FALL 2021
FROM THE CENTER FOR ORAL SURGERY & DENTAL IMPLANTS 4
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• New Patient Chairs • Welcome Dr. Grinzinger!
Better Outcomes for TMJ Disorder Surgery
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4 Reasons to Prepare Now for ICD Coding
• Fall CE Event • Dr. Julie Billups Retires
Our surgeons, from left: Justin M. Pisano, DDS, Roseanna P. Noordhoek, DDS, Emily J. Van Heukelom, DDS, Richard W. Panek, DDS, and Mark N. Grinzinger, DDS, MD.
COMMITTED TO EXCELLENCE Welcome to the second issue of our clinical update newsletter! We hope you find it helpful and invite you to suggest any topics you’d like to see covered (just give us a call to request). We welcome referrals from colleagues and invite you to speak to any of our surgeons to discuss the needs of your patients. Informal inquiries are welcome. We look forward to hearing from you! Warm regards, Richard W. Panek, DDS Emily J. Van Heukelom, DDS Roseanna P. Noordhoek, DDS Justin M. Pisano, DDS Mark N. Grinzinger, DDS, MD Contact one of our surgeons at 616-361-7327. OUR OFFICES
4349 Sawkaw Drive NE Grand Rapids, MI 49525
INSIDE TRAUMA CENTER CARE
STORIES FROM ORAL SURGEONS YOU COULDN’T CALL JOHN MACLEOD lucky, exactly, that day in November 2016. Lucky would have been not being shot in the face at all. But with that large exception, fortune was smiling on Macleod. How else, after a 410-gauge shotgun shell was fired at close range from a .45-caliber pistol at his face, could he be looking fine and speaking and chewing normally today? Says the 40-year-old electrical lineman from Lowell: “You can’t even tell I got shot.”
What helped was prompt treatment by several clinicians, including Richard W. Panek, DDS, from the Center for Oral Surgery and Dental Implants (COSDI). This case wasn’t typical—“a once-in-a-career injury for an OMFS,” says Dr. Panek. But it shows what the pros at COSDI must be ready for during weeks on call at a Level I trauma center. Though Macleod is fine today, trauma can create complications for future dental treatment. CONTINUED ON NEXT PAGE
158 Marcell Drive, Suite B Rockford, MI 49341
Center for Oral Surgery & Dental Implants | grandrapidsoralsurgery.com
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INSIDE TRAUMA CENTER CARE
STORIES FROM ORAL SURGEONS
A recent conversation with Dr. Panek and two partners reveals the breadth of their experience dealing with trauma cases—experience they’re happy to share. “If a patient with a prior facial trauma presents in your office, we’re happy to explain what procedures the patient had done in the hospital and, via video or an in-person chat, we’re always ready to consult to make a comprehensive treatment plan,” says Emily J. Van Heukelom, DDS. Such consultations can be very important, explains Roseanna P. Noordhoek, DDS: “A fracture in a joint can, years later, lead to an increased chance of arthritis. In addition, tooth luxations and fractures can have pulpal necrosis that doesn’t become symptomatic until later, and some occlusion problems will require orthodontic evaluation and treatment.” Permanent loss of sensation can result from a trauma, the oral surgeon adds, and there also may be fixation hardware left over from treatment that doesn’t show up on simple bite-wing X-rays.
HE DIDN’T MEAN TO SHOOT
Macleod was shot by a troubled family friend afflicted by a toxic mix of alcohol, drugs and resentment. The friend intended only to wave his pistol and warn Macleod and others off his property. But as he quickly raised the gun, it went off. “I know he didn’t mean to shoot me,” says Macleod. He was airlifted to Spectrum Health Butterworth Hospital in Grand Rapids, a Level I trauma center that draws cases from all over West Michigan. There he
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was given a tracheostomy to maintain his airway, and a feeding tube was inserted into his stomach. “The bullet entered between the chin and the lip and basically shattered the mandible and the teeth in the area,” says Dr. Panek. “Then it broke into several pieces. One piece went through the roof of his mouth into his nose. Two came off and went into his cheeks. The remainder went through his tongue and stopped right at his spine. Had it gone further, it probably would have severed his spine at the C3 or C4 level, and he’d be paralyzed.” Dr. Panek made a 12-centimenter incision under the jaw and “de-gloved” it, pulling the skin upward. Then he reassembled the jaw using seven titanium plates and 28 titanium screws. Macleod has his own way of describing the oral surgeon’s achievement. “They handed Dr. Panek a Ziploc bag full of bones and teeth,” he says, “and he put it back together like a jigsaw puzzle.” The doctors who first stabilized the patient made all this other work possible, as both Macleod and Dr. Panek stress. A spinal surgeon removed the bullet fragment near the spine, and a headand-neck surgeon extracted the one from
his nose. But when that surgeon saw the facial trauma left for Dr. Panek, he said: “Looks like you got the worst of it.” A year later, Dr. Panek removed some of the plates and screws along with additional bullet fragments. He also placed implants on which a prosthodontist secured a prosthesis. Today, Macleod’s scarring is limited to an inconspicuous semicircle under the chin. COSDI’s oral surgeons “are kind of a bridge between medicine and dentistry,” says Dr. Panek. Having completed a rigorous four- to six-year surgical residency beyond dental school, they’re among 13 oral surgeons in West Michigan who take turns on call at the Level 1 trauma center. Starting at 6 p.m. Monday and round the clock for a full week, the surgeon on call must respond within 20 minutes and if necessary be at the hospital within an hour. “We come in and cover all facial trauma services,” says Dr. Noordhoek, “and handle any other pathology or infections for patients admitted to the hospital for other medical reasons.” The oral surgeons also advocate for their emergency patients, helping to assure a smooth transition back to their regular dentist if they have one—or to find one if they don’t.
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ACCIDENT IN AN APPLE ORCHARD
In June 2019, Timothy Emmons of Sparta, 53, a corporate pilot, was driving an ATV in his apple orchard when he collided with a wire trellis tied to an apple tree. Summaries of his injury include a terrifying word: He was, in effect, partially decapitated. Emmons was driven to the hospital by his girlfriend—she didn’t wait for an ambulance—and taken straight to the O.R. After doctors gave him a tracheostomy and closed his neck wound, Dr. Noordhoek removed fragments of his broken right mandible to prevent infection or bone necrosis. But there were so many small fragments that would have lost blood supply if plates and screws were used that she had to wire Emmons’s jaw shut with arch-bars for six weeks while he took nutrition through a feeding tube in his nose. That, Dr. Noordhoek explains, is “our way of putting a cast on.” “It was uncomfortable having my jaw wired shut,” says Emmons. “But it healed back, no problem.” Because of the fracture, Dr. Noordhoek eventually removed tooth #31 and replaced it with an implant. Today Emmons is grateful that he didn’t lose any taste or smell and can bite normally. There’s some loss of sensation in the skin over part of his jaw, he says, but “most of the time I don’t even notice that.”
EQUIPMENT FAIL ON THE SLOPES
Downhill ski racer Georgette Sake, now 16, of Cadillac was hitting a slope February 24, 2021, after a competition at Caberfae Peaks. Suddenly, the binding came loose on one ski. Trying to proceed on the other, she collided with a tree—and the impact broke her helmet, a POC-brand racing model of recent construction. She also broke an arm and suffered internal injuries. “Georgette was doing things right,” says Dr. Van Heukelom. “She was wearing a quality helmet. She was skilled enough to be skiing where she was. But she had an equipment malfunction.” Again, there’s a bright side. “Having the appropriate helmet probably saved her life,” says the oral surgeon. “It certainly saved her from a devastating brain injury.” Georgette was transported to Helen DeVos Children’s Hospital. As the surgeon’s notes report, she suffered “a severely comminuted and displaced fracture of her left mandibular angle and body, a minimally displaced fracture of the right mandibular parasymphysis, as well as multiple fractures of the left maxillary sinus and floor of the orbit.” She’s responded well to treatment, which stabilized bone to allow healing and aligned the teeth. Some pain has developed around tooth #18, but that’s no surprise. “That molar was deeply embedded in the fracture segments, and I used it short-term to help stabilize
things, knowing that it wasn’t going to be a good tooth for her long-term,” Dr. Van Heukelom explains. Soon, she plans to extract that molar and remove one of the adjoining plates. After letting the bone grow stronger for a few months, she’ll address a wisdom tooth that was displaced by the injury. Georgette’s case shows how trauma can create continuing dental issues. “Some of her lower front teeth have been displaced,” says Dr. Van Heukelom. “They’ll probably be fine for years. But when she’s in her 40s or 50s, they may start to fail. Knowing that she has this trauma history might influence a dentist’s decision whether to use neighboring teeth to create a bridge or go with dental implants or other choices.” Thus, it’s imperative to have the best possible records on a patient’s history, including any traumas. And when a dental patient has suffered trauma, it can be valuable to consult with the surgeons at COSDI—even if they weren’t the ones who treated the trauma. Meanwhile, for these patients, gratitude extends into personal admiration. Says Macleod of Dr. Panek: “He’s one of the greatest guys I’ve ever met in my life. He deserves an award.” Emmons is equally enthusiastic about the “fantastic job” done by Dr. Noordhoek. “She’s a saint!” he says. And Georgette’s mom, Andrea Sake, when asked about Dr. Van Heukelom, responds: “Oh, my gosh! We love her!”
Center for Oral Surgery & Dental Implants | grandrapidsoralsurgery.com
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brumaba.com
3 CHEERS FOR THE CHAIRS—
A LESSON IN ERGONOMICS
YOU DON’T BUY NEW PATIENT CHAIRS every day, and neither do the oral surgeons at our office. The practice’s current chairs were acquired in 1994, just before we all started using a novel thing called email. It’s time to start replacing them, so the practice is investing in ergonomic patient chairs from German manufacturer Brumaba.
The new chairs accommodate bariatric patients up to 660 pounds, while the old ones had a 330-pound limit. They also cradle a patient’s head and neck more effectively, assuring greater comfort for those with limited neck mobility. For administering anesthesia, this improved support helps patients maintain “what we call
AN OLD FRIEND BECOMES A NEW COLLEAGUE RICHARD W. PANEK, DDS, could have scoured the globe for a new oral surgeon for the Center for Oral Surgery and Dental Implants (COSDI) and not found a better-qualified candidate than the kid who grew up next door. Grand Rapids resident Mark N. Grinzinger, DDS, MD, 32, who joined the practice this summer, was Dr. Panek’s next-door neighbor in Rockford for years. As a sophomore at Rockford High he “job-shadowed” Dr. Panek for a day—and quickly dropped ideas of becoming a pilot to aim at an oral surgery career instead. “He was a really smart kid from a great family,” says Dr. Panek. “I could tell he had good hands. He liked building models—not just plastic ones
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a ‘sniffing’ position, with the airway open,” as Emily J. Van Heukelom, DDS, explains. The surgeons will benefit too. “Plenty of studies show the long-term detrimental issues of ergonomics for dentists and surgeons, including our high rate of career-ending disability,” says Dr. Van Heukelom. The new chairs help in two principal ways: The contour of the shoulder support is tapered so that the surgeon can move in closer and needn’t reach as far—and therefore doesn’t have to maintain an awkward position. In addition, the chairs can tilt from side to side like a banking airplane, so that the surgeon can keep his or her neck and torso upright for less cumulative strain. View a video of the new chairs at www.bit.ly/COSDIchair, or stop by our Grand Rapids office to check them out!
you assemble, but airplanes made with balsa wood and paper.” A 2011 Michigan State graduate, Dr. Grinzinger finished at the University of Michigan School of Dentistry (where Justin M. Pisano, DDS, another member of the COSDI team, was a classmate and friend) in 2015. Then came more training, with an MD at Wayne State’s medical school followed by a residency in oral and maxillofacial surgery in Detroit’s Ascension St. John Hospital system. Dr. Grinzinger will practice full scope oral surgical procedures, see patients at our Rockford and Grand Rapids locations and be on staff at Spectrum Hospital. Dr. Grinzinger, who will marry fiancée Andrea Adams in October, lauds the “family feeling” he finds at COSDI. He plans to welcome his patients like old friends and neighbors. In many cases, that’s exactly what they’ll be.
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Temporomandibular joint arthritis and anteriorly displaced disk.
BETTER OUTCOMES FOR TMJ DISORDER SURGERY PAIN AND RESTRICTED JAW function due to temporomandibular joint (TMJ) disorders make it difficult for patients to eat and speak, leading to significantly reduced quality of life. Usually caused by degenerative changes or mechanical disturbances, TMJ disorders are most common in middle-aged women. In about 10% of cases, conservative therapy, such as a bite split, physical therapy, a soft diet and NSAIDS, aren’t enough to relieve pain and improve function of the TMJ. “If a patient has tried conservative therapy for a minimum of three months and has had no or minimal improvement, I recommend a consultation with an oral surgeon,” says Justin M. Pisano, DDS, an oral surgeon at the Center for Oral Surgery and Dental Implants. One of a few TMJ surgeons in West Michigan and the surrounding area, Dr. Pisano completed a fellowship focused on TMJ surgery with one of the foremost TMJ surgeons in the world: George Dimitroulis, MDSc, FDSRCS, FFDRCS. Dr. Dimitroulis is senior consultant maxillofacial surgeon at St. Vincent’s Hospital in Melbourne, Australia.
Predictable Surgical Outcomes
Indications for surgery include limited mouth opening, jaw locking and osteoarthritis of the TMJ. When a thorough evaluation shows that surgery is indicated, minimally invasive techniques and other advances in surgery and biomaterials enable Dr. Pisano to safely and effectively restore, repair or remove damaged or diseased TMJ tissue. “TMJ disorder surgery has evolved a lot in the last 20 years,” says Dr. Pisano. “Today, we’re able to address disturbances in the TMJ surgically with excellent predictability and outcomes.” He uses TMJ Surgical Classification to determine which procedure is appropriate for each patient. Minimally invasive techniques can help relieve pain and restore TMJ function in most cases. Arthroscopy and arthrocentesis, some of the most common procedures performed by Dr. Pisano, are both minimally invasive. These procedures break up adhesions in the TMJ that limit movement and lavage the joint with fluid to remove inflammatory cytokines and fibrous debris. Studies show that arthroscopy and arthrocentesis are both effective.1,2
Discectomy and disc repositioning, a common procedure for TMJ disorders, can reposition or remove a damaged disc. These procedures can significantly reduce pain and improve function. In one study, 82% of the 17 discectomy patients followed had significantly improved function and reduced pain, measured as clinically symptom-free or only small dysfunction.3 Total joint replacement is reserved for extreme cases. When this is the only surgical solution, Dr. Pisano designs a customized prosthesis for the patient, guided by 3-D reconstructions of CT scans. “More than 20 years of data demonstrate the success of TMJ replacement,” says Dr. Pisano. A study of 56 patients at a median of 21 years after undergoing a TMJ replacement found that the prosthesis continued to function well.4 Patients reported considerably less TMJ pain, improved jaw function and ability to eat solid food, and improved quality of life. REFERENCES 1. D imitroulis G. A review of 56 cases of chronic closed lock treated with temporomandibular joint arthroscopy. J Oral Maxillofac Surg. 2002;60:519– 524. 2. Holmlund AB, Gynther GW, Axelsson S. Efficacy of arthroscopic lysis and lavage in patients with chronic locking of the temporomandibular joint. Int J Oral Maxillofac Surg. 1994;23:262– 265. 3. Miloro M, McKnight M, Han MD, Markiewicz MR. Discectomy without replacement improves function in patients with internal derangement of the temporomandibular joint. J Craniomaxillofac Surg. 2017 Sep;45(9):1425-1431. doi: 10.1016/j. jcms.2017.07.003. Epub 2017 Jul 17. 4. Wolford LM, Mercuri LG, Schneiderman ED, Movahed R, Allen W. Twenty-year follow-up study on a patient-fitted temporomandibular joint prosthesis: the Techmedica/TMJ Concepts device. J Oral Maxillofac Surg. 2015 May;73(5):952-60. doi: 10.1016/j. joms.2014.10.032.
For more information about surgical treatment of TMJ disorders at the Center for Oral Surgery and Dental Implants, CALL 616-361-7327.
Center for Oral Surgery & Dental Implants | grandrapidsoralsurgery.com
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4 REASONS TO PREPARE NOW FOR ICD CODING IS YOUR PRACTICE READY for widespread ICD-10 diagnosis coding? If not, says Grand Rapids dentist Chris Smiley, DDS, a past chairman of the ADA Council on Dental Benefit Programs and current editor of the Journal of the Michigan Dental Association, it’s time to get ready. You know CDT codes, which identify procedures for patient recordkeeping and claims submission. ICD codes designate a diagnosis, not the service provided. The letters stand for International Classification of Diseases, and these codes are promulgated by the World Health Organization. There’s a place on the standard ADA claim
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form and the HIPAA standard electronic claim for ICD codes, but, except for use with some state Medicaid plans and for specific surgical procedures, they’re not required by dental payers—yet. ICD codes’ current incarnation—the ICD-10-CM (for “clinical modification”)— is the HIPAA standard maintained by the federal government that became effective in 2015, and it was a whopping change. While the predecessor ICD-9-CM had 13,000 different codes, ICD-10-CM boasts 68,000. “ICD-10 is extremely robust,” explains Dr. Smiley. “For example, there’s a code for ‘trauma from bite by a turtle.’ Then
there’s a separate code for ‘trauma from bite by a turtle—second occurrence.’ Somebody’s extremely slow in getting out of the way of that turtle!”
SEEKING DATA TO DRIVE DECISIONS
But diagnosis codes can’t be laughed away. They’re part of healthcare’s effort to use data to become more costeffective, and while medical doctors were affected first, that bell tolls for dentists too. ICD-10-CM codes are likely to be required by dental payers before long, and in mastering their use you can’t afford to be turtle-slow.
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“They’re coming,” says Dr. Smiley. “It behooves dentists and dental office billing staffers to start becoming familiar with them.” ICD-10-CM codes comprise a letter followed by two numerals, a period, then a varying number of further numerals (and sometimes letters). They can be tricky. Code K08.1, “complete loss of teeth,” for example, is followed on the list by 32 other complete-loss-of-teeth codes broken down by cause, including four classes each of trauma, periodontal disease and caries. To make sense of all this, Dr. Smiley swears by a volume called CDT Coding Companion: Training Guide for the Dental Team published by the ADA, which can be ordered from the member service center (800-621-8099) or online at ada. org. In it, CDT codes are “cross-walked” to appropriate ICD-10-CM codes. Additionally, CDT 2020 and CDT 2021 provide pertinent instructional detail found in Section 3, “Diagnoses for Dental Diseases and Conditions.” Your office likely already reports ICD-10-CM codes when billing medical insurers for treating conditions that bridge dentistry and general medicine. For example, for dental airway appliances used to treat sleep apnea; cone-beam/ CAT scan imaging; and dental repairs needed in treating auto-accident injuries. Samantha Hanes, business assistant supervisor at the Center for Oral Surgery and Dental Implants in Grand Rapids and Rockford, spends half her work day coding—and for oral surgery that includes ICD-10-CM. Her tip: “Make sure the doctors’ notes support the diagnosis code you choose.” To help her code diagnoses effectively—correctly identifying, say, an underlying condition that could have implications later in treatment—she relies on three tools: • Coding software from Salt Lake Citybased Optum360 (optum360.com) • A personal crib sheet of codes that come up most often
• Coding workshops put on by the Michigan Dental Association (MDA). To view the MDA’s current CE offerings, visit www.bit.ly/ MDA_CE or call 517-372-9070 and ask for the Continuing Education Department. “All payers are different,” says Dr. Smiley. “Seemingly, some administrators just look at the submitted services and the patient and provider information to process a claim. Others may synthesize all of the information on the claim form to build a profile to assess a provider’s effectiveness and/or measure the plan’s success at assuring access to care, utilization of services and cost containment.” What can practices do to prepare for the ICD era? For one thing, take Hanes’s hint and keep good treatment notes. By now, most practices have invested in chairside clinical software that makes it easier to record clinical information in detail. (If you haven’t yet, Eaglesoft, Dentrix and Epic are brands to check out, says Dr. Smiley.) But whether you click or scribble, you need to document detailed diagnosis information. For instance, says Dr. Smiley: “The hygienist should record what type of periodontal disease a patient has—type 1, 2 or 3—when care is provided to treat those conditions. Clinical notes should build a history there from past encounters with the patient to support treatment decisions.” No one’s suggesting you deputize a staffer to memorize the 68,000 ICD-10CM codes. “But he or she should know where to find them,” suggests Dr. Smiley. Again, a great resource is CDT manual Section 3, which presents a subset of some 750 ICD codes that are likely to be most relevant to the patient conditions encountered by dentists in practice.
HOW ICD CODES CAN HELP YOU
It’s not clear when payers will begin requiring dentists to enter ICD-10-CM
codes—it may depend on what new health reform legislation follows the election. But there are four reasons it could be smart to use these codes starting today: 1. T hey could reduce the need to file an appeal should a payer come back to you on a claim asking for information about why a service was needed. 2. T hey could protect you by documenting patients’ status. A 2013 journal article noted that such coding “could potentially provide private practitioners with beneficial information about the overall health status of patients in their practice.” For example: Suppose a payer’s data shows that your fillings fail at a higher-than-average rate. Information that ICD-10-CM codes provide could prove that those patients have a greater level of risk or rate of decay. 3. T hey could garner some patients an enhanced level of benefits. For patients with specific medical diagnoses, some dental plans provide added benefits. For example, they may cover additional cleanings and periodontal services for expectant mothers and patients with diabetes. Reporting an appropriate diagnosis code will allow for more complete documentation of your patients. 4. T hey’re the future. Reporting ICD codes may well be a way to reduce the need for claim attachments and supporting narratives, making the submission process more efficient. Says Dr. Smiley: “A dental office is going to be able to better serve the future needs of its patients (and get paid doing it) if it knows how to appropriately apply diagnosis coding with their claims submissions. The time to learn is now!”
Center for Oral Surgery & Dental Implants | grandrapidsoralsurgery.com
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4349 Sawkaw Drive NE Grand Rapids, MI 49525
FALL CONTINUING EDUCATION EVENT 4 AGD CONTINUING EDUCATION CREDIT HOURS PRESENTED BY
A FOND FAREWELL:
JULIE BILLUPS, DDS PLEASE HELP US WISH Julie B. Billups, DDS, a happy retirement! Dr. Billups has been with the Center for Oral Surgery and Dental Implants for 27 years. She was only the second female resident in the history of the University of Michigan’s prestigious OMS program and has had the longest practicing career of any female in the specialty in our state to date. Julie will definitely not sit idle in retirement, as she has been pursuing and growing her successful, award-winning jewelry business, Silverfish Designs. Make sure to stop by her website shopsilverfish.com or any number of local art galleries to see her work. Congratulations and good luck, Julie!
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DATE: October 22, 2021 TIME: 7:45 a.m. to 12 p.m. LOCATION: Frederik Meijer Gardens FEATURING KEYNOTE PRESENTERS:
MS. JANIS SPILIADIS
DR. JUSTIN PISANO The Role of Surgery in Temporomandibular Joint Disorders
The Implant Is Restored, Now What?
All doctors and auxiliary staff invited. RSVP
events@grandrapidsoralsurgery.com 616-361-7327 Register early to save your seat! 8/31/21 1:19 PM