provide the latest and best knowledge, training, and experience in all aspects of head and neck, oral, and maxillofacial pathology, trauma, and disease. This is being done through single- or double-degree programs in which clinical practice, teaching, and research are the foundation blocks.3,4 A basic surgical education for all residents is in some institutions supplemented with post-residency fellowships in special areas that require additional training and experience to achieve additional expertise (eg, head and neck oncology, pediatric craniofacial deformities, cosmetic surgery, microsurgery).5 This is the pattern of training that has been successfully adopted by other surgical specialties that involve surgical care of the head and
ROGER A. MEYER, DDS, MS, MD SHAHROKH C. BAGHERI, DMD, MD Marietta, GA
References 1. Abubaker AO: Oral-maxillofacial surgery residency training— Practice pattern mismatch: Response to the editor (letter). J Oral Maxillofac Surg 72:1037, 2014. 2. Meyer RA: Plus ca change, plus c’est la meme chose (letter). J Oral Maxillofac Surg 65:2389, 2007. 3. Meyer RA, Bagheri SC: Double degree training supported (letter). J Oral Maxillofac Surg 68:1703, 2010. 4. Meyer RA, Bagheri SC: Single degree and dual degree: We are all oral and maxillofacial surgeons (letter). J Oral Maxillofac Surg 68:2926, 2010. 5. Meyer RA, Bagheri SC: Familiarity does not breed competence (letter). J Oral Maxillofac Surg 69:2483, 2011.
http://dx.doi.org/10.1016/j.joms.2014.06.462
RESPONSE TO LETTER TO THE EDITOR This is a response to Drs Meyer and Bagheri’s response letter to my comments published in the June issue of the Journal of Oral and Maxillofacial Surgery.1 Although I agree with some of their comments, I respectfully disagree with some of what they stated. Some of this disagreement may be related to from where the issue is being viewed. From my academic prospective, where I encounter such issues on a regular basis, here is how I see it. First, it is true that what we are witnessing is a phenomenon of our times that is dictated by many forces, and such phenomena also are affecting many other specialties, not just ours. However, I do not accept the premise that we should stand idly by, because such factors and forces can ultimately shape the future of the specialty. Our specialty
LETTERS TO THE EDITOR mandibular ramus and posterior body in the mediolateral and superoinferior planes,4 2) protecting the IAN within the pterygomandibular space while making the horizontal osteotomy cut through cortical bone superior to the mandibular foramen on the medial surface of the mandibular ramus, 3) making the vertical osteotomy cut just barely through the lateral cortical bone of the mandibular body in the molar region to avoid an IAN resting just medial to this area, 4) using inferior and superior border spreaders to begin separation of the proximal and distal mandibular segments until the IAN is visualized and then completing the separation of the segments using osteotomes with the IAN under direct vision and retractor protection, 5) removing irregular bone and enlarging the groove for the inferior alveolar canal on the medial surface of the proximal mandibular segment to lower the risk of compression of the IAN when the segments are fixated, 6) placing a bone graft between the superior portion (above the inferior alveolar canal) of the proximal mandibular segment and the tooth-bearing distal segment to lower the risk of compression of the IAN during the application of internal fixation screws, and 7) using monocortical (rather than bicortical) fixation screws when indicated to lessen the chance of trauma to the underlying IAN. An operation as technically demanding as the SSRO requires the surgeon to exercise dexterity and caution no matter what instruments are chosen to perform the procedure. However, the choice of which type of instrument to use in making the cortical bone cuts (high-speed burs, reciprocating saw, piezosurgery instrument) seems of lesser importance in the risk to the IAN during SSRO compared with the surgical precautions listed earlier. ROGER A. MEYER, DDS, MS, MD SHAHROKH C. BAGHERI, DMD, MD Marietta, GA
References 1. Monnazzi MS, Gabrielli MFR, Passeri LA, et al: Inferior alveolar nerve function after sagittal split osteotomy by reciprocating saw of piezosurgery instrument: Prospective double-blinded study. J Oral Maxillofac Surg 72:1168, 2014 2. Bagheri SC, Meyer RA, Ali Khan H, et al: Microsurgical repair of the peripheral trigeminal nerve after mandibular sagittal split ramus osteotomy. J Oral Maxillofac Surg 68:2770, 2010 3. Meyer RA, Bagheri SC: Etiology and prevention of nerve injuries, in Miloro M (ed). Trigeminal Nerve Injuries. Heidelberg, Germany, Springer, 2013. pp 41–43 4. Yoshioka I, Tanaka T, Khanal, et al: Relationship between inferior alveolar nerve position at mandibular second molar in patients with prognathism and possible occurrence of neurosensory disturbance after sagittal split ramus osteotomy. J Oral Maxillofac Surg 68:3022, 2010
http://dx.doi.org/10.1016/j.joms.2014.06.463
RESPONSE TO JULY 2014 PERSPECTIVES ARTICLE To the Editor:—I am writing in regard to the Perspectives article published in the July 2014 issue of the Journal of Oral and Maxillofacial Surgery ( JOMS). I was excited to see the subject, and the data, because this has been a constant concern of mine. I have experienced this trend for
years in my local practice and at the hospitals that I serve. It is indeed an important issue and needs to be addressed by those who represent our profession and carry the burden of shaping our specialty’s delivery of services. However, I was disappointed by the entire ‘‘Implications for Oral-Maxillofacial Surgeons’’ section. First, although this is a ‘‘perspectives’’ article, it seems to me that the same principles of presentation should apply as to any other learned piece. The authors state 2 problems that they would glean from the data, but the problems are opinion and not necessarily supported by the data at all. Second (and the reason for my response), I am so tired of the hand-wringing over the ‘‘cottage industry.’’ Previous articles in the JOMS have referred to ‘‘teeth and titanium’’ oral surgeons. Fundamental to our profession (and to every other profession) is that we treat the conditions that present to us and the needs of our community. There are certainly those among us who have built reputations important enough that patients seek them out for treatment of the ‘‘full scope’’ of oral surgery. This can be achieved in a variety of ways, but marketing seems to be the primary method. And now we are overrun with our general dental colleagues marketing their way into our scope. Most of us, thankfully, can still keep very busy just serving the needs of the community in which we practice, with little need for billboards or TV spots. Third (and most concerning), the conclusion of the article seems to be that the data trend is the fault of oral surgeons abandoning the hospital. I have been on staff at the same hospital since I finished my residency. I have taken calls and, until recently, I never said no to any request for my care. The alarming trend is not that the oral surgeons have left, but that the hospital gives no incentive to the oral surgeon and is only too happy to keep minor dental infections in-house for days and weeks. On a weekly basis I receive calls for inpatient consultations on patients who have been in-house for days and have had extensive workups. Invariably the patient will be found to have a minor dental abscess that could have been treated in my office and followed as an outpatient. More often than not, the answer I get when I look into it is that the patient was seen in the emergency room previously and ‘ failed to follow-up’’ on discharge. After years of attrition, I am now the only oral surgeon on staff at my hospital (and in fact any hospital in my region). I spoke to the hospital administration about my predicament, in that I was the only oral surgeon left and I was taking all the emergency room calls. I suggested that perhaps it was time that they consider a per diem. They were not interested and I was told that I was responsible for the calls. I decided to go to consulting staff. The story goes on, but you get the picture. This cannot be a unique situation. I am aware that hospitals have a mandate to serve the acute-care patients who arrive at their door. Also, I am aware that they receive governmental compensation that they do not share with the surgeon who actual provides the care. Our system is broken and I do what I can to serve my share of the population. I take public aid and sometimes just treat patients without compensation. However, I choose to do this in my office, where I know that I am more efficient (by an order of magnitude). Whatever absurdity exists in our system that allows the ‘‘self-pay’’ (no-pay) patient to be admitted for a week or more for a vestibular abscess (or less) is unfortunate, but far beyond my ability or interest to correct. It is not a system that I will willingly involve myself in. To the extent that the American Association of Oral and Maxillofacial Surgeons and the JOMS want to force us or guilt
2100
LETTERS TO THE EDITOR
us into being a part of this system is the same extent to which many of us will distance ourselves from the association. The data presented are irrefutable, but the conclusion drawn is contrary to my reality.
PAUL WOLF, DDS
http://dx.doi.org/10.1016/j.joms.2014.07.039
In reply—Please note that the opinions expressed in Perspective essays and Letters to the Editor do not necessarily represent the positions or opinions of the American Association of Oral and Maxillofacial Surgeons. The Journal of Oral and Maxillofacial Surgery ( JOMS) does not have official positions. Opinions offered in the JOMS are those of the author(s). JAMES R. HUPP, DMD, MD, JD Editor-in-Chief Journal of Oral and Maxillofacial Surgery
http://dx.doi.org/10.1016/j.joms.2014.07.040
neck region (ie, otolaryngology and head and neck surgery, plastic surgery). These specialties and others in medicine and surgery have seen the same limitations in private practice versus what was taught in residency programs. Thus, we as OMSs are not alone in this quandary. Factors that might affect the nature of a private practice in oral and maxillofacial surgery (and other specialties) include (but are not necessarily limited to) the need to discharge educational debt, lifestyle considerations, and economics of managed care. One hopes that some sort of role-model influence from faculty members can have an impact on where and how a trainee decides to conduct his or her practice after residency, but such considerations are outside the ability of the academic oral and maxillofacial surgery community to totally control. Certainly, the bottom line is that today’s OMS is better prepared and trained to enter private practice than ever before in the history of our specialty. The credit for that goes to our academic oral and maxillofacial surgery community. How each OMS decides to conduct private practice is a matter for only him or her to decide. If the academic OMS continues to do an excellent job, there will be an adequate supply of well-trained surgeons to handle all patients who require treatment to within the scope of oral and maxillofacial surgery practice. This concern, then, will not be a crisis, but more of a ‘‘tempest in a pot of tea.’’
CRISIS OR CHRONIC COMPLAINT? To the Editor:—Dr Abubaker in his recent letter to the Journal bemoans the apparent discrepancy between what is taught in oral and maxillofacial surgery residency programs and what is actually practiced by oral and maxillofacial surgeons (OMSs) in the community.1 Dr Abubaker refers to the current situation in which many OMSs in private practice no longer take emergency department calls or have staff privileges to perform major operations at hospitals, but instead have office-based practices in which the preponderance of their work is limited to dental alveolar surgery. He labels this ‘‘the mismatch crisis’’ and speculates on whether we should ‘‘be proactive and have a preemptive approach now, rather than facing this issue down the line.’’ His concern is understandable; however, this issue has been addressed many times in the past 50 years as our specialty has progressed (as ‘‘oral surgery’’) from treating dentoalveolar pathology and mandibular fractures to the full-scope surgical specialty of oral and maxillofacial surgery that exists today.2 What is addressed as a ‘‘mismatch’’ is actually the reality of the forces of human nature and economics on the behavior of physicians and dentists in our evolving health care system. These forces are beyond the control of academic OMSs. What should the challenge be for academic training programs? The challenge there is to provide the latest and best knowledge, training, and experience in all aspects of head and neck, oral, and maxillofacial pathology, trauma, and disease. This is being done through single- or double-degree programs in which clinical practice, teaching, and research are the foundation blocks.3,4 A basic surgical education for all residents is in some institutions supplemented with post-residency fellowships in special areas that require additional training and experience to achieve additional expertise (eg, head and neck oncology, pediatric craniofacial deformities, cosmetic surgery, microsurgery).5 This is the pattern of training that has been successfully adopted by other surgical specialties that involve surgical care of the head and
ROGER A. MEYER, DDS, MS, MD SHAHROKH C. BAGHERI, DMD, MD Marietta, GA
References 1. Abubaker AO: Oral-maxillofacial surgery residency training— Practice pattern mismatch: Response to the editor (letter). J Oral Maxillofac Surg 72:1037, 2014. 2. Meyer RA: Plus ca change, plus c’est la meme chose (letter). J Oral Maxillofac Surg 65:2389, 2007. 3. Meyer RA, Bagheri SC: Double degree training supported (letter). J Oral Maxillofac Surg 68:1703, 2010. 4. Meyer RA, Bagheri SC: Single degree and dual degree: We are all oral and maxillofacial surgeons (letter). J Oral Maxillofac Surg 68:2926, 2010. 5. Meyer RA, Bagheri SC: Familiarity does not breed competence (letter). J Oral Maxillofac Surg 69:2483, 2011.
http://dx.doi.org/10.1016/j.joms.2014.06.462
RESPONSE TO LETTER TO THE EDITOR This is a response to Drs Meyer and Bagheri’s response letter to my comments published in the June issue of the Journal of Oral and Maxillofacial Surgery.1 Although I agree with some of their comments, I respectfully disagree with some of what they stated. Some of this disagreement may be related to from where the issue is being viewed. From my academic prospective, where I encounter such issues on a regular basis, here is how I see it. First, it is true that what we are witnessing is a phenomenon of our times that is dictated by many forces, and such phenomena also are affecting many other specialties, not just ours. However, I do not accept the premise that we should stand idly by, because such factors and forces can ultimately shape the future of the specialty. Our specialty