Center for Oral & Maxillofacial Surgery Newsletter: Fall 2022

COMMITTED TO EXCELLENCE

Richard W.

Emily

Van Heukelom,

Roseanna P. Noordhoek,

Mark N. Grinzinger,

DENTINOGENESIS

IT CAN BE HARD when you’re different, especially for a teenager. And Mia McNinch of Rockford knew she was different in one key way: Her teeth were smaller than most people’s and

translucent instead of white.

“When I got my braces off in middle school,” she recalls, “people still thought I had them on because they could see straight through my

A SUCCESS STORY IN TREATING DENTINOGENESIS IMPERFECTA

teeth to my permanent retainer.”

Then, in high school, her teeth began fracturing, one after another. This was in spite of excellent general health, superb oral hygiene and no caries history.

A RARE CONDITION

Mia used extra care because her dental difficulties weren’t a surprise. She has known since childhood that, like her mom, she has the genetic condition dentinogenesis imperfecta (DI), also known as hereditary opalescent dentin. It’s an autosomal dominant disorder, which means that there is a 50 percent chance of passing the disease to children. The mutations

involve a gene called DSPP (dentin sialophosphoprotein), which is believed to play a role in the normal development of collagen, a key protein in dentin.

Dentists learn in dental school about DI, but they can go decades in practice without encountering it. One recent study of 96,000 Michigan children found a prevalence of 1 in 8,000. 1 In some patients, DI affects only the primary teeth, but often, as in Mia’s case, it involves the permanent teeth as well. DI has three types. People with Type I also have osteogenesis imperfecta , while those with the other two types do not. Type III is a rare condition that has been seen in some individuals

in southern Maryland and some of Ashkenazi Jewish descent; it features multiple pulp exposures and differences in radiographic appearance. Mia has Type II, the most common type; it’s sometimes accompanied by progressive hearing loss as patients grow older.

Cases vary, but this type usually manifests in teeth that are smaller than average, translucent with gray-blue or yellow-brown overtones, and weak and especially vulnerable to fracture. Says one study: “Radiographically, the teeth have bulbous crowns with narrow roots, and a constriction at the cervix.” 2

MASKING THE DARKNESS

When Tara Meachum, DDS, of Greenville took over Mia’s care from a pediatric dentist in 2016, she recognized DI immediately—even though she’d never had a patient with the disorder.

“When I first met her, I did quite a bit of research,” says Dr. Meachum.

She knew that, at the very least, multiple implants and crowns were in Mia’s future. But Mia was not yet 14 so her jaw had some growing to do. At this point, her teeth were still functional, but their dark, translucent appearance bothered and embarrassed Mia.

“Whenever I knew my picture was being taken,” she recalls, “I always made sure I had my mouth closed and my teeth weren’t visible.”

Dr. Meachum addressed that situation in a marathon, eight-hour session with Mia in August 2016, applying composite veneers to all of her teeth. “We masked the darkness with composite,” she explains. To say that Mia was a cooperative patient would understate things. “She was a dream

Mia McNinch of Rockford before and after she was treated for dentinogenesis imperfecta by oral surgeon Roseanna P. Noordhoek, DDS, FACS, in partnership with Mia’s general dentist, Tara Meachum, DDS.

to work on,” says Dr. Meachum.

It was in Mia’s junior year of high school that her teeth began fracturing—and oral surgeon Roseanna P. Noordhoek, DDS, FACS, of the Center for Oral Surgery & Dental Implants in Rockford and Grand Rapids, began extracting them as needed.

“Her deterioration happened really quickly,” Dr. Meachum recalls. It soon became apparent that a game of toothby-tooth whack-a-mole was not going to suffice; a more comprehensive remedy was needed. “We were like, ‘Okay, we need to do something right now.’”

Dr. Noordhoek agreed, she says, noting that Mia “was coming in every two to four months with another fractured tooth.”

DECIDING ON A TREATMENT PLAN

Mia was also Dr. Noordhoek’s first DI patient. Due to Mia’s young age (18) and rapid loss of teeth, she went through multiple treatment plan options with Mia, her mother and Dr. Meachum. Then, on Zoom sessions with a laboratory technician, the two clinicians collaborated in developing the best treatment plan for Mia.

By this time, it wasn’t simply a matter of aesthetics. Yes, Mia’s teeth were small and worn down. “They looked like primary teeth in an adult person’s mouth,” recalls Dr. Noordhoek. But also, due to her loss of vertical dimension and her multiple edentulous spaces, a class III malocclusion had developed and her chewing was compromised. “We had to figure out if she needed corrective jaw surgery,” the oral surgeon says.

Mia’s mother hoped that a single ambitious treatment would correct things for Mia permanently. The two clinicians gently explained that a guaranteed “forever” fix wasn’t possible. It’s in the nature of DI that continued deterioration was likely in store. The

hope was to leave Mia as many future options—and as much bone to work with—as possible.

Thus, the decision went against using a full arch implant hybrid prosthesis, for which Dr. Noordhoek would have needed to remove teeth that were still functional, and also against removable dentures.

“The plan we chose was the least invasive one that still corrected her bite,” says Dr. Noordhoek. “She would be able to keep all of the remaining teeth that had not yet fractured. They’d be covered with full crowns to help keep them, hopefully for another decade or so while at the same time opening her vertical dimension of occlusion and placing her again in a class I position.” In a full-mouth dental reconstruction, she would receive implants with crowns for the missing teeth. “And we can still have a plan B for later on. If Mia does end up needing to go to an all-on-4, we’ll still have some bone left to do that on.”

FOR TIMING, A BALANCING ACT

Dr. Meachum sent Mia’s STL files and CBCT scans to an aesthetic laboratory and had them remake her teeth in wax— “with full-coverage crowns and with implant teeth”—so that Mia could wear the resulting acrylic “mock-up” to make sure her jaw muscles could comfortably adapt to the new form.

Because Mia had grown accustomed to her too-small teeth, the mock-up teeth felt “noticeably larger than what I had,” she recalls. “It felt like a mouthful at first.” But fortunately, Mia was able

to adapt, and orthognathic jaw surgery wouldn’t be necessary.

In early 2021, Drs. Meachum and Noordhoek faced a delicate balancing act in terms of timing. “When I started practicing a decade ago, it was considered okay to put anterior implants in 15- and 16-year-old girls,” Dr. Noordhoek explains. “But a lot of new literature shows that we’re really not finished with the micro-growth of our anterior jaws at those ages—and sometimes even into our 30s.”

Thus, one worry was whether Mia had enough maxillary maturity to accommodate the implants. Measured against that was pressure to act right away to relieve Mia’s already damaged chewing and give her a new smile in time for her freshman year at Michigan State University in the fall of ’21. The clinicians weighed the benefits against the risks and decided that her other teeth had to be given full-coverage restorations as quickly as possible, and posterior occlusion would be necessary to support this rehabilitation.

On July 1, 2021, using a comprehensive digital plan based on 3D X-rays, Dr. Noordhoek employed fully guided technology to place five maxillary implants. When they had healed enough to accept crowns, Dr. Meachum—in another marathon eight-hour session in September 2021, and a further visit in January 2022—placed crowns on 20 existing teeth and on the new implants too.

“Normally I would have made the crowns on the regular teeth while we were waiting for the implants to heal,”

Surgery

Dental Implants

“I’ve received so many positive comments on my smile that I never thought I would get.”

Mia McNinch, patient

A SUCCESS STORY IN TREATING DENTINOGENESIS IMPERFECTA

Dr. Meachum explains. “But she would only have been biting on her front teeth, and they would have just broken. Plus, it would have looked terrible.”

A CHANCE TO ‘SHINE’

Unfortunately, Mia had no dental benefits coverage and her family’s medical plan didn’t cover congenital dental conditions. Dr. Meachum and Dr. Noordhoek planned to donate their considerable time, but there remained the substantial cost of the implant components and lab fees. But when Dr. Noordhoek mentioned Mia’s case to a representative of the Straumann Group, the Basel, Switzerland-based implant vendor she often uses, the rep said, “That sounds like a really good case for our ‘Let Them Shine’ program.”

Through that initiative, Straumann offers financial assistance to help provide implants to patients who can’t afford the treatment. Mia’s family isn’t poor, but the heavy treatment cost necessitated by her hereditary condition could have blown a vast hole in the budget of even the most solidly middleclass family. It would have equaled “definitely a couple years in college,” Mia says with a laugh.

So Dr. Noordhoek set about preparing an application for Mia to the “Let Them Shine” program. That required organizing the information she’d gained about DI, describing Mia’s history and writing up a detailed treatment proposal. It was four or five months before she received a response as, evidently, the pandemic had slowed the decision process.

During that time, Dr. Noordhoek had

to proceed with the surgery to meet the timetable for Mia’s departure for college in the fall. But, finally, good news came—Mia was approved for the funding. In a thank-you letter to Straumann, Mia called the program “a blessing and a life-changer.”

As she turns 20 this October and ceases to be a teen, Mia is embarking on her second year at Michigan State, majoring in environmental biology and plant biology. She knows that her future will probably include further dental challenges. She’s still cautious about eating sticky things, she says, but less so than she was with her original teeth “because I know these ones are stronger than my teeth were naturally.”

“I’ve received so many positive comments on my smile that I never thought I would get,” Mia reports. While the difficulties caused by her DI have “kind of swayed me against having kids” because of the hereditary risk, she says that if she did have children, she would

reassure them that “there are ways to fix it.”

Dr. Meachum and Dr. Noordhoek look forward to years of being there for Mia when she needs them.

“I want Mia to still be my patient when she’s 40, if I’m still practicing,” says Dr. Noordhoek. “At our office, we’re always focused on collaboration with our referring doctors for the best outcome. As this case shows, when we work together we can make a truly dramatic change in someone’s life.”

REFERENCES

1.  Jeffrey Dean, DDS, MD, Acquired and developmental disturbances of the teeth and associated oral structures, in David R. Avery and Ralph E. McDonald, ed., Dentistry for the Child and Adolescent, 2022, downloaded via ScienceDirect.

2.  Kawther Taleb, et al, Dentinogenesis imperfecta type II—genotype and phenotype analyses in three Danish families, Molecular Genetics & Genomic Medicine, 2018 May; 6(3): 339–349.

Mia McNinch’s immediate postoperative panoramic X-ray

FOR A HAPPY RETIREMENT,

RESIST THESE 4 TEMPTATIONS

FOR A DENTIST—especially one who owns his or her practice—planning to retire is a very emotional thing. But if you trust your gut instincts, you’re liable to screw it up.

Often, you must go against the grain of your inclinations for the big decisions involved in selling a practice and retiring, says Novi, Michigan-based transition specialist Patrick W. Houlihan, DDS.

Dr. Houlihan has been advising dentists on practice transitions for 20 years, and three years ago he sold his own Plymouth, Michigan, dental practice and made such consulting a full-time focus. The biggest potential threat to your happy retirement, he insists, isn’t financial. It’s emotional. It’s YOU.

It’s only human to feel these four temptations. Your job is to resist them.

1 The temptation to go it alone.

Typically, your retirement planning will include the sale of your practice and a deal by which, for a time, you work for the new owners to ease the transition for patients and staff. Attorneys and accountants must

handle official duties only they can perform; beyond that, many businesssavvy dentists believe that with their smarts they can make the big decisions unaided. Put that thought in the waste receptacle—you’ll need help.

“As dentists, we think we’re pretty smart people who can figure anything out,” Dr. Houlihan says. “But our information is limited to our experience. We don’t often see what’s happening in the dental marketplace in general.”

Now 65, Dr. Houlihan walked the walk when he sold his own practice. “I’ve quarterbacked over a hundred of these deals, and still I didn’t trust myself to handle my own,” he says. “It’s too hard. It’s too personal.”

2 The temptation to take transactions personally.

The biggest mistake retiring dentists make, says Dr. Houlihan, is viewing their practice sale price as a measure of their professional worth. “They believe they need a certain figure—or a certain scenario—to validate their practice career,” he says. “They’ll say, ‘You mean I worked for 35 years taking

care of these people, coming in on Saturdays for emergencies, and this is all it amounts to?’

“When it ends, it’s business,” continues Dr. Houlihan. “It’s not a personal thing. Obviously, you want to make sure your patients are well taken care of. But you can’t let the business side determine how you view your professional life.”

3 The temptation to kid yourself about corporate buyers. There’s nothing inherently wrong with selling to a corporate entity, Dr. Houlihan says. Often, it’s the most lucrative option. But don’t sell your private practice to a chain and expect its culture not to change. “These companies buy a practice to grow it for their investors,” he says. “They don’t want it to stay the same. To grow a practice, you have to do things differently.”

What you don’t want is to recall your practice sale with regret. At a minimum, Dr. Houlihan recommends, “make absolutely sure you speak with five or six dentists who have sold to that corporation, hopefully more than two months ago. And seek out names the company didn’t give you to call.”

4 The temptation to see retirement as all-or-nothing. “Retirement should be going to something, not just leaving something,” advises Dr. Houlihan. Today, locum tenens work (on a schedule you craft), teaching, supervising younger dentists in university outreach programs and doing charity dental work overseas are among the myriad ways you can stay intellectually and socially engaged in your field and still have the increased leisure you crave.

“Golden years” platitudes aside, retirement can be an alluring picture. And after all, not all temptations need to be resisted.

OFFICE-BASED ANESTHESIA: 5 KEY POINTS

1PATIENT SELECTION IS KEY. Dentists choose patients to refer to oral surgeons based on the dental complexity of the case and their knowledge of the patient’s medical history—along with their confidence in the surgeons. But that’s just the start of the selection that must take place. “The number-one requirement for making sure anesthesia is safe for our patients is patient selection,” says Dr. Van Heukelom. “We have a range of different anesthesia options to offer, from traditional numbing with lidocaine to anti-anxiety medications patients take before coming in to nitrous oxide and different depths of intravenous anesthesia. And it’s important to understand that not every patient is a good candidate for all of those different treatment options.”

GENERAL DENTISTS and oral surgeons are kindred spirits in that they put patient safety first. Anesthesia has inherent risks which are minimized as much as possible with proper training, preparation and case selection—and therefore no issue is more important than patient safety. At the Center for Oral Surgery & Dental Implants (COSDI), Emily J. Van Heukelom, DDS, states, “Our practice exceeds all of the anesthesia safety standards in the state of Michigan and nationally.” Besides being board-certified in oral surgery, the clinicians at COSDI are certified by the National Board of Dental Anesthesiologists as well. Such is COSDI’s passion for patient safety that its doctors and surgical assistants all have advanced cardiac life-support training too, and basic life-support training is given to all employees, including those at the front desk and in the call center.

It’s little surprise, then, that Dr. Van Heukelom is one of Michigan’s leaders in understanding the safe use of anesthesia in the office. She was recently appointed by the Michigan

Society of Oral and Maxillofacial Surgeons to head its Office Anesthesia Evaluation Committee in Michigan. That means, as she explains, that AAOMS in Michigan has put her in charge of “making sure that we’re doing our periodic peer evaluations up to the highest standard.”

But Dr. Van Heukelom isn’t alone in having served as an anesthesia resident—such experience is required of all COSDI surgeons. The team’s newest member, Mark N. Grinzinger, DDS, MD, recalls “working under an MD anesthesiologist just as any other anesthesia resident would,” seeing patients preoperatively, doing an evaluation of their airway needs, handling anesthesia during procedures of various kinds and following up to make sure patients were ready for their next destination, either home or a hospital bed.

The anesthesia experience of Drs. Van Heukelom and Grinzinger and their colleagues at COSDI suggests five points they stress with referring dentists—just as they’re always eager to learn, in turn, from these dentists.

Says Dr. Grinzinger: “It’s part of our training to be prepared to intervene when necessary to rescue a patient who slips into a deeper-than-intended level of sedation” or to handle an airway or medical emergency. But heading off the risk of such an event beforehand is obviously preferable. Thus, some patients aren’t good candidates for sedation in the officebased “single-provider” model in which the anesthesia is controlled by the same person who does the procedure. “The reason we have such a good safety record,” he continues, “is because we’re selective about the people we sedate.”

Patients who might not be safe candidates for in-office sedation include: moderate to severely obese patients; those with uncontrolled diabetes; daily marijuana users; elderly patients with dementia; people with difficult airways; those with brain or central nervous system injuries; individuals with Down syndrome; and those born with congenital heart defects. These conditions may sometimes require that even relatively

simple dental extractions and other procedures be performed in a hospital with a medical anesthesiologist on the job. COSDI regularly works with three affiliated Spectrum West Michigan hospitals—Blodgett Hospital, Butterworth Hospital and Helen DeVos Children’s Hospital—to serve these patients’ needs.

2ORAL SURGEONS ARE SPECIALISTS.

Individuals in the previously mentioned categories don’t always require treatment in a hospital.

Sometimes traditional numbing may suffice. When dentists think of what’s practicable in an office setting, they should remember that oral surgery practices such as COSDI have especially well-equipped facilities that can sometimes make even challenging procedures surprisingly straightforward and quick. “Dentists are sending patients to us for specialty-level care,” says Dr. Van Heukelom. Accustomed to a steady stream of complex multiple extractions procedures—for example, patients present with unusual anatomy of the roots—oral surgeons often can perform these procedures with great efficiency. It stands to reason that professionals become more effective at tasks they perform frequently.

For that reason, Dr. Van Heukelom explains, it’s important to give positive expectations about working with an oral surgeon. A patient may question the need for a referral (“You took out those other teeth of mine 10 years ago—why not these?”) when in fact the new situation may be notably different (“Ten years ago you weren’t an insulindependent diabetic taking two blood thinners”). The wise dentist doesn’t habitually suggest to patients that going to an oral surgeon means being “put to sleep so you won’t remember a thing.” In point of fact, among the available levels of sedation, being “put to sleep” may not be safely possible

in some cases—and may not be necessary in others. And sometimes patients assume that they’ll be “out” even when they’re not told so in so many words. “It’s not only what the dentist says,” Dr. Van Heukelom points out. “It’s also what the patient hears.”

3

A CONSULTATION HELPS. To make sure an oral surgeon’s plans and a patient’s expectations coincide, COSDI’s professionals schedule an in-person anesthesia consultation with patients who face complex oral surgery. On a no-pressure day prior to the surgery, patients discuss their medical history, hear their options for anesthesia explained and, where appropriate, are asked to make a choice. Says Dr. Van Heukelom: “We have a terrific facility and are ready to provide top-level care. Part of doing that is a custom patient evaluation to make sure we offer a plan that is a good fit for the patient.”

frequency is a middle-aged patient who is 80 pounds overweight, snores loudly, is tired during the day and is taking medication for diabetes. Even if the patient has not gone on to have underlying medical issues diagnosed, from an anesthesia standpoint, they must be assumed to have underlying obstructive sleep apnea and cardiovascular disease. In this situation, the oral surgeon may look to collaborate with the patient regarding anesthesia options or possibly to work with the patient’s physician to optimize patient health before surgery.

5

PATIENTS ARE CHANGING . Over the last two decades, Dr. Van Heukelom stresses, the problem of obesity has grown phenomenally in the U.S. Dentists and oral surgeons also face patients who are living longer with numerous other comorbidities that complicate both treatment and the necessary anesthesia. Thus, it’s more common to encounter, say, an elderly patient with dementia—even such a person in robust physical health may be a poor candidate for sedation because of its effects on memory. And the anesthesia decision may turn not simply on this patient’s physical condition and medical history, but also on his or her social circumstances.

4

Does the elderly patient live in a facility that provides memory care or at home with a capable spouse and an adult child nearby? Or does someone simply check in on him or her twice a week?

That distinction can matter. Another situation that comes up with increased

KIDS ARE DIFFERENT. The truism that children are “more than just miniature adults” goes double when it comes to anesthesia. “With pediatric patients, the main issue is dosing,” says Dr. Grinzinger. “You need to understand weight-based medication dosing. Children have a much lower physiologic reserve; they tend to go downhill faster should something go wrong. So, you really need to be on your toes when you’re sedating a child. Their airway is much different anatomically from an adult’s—it’s higher and more anterior. A child’s epiglottis is larger and floppier. And children are more difficult to intubate should that need arise. You need pediatric anesthesia training.”

COLLABORATION IS KEY

This era of dentistry and oral surgery is full of new opportunities—and new challenges. Electronic medical records can make a patient’s history more accessible, but dentists must act to make sure they’re “in the loop” with those records.

When dentists and oral surgeons share insights and experience, the resulting two-way flow of information can be good for both. That’s its second most important benefit. Benefit number one? Of course, it’s good for the patient too.