OMFS should be a dual-degree specialty ONLY

[280040]

why do you say that?

I'm in the minority on this one. I'm not a perio hater. I believe their old scope is dead and their new scope is implants, site augmentation, taking out teeth. If oms abandoned coda, that's a huge deal.

I think some oms residents would be surprised what their perio friends are doing in residency. They read every damn article on the topic, beat it to death, and have incorporated quite nicely those small surgeries that make up the majority of oms private practice. They are never distracted by trauma cases, call, hospital responsibilities, long work weeks. It's focused on dentoalveolar sx.

And I don't wanna hear how painfully slow it is to watch them take out a 3rd. Yes, it's slow. But in private practice, it isn't. I've seen it.

Not that a gp would actually care about coda vs acgme in making referrals. Maybe???

You all are awesome and provide very impressive insight. I much enjoy this banter. Your perspective and thought process is much better than mine!!!

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[schmack]

I agree with "serveitup" OMFS should join ACGME. I wouldn't call what OMFS is going through now as a change, I would say it is going through a major revolution.

The reason I say this is that 30 years ago orthognathics and TMJ were the new big thing. As we all know at that time the program that was leading the way in orthognathic surgery was Parkland. So many of its graduates went on to become the current leaders of OMFS (i.e., Turvey, Fonseca, Schendel, Epker, Bell Sr.). If you think about it >90% of current chairmen specialize in orthognathics or TMJ, which kept us closer to our dental roots.

However, in 20 years the chairmen in OMFS will not be orthognathic surgeons. We all know this is a slowly dying art. The demand is much less today with the advent of mini-implants, anchorage devices, and facial implants. So in 20 years most of the chairmen will be micro/oncology surgeons. If you don't believe take a look at all the current young all-stars in OMFS (i.e., Bailey, Fernandes, Schmidt, Ward, Bell Jr., Hirsch, etc...). In order to seriously do Micro/Oncology you will need an MD, and General Surgery training. Also, many of these guys are pushing for ACGME for these areas of surgery are purely medical and have very little to do with dentistry.

This is why to all current applicants don't let this discussion discourage you. Just realize where the specialty is heading, and make sure you select a program that will keep you at the top. Make sure that mandibles and BSSO are not the only things you know how to do coming out of residency. This advice is more for people interested in becoming faculty.

To those interested in private practice, think cosmetics, cosmetics, cosmetics. Take a look at the big private practices out there today, they are all building surgery centers and hiring cosmetic trained surgeons. You may ask why? Well just like academic practices are doing less orthognathics, private practices are placing less implants. Implants are becoming much easier today, and with implant specialists, periodontists, general dentists, prosthodontics placing them there is much less to go around. With the increasing pressure by society for people to look young and beautiful the interest in cosmetic surgery is rapidly increasing. Private practice guys know this, and are doing everything they can to get into it. So if your interested in private practice I would recommend to all the current applicants make sure you go to a program where you will gain a lot of exposure to cosmetics. The reality is you will not be doing mandibles and BSSOs in private practice especially with compensation for medical procedures decreasing by the hour.

Ok, I think this is one of the most ridiculous statements you could have made. Aspirations such as these are the reason that the AMA is targeting OMS right now. (and, yes, if you read into that AMA statement, the bottom line they are trying to pursue is that OMS should stay the hell out of Cosmetic surgery). To think that OMS should take the direction of heavily pursuing cosmetics is absurd. It is a VERY small part of OMS scope and, to be quite frank, a very difficult one to pursue as part of an OMS residency, be it 4 or 6 years. You simply don't have the exposure, and if you have ANY sort of ENT or PRS influence in the area where you are training, you will be fighting turf battles incredibly hard. There's a reason that the AMA statement didn't mention much about trauma, that's because $$ talks my friend. Crossover with other specialties in areas that don't pay (ie, cancer, trauma, microvascular, orthognathics, etc.) are MUCH easier to pursue as an expanded OMS scope, simply because there is much less of a battle to be fought. But start encroaching on these guys money makers (cosmetics) and you'll likely be sorry for it. It is my opinion that if you want to do extensive cosmetic surgery (I'm not talking about Botox, fillers, blephs, & submental lipo), a cosmetics fellowship should be required, or you should just go to medschool to become a plastics guy. OMS scope is FAR too broad to think that you can come out of residency and immediately start doing face lifts.

Each and every medical specialty these days are trending to be more and more superspecialized. To think that you can be excellent in EVERY aspect of OMS is just absurd. Look at all the top orthopaedic surgeons in the country (you know, the ones who operate on athletes, etc.). There is always a guy who just does knees, a guy who just does Tommy John surgery, etc. Unless you are one of the old school guys doing general orthopedics, don't kid yourself into thinking that you can be excellent in every area of your specialty. Personally, if I were to have a rhinoplasty, I'd go to a plastics guy who ONLY does noses. I'd never go to an plastics guy who does whole body stuff like hand reconstruction, free flaps, boobs, etc. The amount of expertise & experience is unmatched by someone who becomes an expert in that area.

To those of you who think you are going to be a badass bigdoc oral surgeon who is awesome in cosmetics, cancer, microvascular, orthognathics, craniofacial, trauma, AND, not too mention, dentoalveolar and implant surgery, you are kidding yourself. The scope is far too broad to practice all of these with expertise. It is great to be exposed to these things while in residency, so that if you determine one of these areas is a direction you'd like to go into then you can make plans accordingly and do a fellowship or pursue the academic route to try and get more exposure.

Once again, I'll state that I think it would be a BIG mistake to both join ACGME and make every program a mandatory 6 yr dual degree specialty. Doing so is a slippery slope away from the specialty's roots in dentistry. The expanded areas of OMS scope are great and good for the specialty. Those interested in pursuing these areas will almost without exception have to remain in an academic setting, regardless of degree.

As one poster stated, to reiterate, I feel that with the way health care industry is being so radically changed with health insurance and increased level of government control, I think now, more than ever, it is imperative that OMS stay even CLOSER to it's dental roots (I.e, CODA, single/dual degree programs, etc.). Medicine saw a rapid decline in its progress with the implementation & increase in managed care and external controls. Dentistry has, largely, kept itself away from that and that is where it needs to stay. Taking more steps closer to Medicine and away from dentistry will ultimately lead us in that direction we don't want to go.

 

[MRSA]

I agree with "serveitup" OMFS should join ACGME. I wouldn't call what OMFS is going through now as a change, I would say it is going through a major revolution.

is it possible that, if OMS Residencies come under the authority of ACGME, it will open up spots to med students?

since it seems some think that this would deemphasize dentistry anyway, is this possible?

 

[servitup]

OMS scope is FAR too broad to think that you can come out of residency and immediately start doing face lifts.

If so, the same could be said for plastic surgeons. Further, most general dentists have never heard of CODA nor ACGME. They don't care who accredits OMFS. They just want their patients taken care of and shipped back for their primary care. No reason to think mandating an MD or joining ACGME would alienate them. A number of them prefer to send patients to MD-trained surgeons (I understand that most do not care).

 

[280040]

So in 20 years most of the chairmen will be micro/oncology surgeons. If you don't believe take a look at all the current young all-stars in OMFS (i.e., Bailey, Fernandes, Schmidt, Ward, Bell Jr., Hirsch, etc...). In order to seriously do Micro/Oncology you will need an MD, and General Surgery training. Also, many of these guys are pushing for ACGME for these areas of surgery are purely medical and have very little to do with dentistry.

Is there even a need in medicine for micro/oncology folks who are dentists also? The european model of oms that gets mentioned may have the need if ENT is not as strong. Or if plastics doesn't touch the face or something like that...

 

[Truedat]

Ok, I think this is one of the most ridiculous statements you could have made. Aspirations such as these are the reason that the AMA is targeting OMS right now. (and, yes, if you read into that AMA statement, the bottom line they are trying to pursue is that OMS should stay the hell out of Cosmetic surgery). To think that OMS should take the direction of heavily pursuing cosmetics is absurd. It is a VERY small part of OMS scope and, to be quite frank, a very difficult one to pursue as part of an OMS residency, be it 4 or 6 years. You simply don't have the exposure, and if you have ANY sort of ENT or PRS influence in the area where you are training, you will be fighting turf battles incredibly hard. There's a reason that the AMA statement didn't mention much about trauma, that's because $$ talks my friend. Crossover with other specialties in areas that don't pay (ie, cancer, trauma, microvascular, orthognathics, etc.) are MUCH easier to pursue as an expanded OMS scope, simply because there is much less of a battle to be fought. But start encroaching on these guys money makers (cosmetics) and you'll likely be sorry for it. It is my opinion that if you want to do extensive cosmetic surgery (I'm not talking about Botox, fillers, blephs, & submental lipo), a cosmetics fellowship should be required, or you should just go to medschool to become a plastics guy. OMS scope is FAR too broad to think that you can come out of residency and immediately start doing face lifts.

Each and every medical specialty these days are trending to be more and more superspecialized. To think that you can be excellent in EVERY aspect of OMS is just absurd. Look at all the top orthopaedic surgeons in the country (you know, the ones who operate on athletes, etc.). There is always a guy who just does knees, a guy who just does Tommy John surgery, etc. Unless you are one of the old school guys doing general orthopedics, don't kid yourself into thinking that you can be excellent in every area of your specialty. Personally, if I were to have a rhinoplasty, I'd go to a plastics guy who ONLY does noses. I'd never go to an plastics guy who does whole body stuff like hand reconstruction, free flaps, boobs, etc. The amount of expertise & experience is unmatched by someone who becomes an expert in that area.

To those of you who think you are going to be a badass bigdoc oral surgeon who is awesome in cosmetics, cancer, microvascular, orthognathics, craniofacial, trauma, AND, not too mention, dentoalveolar and implant surgery, you are kidding yourself. The scope is far too broad to practice all of these with expertise. It is great to be exposed to these things while in residency, so that if you determine one of these areas is a direction you'd like to go into then you can make plans accordingly and do a fellowship or pursue the academic route to try and get more exposure.

Once again, I'll state that I think it would be a BIG mistake to both join ACGME and make every program a mandatory 6 yr dual degree specialty. Doing so is a slippery slope away from the specialty's roots in dentistry. The expanded areas of OMS scope are great and good for the specialty. Those interested in pursuing these areas will almost without exception have to remain in an academic setting, regardless of degree.

As one poster stated, to reiterate, I feel that with the way health care industry is being so radically changed with health insurance and increased level of government control, I think now, more than ever, it is imperative that OMS stay even CLOSER to it's dental roots (I.e, CODA, single/dual degree programs, etc.). Medicine saw a rapid decline in its progress with the implementation & increase in managed care and external controls. Dentistry has, largely, kept itself away from that and that is where it needs to stay. Taking more steps closer to Medicine and away from dentistry will ultimately lead us in that direction we don't want to go.

Amen!

 

[buggzzen]

Amen!

Dr. Ruska any thoughts???

 

[servitup]

Is there even a need in medicine for micro/oncology folks who are dentists also?

Who does mandible fractures the best? OMFS. Who gets the most training in manipulation of facial proportions and esthetics using the facial skeleton? OMFS. Seems to me these skills would make OMFS an ideal choice to treat oral cancer.

 

[gary_ruska]

Who does mandible fractures the best? OMFS. Who gets the most training in manipulation of facial proportions and esthetics using the facial skeleton? OMFS. Seems to me these skills would make OMFS an ideal choice to treat oral cancer.

Gary "more skills required" Ruska here,

This is only partly true. There are few reasonable arguments that can be made against the statement that among OMFS, ENT and PRS, OMFS know the most about occlusion and are thus theoretically the most prepared to treat fractures of the lower and midfacial skeleton. What is more debatable is whether these skills translate directly to the resective and reconstructive procedures involved in oncologic surgery.

While GR agrees that knowledge of facial esthetics and occlusion are important for oncologic surgery, they are by no means as critical as they are for trauma management, orthognathic surgery or alloplastic augmentation. Most patients who have extirpative surgery for head and neck cancer know that they will have a deformity. The reason for this is that it is often difficult to plan the size of the defect because you don't know a priori what the margins will be.

Finally, many people (GR included), will make the argument that the most challenging aspect of H+N cancer care is not the operation but the post-operative management. These patients are usually very sick and have multiple comorbidities. Knowledge of facial esthetics and occlusion does not prepare for the prolonged SICU stay or any of the numerous complications these patients can develop.

In the end, these are all fairly moot points. OMFS, like everyone else, will do what the market forces determine and will lobby for their fair share of the $$$$ pie. History has a habit of repeating itself. In the 80s, when orthognathic surgery paid tens of thousands per procedure, PRS/ENT surgeons insisted that they were the only ones adequately trained to do these operations. Now that that well has dried up, the focus has been on cosmetics for these specialties. OMFS, who have always had the market cornerned on orthognathics, have, in the past 20 years, made their move into cosmetics, which is a reasonable progression, but would not be as aggressive a move if the market for orthognathic surgery still reimbursed well. Just wait and see what happens when the third molar well begins to dry up and implants become the predominant domain of the general dentist...

The best argument to be made for broad-training and broad-scope practice is that no one knows what the next money-maker will be. Keeping your skills sharp in dentoalveolar, TMJ, trauma and orthognathic surgery, the "core operations" for OMFS is the best way to prepare for what lies ahead. The MD degree is not critical to this strategy, though it may be, in some instances, an additional asset for what unknowns the future may bring.

 

[DREDAY]

It is a bit off subject, but since we are talking about compensation for services. Is the compensation for a Bimax advancement for sleep apnea the same as compensation for Bimax advancement for orthognathics?

 

[gary_ruska]

It is a bit off subject, but since we are talking about compensation for services. Is the compensation for a Bimax advancement for sleep apnea the same as compensation for Bimax advancement for orthognathics?

Gary "rising RDIs and decreasing UCRs" Ruska here,

Generally - yes. Both will be reimbursed as "medically necessary" and covered in the same manner.

Orthognathic surgery is sometimes not covered if it is determined that the operation is more for esthetic reasons than functional ones. OSA surgery is almost always covered, provided that polysomnographic testing demonstrates a functional problem of significant severity and there is documented failure of alternative treatments (e.g. CPAP). MMA has not yet, in most instances, been approved as a first-line treatment for severe OSA.

Neither is a real money-maker though. Given the amount of time spent with pre-operative planning (models, splints, etc.) and post-operative care, as well as the increased risk of operating on OSA patients, who are at the other end of the health status spectrum when compared to adolescent orthognathic patients, MMA for OSA is not a real money maker. It can be feasible, however, if one is in an academic center where the residents do the majority of the busy work.

 

[OMFSPrime]

Third molar well don't you dry up! Oh Please Oh Please, I have never asked for anything besides boston cream doughnuts and strippers in heaven.

Kidding aside, these are all major changes in scope, turf, and credentialing that if it takes place (most likely will), it will take 10-20 years to see the full impact, definitely within our career (life) time.

There are still so many opportunities for growth in the U.S. given the midwest and central areas that are under served.

In the end, all that matters is your ability, your chairside manner, and what you do inside/outside the office to elevate your status as a respected member of the community you are a part of.

Dentistry & Medicine is constantly evolving, we still do not know everything there is to know. Always keep learning, reaching out for new materials, techniques, evidenced based care, and for both 4 & 6 years...move our field ahead by doing research...clinical, pharma, biomaterial, whatever it is...keep moving forward.

Challenge yourself on a daily basis, leave the rest for everyone else to worry about.

Enough run-ons for one day...i think.

OMFSPrime

P.S. I'm more afraid of Perio than the AMA...it really gets to me to see perio departments at schools get most of the funding. It is almost as if we teach rising dental students that perio are the go to people for atraumatic exo, grafting, lifts, implants...and in some places, dare I say, sedation. Pretty soon, what will be the difference between Perio & OMFS...only orthognathics, trauma, head & neck?

It seems to me we are getting hit from both sides...within dentistry & outside.

 

[280040]

Gary "rising RDIs and decreasing UCRs" Ruska here,

wow. You're at an academic center? I wish I knew if I interviewed with you this past year.... Always great insight and gives us some perspective that we don't have!

 

[280040]

P.S. I'm more afraid of Perio than the AMA...it really gets to me to see perio departments at schools get most of the funding. It is almost as if we teach rising dental students that perio are the go to people for atraumatic exo, grafting, lifts, implants...and in some places, dare I say, sedation. Pretty soon, what will be the difference between Perio & OMFS...only orthognathics, trauma, head & neck?

tread lightly on this subject there buddy. Last time I mentioned this I got some private messages of disgust, haha. I could go on and on about that topic. Perio can usually do a better job of educating students, covering the clinics, and ultimately patient care because they are physically, politically, and time wise more connected than the oms residents. Oms is at the hospital, on call, traveling to and from other sites, off rotation, or simply NOT THERE. Perio MUST be there because they largely are dental school based. I have no opinion on who actually executes the surgical procedure the best.

 

[servitup]

tread lightly on this subject there buddy. Last time I mentioned this I got some private messages of disgust, haha. I could go on and on about that topic. Perio can usually do a better job of educating students, covering the clinics, and ultimately patient care because they are physically, politically, and time wise more connected than the oms residents. Oms is at the hospital, on call, traveling to and from other sites, off rotation, or simply NOT THERE. Perio MUST be there because they largely are dental school based. I have no opinion on who actually executes the surgical procedure the best.

Just as OMFS has evolved from mandible fractures and orthognathics to today's broad scope, perio will do the same during our careers. They already do everything we can do short of those cases we do in the OR. No question we do it better and faster but they do it.

 

[Regmata]

You guys make it seem as if perio is a real financial threat to OS. Are periodontists really taking that much dentoalveolar business from surgeons? I have heard from several GPs that they won't refer implants to OS's b/c perio's management of soft tissue is superior (not my opinion, just what I have heard). And what is this talk to the 3rd molar well drying up? Due to perio? GPs?

 

[toofache32]

...

Best. Screen name. Ever.

 

[bobby6]

Who does mandible fractures the best? OMFS. Who gets the most training in manipulation of facial proportions and esthetics using the facial skeleton? OMFS. Seems to me these skills would make OMFS an ideal choice to treat oral cancer.

I don't think oral cancer is that simple. To treat oral cancer effectively, you have to be proficient in doing neck dissections. An oral cancer with greater than 4mm depth of invasion should have a neck dissection because of the high risk of cervical metastasis. If you take more than 1/2 of the tongue, what are you going to reconstruct it with? It may need a free flap like a radial forearm. What if the oral cancer extends into the base of tongue which is a extremely difficult area to access? How are you going to be able get good enough visualization to get a clear margin around the tumor? You may need to do a mandible and lip split to distract the mandible to access the tumor.

The standard of care for any kind of head & neck cancer is having a multidisciplinary Head & Neck Tumor Board with the inclusion of Medical Oncology and Radiation Oncology on board.

 

[servitup]

I don't think oral cancer is that simple. To treat oral cancer effectively, you have to be proficient in doing neck dissections. An oral cancer with greater than 4mm depth of invasion should have a neck dissection because of the high risk of cervical metastasis. If you take more than 1/2 of the tongue, what are you going to reconstruct it with? It may need a free flap like a radial forearm. What if the oral cancer extends into the base of tongue which is a extremely difficult area to access? How are you going to be able get good enough visualization to get a clear margin around the tumor? You may need to do a mandible and lip split to distract the mandible to access the tumor.

The standard of care for any kind of head & neck cancer is having a multidisciplinary Head & Neck Tumor Board with the inclusion of Medical Oncology and Radiation Oncology on board.

Those were only a few of the multitude of reasons why there is utility in having an OMFS treat cancer patients. The list was not meant to be all-inclusive.

 

[sarah_bellum]

Best. Screen name. Ever.

http://www.youtube.com/watch?v=uLBvo8ExTtE

 

[OralFacialSx]

To solve this problem a name change would be a simple fix.

1. First, the name Oral and Maxillofacial Surgeon is too cumbersome. Pts can't say it, colleagues can't say it, even my parents have problems saying it. It is simple- Oral and Facial Surgeon. That should be our new name. Otolaryngology is trying to change theirs to Head and Neck we should do the same. It describes in laymens terms who we are. The term Oral and Maxillofacial surgeon is anatomically correct but confuses people. It also causes people to shorten our name to Oral surgeon, which misrepresents who we are.

2. Separate the field into two fields: Oral surgeons, and Oral and Facial surgeons. 4 year guys do Oral surgery and face trauma with mandible. 6 year guys do full scope face surgery. It is copying what is already in place in Europe. Or separate it however you like but MD guys become known as full scope and 4 year guys become the limitted scope guys. This way if you truly want to go out and do all these big surgeries you do the 6. If you want to do Oral surgery do the 4.

 

[OralFacialSx]

Third molar well don't you dry up! Oh Please Oh Please, I have never asked for anything besides boston cream doughnuts and strippers in heaven.

Kidding aside, these are all major changes in scope, turf, and credentialing that if it takes place (most likely will), it will take 10-20 years to see the full impact, definitely within our career (life) time.

There are still so many opportunities for growth in the U.S. given the midwest and central areas that are under served.

In the end, all that matters is your ability, your chairside manner, and what you do inside/outside the office to elevate your status as a respected member of the community you are a part of.

Dentistry & Medicine is constantly evolving, we still do not know everything there is to know. Always keep learning, reaching out for new materials, techniques, evidenced based care, and for both 4 & 6 years...move our field ahead by doing research...clinical, pharma, biomaterial, whatever it is...keep moving forward.

Challenge yourself on a daily basis, leave the rest for everyone else to worry about.

Enough run-ons for one day...i think.

OMFSPrime

P.S. I'm more afraid of Perio than the AMA...it really gets to me to see perio departments at schools get most of the funding. It is almost as if we teach rising dental students that perio are the go to people for atraumatic exo, grafting, lifts, implants...and in some places, dare I say, sedation. Pretty soon, what will be the difference between Perio & OMFS...only orthognathics, trauma, head & neck?

It seems to me we are getting hit from both sides...within dentistry & outside.

The reason that OMFS is losing the battle with perio is because we are not willing to work at the school and teach the general dentists that we are those guys. We are the best referral for the dentists because we can do everything. However, we are too busy in the hospital. Where we will convince no one that we are the best. Every OMFS program needs to have a branch specifically for the dental school implants and dentoalveolar or we will lose it all together.

 

[1992Corolla]

2. Separate the field into two fields: Oral surgeons, and Oral and Facial surgeons. 4 year guys do Oral surgery and face trauma with mandible. 6 year guys do full scope face surgery. It is copying what is already in place in Europe. Or separate it however you like but MD guys become known as full scope and 4 year guys become the limitted scope guys. This way if you truly want to go out and do all these big surgeries you do the 6. If you want to do Oral surgery do the 4.

Let's vote for Obama again in 2012 too.

 

[charlestweed]

You guys make it seem as if perio is a real financial threat to OS. Are periodontists really taking that much dentoalveolar business from surgeons? I have heard from several GPs that they won't refer implants to OS's b/c perio's management of soft tissue is superior (not my opinion, just what I have heard). And what is this talk to the 3rd molar well drying up? Due to perio? GPs?

This is not the reason why many GPs (and prosth) prefer the periodontists to place the implants. GPs like to refer implant cases to perio because perio pay more attention to the overall implant tx plan (both placement and restoration) than the OS. Periodontists spend more time than the OS to communicate with the GPs regarding to the overall restorative plan before and after the implant placements. Periodontists also spend more time helping the GPs to deal with common problems such as implant failures, broken screws during the restorative procedures, problems with the esthetic, poor lab works etc. Since implants are new to a lot of GPs and most dental schools don’t teach implants in great details, the GPs need a lot of guidance from the specialists (periodontists and OMFS). You don’t just place the implants and assume that the GPs know what to do next.

 

[armorshell]

This is not the reason why many GPs (and prosth) prefer the periodontists to place the implants. GPs like to refer implant cases to perio because perio pay more attention to the overall implant tx plan (both placement and restoration) than the OS. Periodontists spend more time than the OS to communicate with the GPs regarding to the overall restorative plan before and after the implant placements. Periodontists also spend more time helping the GPs to deal with common problems such as implant failures, broken screws during the restorative procedures, problems with the esthetic, poor lab works etc. Since implants are new to a lot of GPs and most dental schools don't teach implants in great details, the GPs need a lot of guidance from the specialists (periodontists and OMFS). You don't just place the implants and assume that the GPs know what to do next.

This sounds a lot more provider personality dependant than specialty dependant. I'm just starting my residency but I plan to do all of this and more when I'm in practice.

 

[mileycyrus1]

Periodontists ..... are nicer, more welcoming, and gentler than the oral surgeons to both students and the patients.

You obviously haven't been to University of Marlyand. Our periodontists are complete *****h0les. The oral surgery department on the other hand are awesome.