Oral Surgery Success

Today, I want to dive into a topic that affects us all: fatigue in our dental practices, particularly in oral surgery. We all experience tiredness from the daily grind of dentistry, and I want to share some insights on the different types of fatigue we face and how to manage them. Physical fatigue is often the most obvious. It can stem from poor sleep habits, lack of exercise, or simply working long hours. While I've improved in this area, it's still a challenge for many. Mental fatigue, or decision fatigue, is a big one for me. Our job requires intense mental engagement from start to finish, and it can be draining. Techniques like meditation can help, but I still struggle with this aspect. Emotional fatigue comes from dealing with charged situations - difficult patients, conflicts with colleagues, or frustrations with insurance companies. Compassion fatigue is another challenge, especially as we progress in our careers. It's when we start to lose our capacity for empathy and begin to objectify patients. This can be a sign of burnout and may require professional help to address. Other types of fatigue include creativity fatigue (though less applicable in dentistry) and sensory fatigue from constant exposure to things like handpiece noise. When these different types of fatigue stack up, it can lead to burnout. For me, the top three are mental fatigue, emotional fatigue, and compassion fatigue. It's crucial to find ways to counteract these, whether through hobbies, time off, or setting boundaries in your practice. It's okay to say no to cases or patients that aren't a good fit. Refer out what you're not comfortable with - I do this with certain complex procedures I no longer regularly perform. Ultimately, focus on what you enjoy and what you're good at. Set boundaries, refer when necessary, and don't be afraid to dismiss problematic patients. These strategies can help reduce overall fatigue and make your practice more enjoyable. Remember, it's okay to ask for help if you're struggling. If you have any questions or comments, feel free to reach out at [email protected]. Talk to you next time!

Oral Surgery Is Hard

Hey everyone, it's Russell. Today, I want to talk about something a bit different – our profession itself and the challenges we face. The main thing I want to emphasize is that oral surgery is hard. We all struggle sometimes, and that's okay. As we progress in our careers, more experience leads to better outcomes and techniques. You'll find the instruments and approaches that work best for you, and case selection improves with time.

Early in our careers, we often face pitfalls like taking on cases beyond our skill level, and our ego can cloud our judgment. But even as we gain experience, we'll always have wins and losses. Referrals are sometimes necessary, even for experienced surgeons, and consulting colleagues for validation is valuable.

Having support is crucial in our field. We need people to bounce ideas off of, and it's important to keep going and improving. Our ultimate goal should be to have more wins than losses, but we must accept that some cases won't go as planned. It's also vital to recognize when we simply can't help certain patients.

We need to extend grace to ourselves. We're human and imperfect – it's called a "practice" for a reason. Over time, we should have more successes than failures. It's equally important to support our colleagues. Be kind when others share struggles online and avoid harsh criticism – we don't know the full context. Remember, everyone has complications, even the "experts."

Ultimately, what we do is valuable and unique. Be proud of your skills and the good you bring to the world. I hope this reflection helps you feel less alone in your challenges. We're all in this together. As always, feel free to reach out at [email protected] or follow me on X @RussellKirkDDS.

Talk to you next week!

I want to share a story that highlights the importance of comprehensive evaluation and patient education when it comes to third molar pain. Imagine this scenario

A 17-year-old female presents with bilateral jaw pain. Exam reveals
Impacted third molars, no obvious pathology
No intraoral signs of infection or pericoronitis
Teeth are removed without complication

But at post-op visits, the patient reports
Pain persists or worsens
No response to anti-inflammatories
Headaches develop

What's going on? In this case, we may have missed an underlying diagnosis of TMD, specifically myofascial pain in the muscles of mastication.

Key signs of TMD to watch for
1. Headaches, often behind the eyes or at the temples
2. Tenderness at the temporalis insertion (near maxillary first molar)
3. Pain at the angle of the mandible (masseter attachment)
4. Pre-auricular pain (pterygoid involvement)
5. History of gum chewing, ice crunching, or other parafunctional habits

The problem: When we assume third molars are the sole cause of pain and remove them, we set ourselves up for trouble if TMD is the true culprit. The patient's pain persists, and they may blame us for their worsened condition.

The solution: Thorough assessment and clear communication
Palpate the muscles of mastication for tenderness
Document pre-existing TMD in the patient's record
Discuss the distinction between third molar pain and myofascial pain
Set expectations for potentially prolonged recovery due to TMD
Consider the necessity of third molar removal if no obvious pathology is present

I learned this lesson the hard way when a patient reported me to the dental board, claiming I had caused her TMD by "dislocating her jaw" during surgery. Thankfully, my documentation of her pre-existing condition exonerated me, but it was a stressful experience.

By sharing this story, I hope to help others avoid similar pitfalls. Remember, a thorough exam and clear patient communication can make all the difference in achieving optimal outcomes and maintaining trust.

As always, I'd love to hear your thoughts and experiences. Feel free to reach out at [email protected], and follow me on X @RussellKirkDDS for daily posts on all things oral surgery.

Talk to you next week!

Case Selection Versus Case Complexity

Hey ya'll. In a recent post on X (formerly Twitter), I proposed that case selection is one of the most critical factors in achieving good surgical outcomes. Today, I want to dive deeper into that idea and explore some common pitfalls that can lead us astray.

Why do we sometimes struggle with case selection?

1. Ego and overconfidence: We overestimate our abilities and take on cases that exceed our skills and experience.

2. Inability to admit limitations: We're reluctant to acknowledge when a case is beyond our current scope of expertise.

3. Lack of self-awareness: We have blind spots and don't recognize areas where we need improvement.

4. Ignoring feedback: We dismiss constructive criticism from patients, team members, or colleagues that could help us grow.

5. Financial incentives: The prospect of higher fees for complex cases can cloud our judgment.

6. Institutional pressures: Quotas or expectations from employers (academic, military, DSOs) may push us to take on more than we should.

7. Fear of losing referrals: As specialists, we worry that referring out challenging cases will diminish our referral base.

The dangers of poor case selection include: choosing case complexity that exceeds our skills and experience sets us up for suboptimal outcomes. Negative results can damage our reputation and lead to a loss of referrals.

8. Focusing on successes while downplaying failures gives us an inflated sense of capability. Dunning-Kruger effect: Early-career practitioners may not recognize their limitation.

9. Inadequate training in specific areas (e.g., an OMS skilled in craniofacial surgery but undertrained in implants)

10. Stress, rapid pace, decision fatigue, and burnout can skew our judgment

The key to success is aligning case complexity with skills and experience.

When skills/experience exceed the complexity of the case, success is likely.

When they're evenly matched, consider patient factors and personal readiness.

When case complexity exceeds skills/experience, refer out or pursue additional training.

This topic resonates with me, as I've personally experienced the consequences of misaligned case selection, including burnout.

By sharing these reflections, I hope to spark meaningful conversations and encourage thoughtful decision-making.

I'd love to hear your thoughts.

Follow me on X @RussellKirkDDS, where I post daily on oral surgery topics (I promise, no controversial tangents).

As always, feel free to reach out at [email protected].

Talk to you next week!

TLDR. Course link: PRFBasics.com

Today we're diving into the world of platelet-rich fibrin (PRF). I learned about this technique from Dr. Anthony Sclar out of Miami, and I've found it to be a game-changer in my oral surgery practice.

Let's break it down into my "P3 Approach":

1. Phlebotomy (Drawing the Blood)-Check local regulations on who can perform phlebotomy; - Draw directly from IV (if sedating patient) or vein-Equipment: Tourniquet, alcohol swab, gauze, Vacutainer with glass tubes (no preservatives) - Typically draw 4 tubes - Free phlebotomy course available at PRFBasics.com

2. Preparation (Making the PRF)-Spin tubes in centrifuge (timing varies by patient; check at 3 minutes)A fibrin "slug" forms on top of blood layers-Remove the slug with cotton pliers, trim red cells if needed, place the slugs in PRF box, and compress into membranes. Reserve some plasma to mix with bone graft for "sticky bone."

3. Placement (Using the PRF)-Extraction sites: Fill with sticky bone and cover with PRF membrane. Cyst/tumor removals: Place PRF membranes to reduce pain and swelling and aid bone healing. Sinus lifts: Use PRF membrane to patch a torn Schneiderian membrane. Ridge augmentation: fill buccal defects with sticky bone, cover with PRF membrane.

Root coverage/recession: not predictable in my experience.

I've found PRF incredibly helpful for reducing post-op pain and swelling, especially in larger cases like third molar cysts. It's cost-effective and relatively easy to implement.

If you're doing oral surgery, I highly recommend exploring this technique! Feel free to check out my free PRF Basics course at PRFBasics.com; it's a quick watch and can get you up and running in no time.

As always, reach out with any questions at [email protected]. Talk to you next week!

Here are the show notes for this episode, where I tackle a few more great listener questions related to previous topics. As always, I'm sharing my personal opinions and experiences, not definitive clinical advice.

Bone Wax, Bisphosphonates, and Type 1 Diabetes: Listener Q&A

Hey everyone, it's Russell again. I really appreciate you sending in these fantastic questions! This week, I'm diving deeper into a few topics we've covered before, based on your queries.

Question 1: How do you use bone wax for bleeding control? Place minimal amount (think ortho wax size) directly in bleeding void, apply pressure, remove excess, aim for wax to be flush with bone level - Leave in place to avoid re-bleeding - Caution: Excess wax can cause inflammation, foreign body reaction, and impaired bone healing - Hemostatic agents like Surgicel or Gelfoam are preferable when possible; diode laser is my go-to

Question 2: MRONJ risk with short-term Fosamax use? Case: Patient on Fosamax 1x/week for 4 months, needs extractions and implants. Key considerations: - Confirm no previous bisphosphonate use - Check for concurrent steroid use (increases MRONJ risk) - Controversial, but I prefer short drug holiday if MD agrees - Ensure complete healing before restarting medication; - Assess other risk factors: smoking, diabetes, overall health - Case-by-case decision based on comprehensive picture

Question 3: Managing type 1 diabetes on steroids for extractions? - Case: Type 1 diabetic with A1c 8.1, on steroids for arthritis, needs #31-32 out - Ideal A1c for surgery: 6-8 based on general surgery literature - Expect increased post-op infection risk, swelling, pain, delayed healing; discuss with patient - Blood sugar management: consult with physician - Minimal intraoperative variation in my experience - Post-op challenges with dietary changes; recommend sugar-free options - Not a contraindication, but high-risk case requiring diligent management - Prophylactic antibiotics - Close follow-up until complete healing - Urgency if teeth are infected; discuss risks/benefits with patient

Keep those great questions coming!

Email me at [email protected].

Remember, every case is unique, so always use your best clinical judgment.

Talk to you next week!

Link to Youtube video

AI Differential Diagnosis Smackdown: ChatGPT vs. Claude vs. Meta AI

Hey everyone, it's Russell, your resident tech nerd and oral surgery geek. This week, I wanted to put some of the big AI language models to the test with a fun little experiment.

The contenders: OpenAI's ChatGPT. Anthropic's Claude3 Opus. Meta AI's LLaMA-3.

The challenge: Given the same photo of a lip lesion and identical prompts, how well can each AI generate a differential diagnosis list?

The lip lesion: Left lower lip, 0.75cm, irregular Pink, firm, mobile, non-tender, non-ulcerated Becoming bothersome due to size.

My initial DDx: Traumatic fibroma (most likely) Mucous cyst (common in this area) Lipoma (less likely based on appearance)

Results: ChatGPT: Impressive! Ranked fibroma/lipoma as most likely, generated a solid 9-item DDx list with descriptions. Even knew my specialty and suggested next steps.

Claude: Also very strong. 5-item DDx with great descriptions, emphasized biopsy for definitive diagnosis. Mentioned referral to OMS or ENT.

Meta AI: Interesting! Seemed to start generating a good list (benign and malignant possibilities) but then apologized and deleted its response. Possible guardrails around medical advice?

My take: While not a substitute for clinical judgment, I'm impressed by the AI's performance in this niche scenario. As capabilities expand and HIPAA/security concerns are addressed, I believe AI will become an increasingly valuable tool in our practices. Exciting (and a bit scary) to think about!

What do you think about AI's potential impact on dentistry and OMFS? I'd love to hear your perspective!

As always, feel free to reach out at [email protected]. Talk to you next week!

P.S. For those following along on YouTube, I've included a video of the AI interactions. Check it out and let me know what you think!

Here are the podcast show notes for this episode, where I answer some common questions from referring dentists and online dental communities. As always, I'm sharing my personal approach and opinions.

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Hey everyone, Russell here. This week I'm switching things up and answering a few questions that have come my way recently. Remember, these are just my thoughts - if you do things differently and get good results, that's great too! Let's dive in.

Sinus Perforation Repair:
- 5mm perforation during #3 extraction
- My approach:
- PRF membrane over exposure
- Collagen plug on top for added soft tissue support
- Primary closure with 4-0 chromic gut, creating 4-corner flap and scoring periosteum
- If repair fails, next step:
- Titanium-reinforced non-resorbable membrane over PRF and collagen plug
- Wait months if needed before removing membrane to avoid re-exposure

Expose & Bond for Impacted Canines:
- Surgical side: Expose tooth, remove bone, etch & bond button/chain (I use Smart Bond), secure to ortho wire with nylon sutures
- Ortho side: My colleague uses elastics and a spring (not twisted wire) to apply traction and prevent debonding
- Key tips: Luxate tooth for mobility, suture chain to a spring on arch wire, get patient to ortho within 7 days

Bone Grafting Extracted Sites:
- I'm comfortable with immediate grafts if no frank pus present
- Clean out site well, use PRF sticky bone and membranes
- Controversial: Are grafts even needed for mandibular molars? Some evidence shows minimal difference vs. non-grafted sites
- Case-by-case basis with many variables to consider

As always, feel free to send me your questions at [email protected] and let me know if you enjoy this Q&A format. Talk to you next week!

MRONJ Review: What You Need to Know

Today I want to dive into the important topic of medication-related osteonecrosis of the jaw, or MRONJ. We used to call this "BRONJ" for bisphosphonate-related osteonecrosis of the jaw, but now we know other medications can also cause this serious complication.

Common culprits I see in my practice:
- Bisphosphonates: Fosamax, Boniva, Actonel, Reclast, Zometa (IV forms like Reclast and Zometa carry higher risk than oral)
- RANKL inhibitors: Prolia, Xgeva

When patients on these meds need extractions or other oral surgery, we take extra precautions:
- Consult with prescribing physician
- For IV drugs, wait as long as feasible after last dose
- For oral, consider 3-month drug holiday (though this is controversial)
- Unfortunately, no reliable pre-op tests to predict individual risk

MRONJ staging and management:
- At-risk: Not yet affected. Focus on prevention, education, and optimizing oral health before starting meds.
- Stage 0: Non-specific symptoms without exposed bone. Conservative care.
- Stage 1: Exposed/necrotic bone, no infection. Rinses, hygiene, avoid further surgery.
- Stage 2: Exposed bone with infection, pain, swelling, pus. Add antibiotics, limited surgical debridement.
- Stage 3: Extensive necrosis, severe pain, pathologic fracture, extraoral fistula. Aggressive resection may be needed.

I have high-risk patients sign a special MRONJ consent so expectations are clear. Extra red flag if they also take steroids!

Feel free to reach out for a copy of our consent form or with any other questions at [email protected]. Talk to you next week!

Risk Factors for Post-Op Infection in Third Molar Extractions

Hey everyone, it's your host, Russell, here. In this episode, I want to share with you an interesting article I came across in the Journal of Stomatology Oral Maxillofacial Surgery, published just a few days ago on March 21, 2024. The article is titled "Risk factors for post-extraction infection of mandibular third molar: a retrospective clinical study" by Muka Naka et al., out of Japan.

Key takeaways:
- This large-scale retrospective study looked at 2,513 third molar extraction cases over 8 years (2014-2022) at a single facility in Kobe, Japan
- The overall post-op infection rate was 5.73% (144 out of 2,513 cases)
- Risk factors for increased post-op infection included:
- Age over 36 (risk increased with each additional year of age)
- Pre-op infection/inflammation (patients given pre-op antibiotics had higher infection rates, likely because infection was already present)
- Post-op paresthesia (suggests more difficult surgery)
- Need for intraoperative hemostatic procedures
- More severe impaction (deeper impactions on Pell & Gregory scale, horizontal/inverted on Winter's classification)
- Delayed treatment in older patients allows more time for disease processes to occur around third molars
- Increased bone density with age makes extractions more difficult

I believe this provides more rationale for preventively removing wisdom teeth in younger, healthier patients rather than waiting until issues arise later in life. While there is controversy over prophylactic third molar removal, avoiding the increased surgical risks and prolonged recovery in older patients is a compelling argument in favor of earlier intervention when indicated.

I hope you found this information interesting and useful. Feel free to reach out to me at [email protected] with any questions. Have a great week!