Featuring Don Kalant, DDS
From the early days of paper scheduling books and payphones to the current era of electronic charting and 3D imaging, the field of oral and maxillofacial surgery has undergone a remarkable transformation over the decades. Don Kalant, DDS, an OMS practitioner with 37 years of experience, has witnessed these sweeping changes in his profession.
In this Q&A, Dr. Kalant's insights reveal how patient demographics, expectations, and preferences have influenced oral and maxillofacial surgery through the years. Advancements in pain management, anesthesia techniques, and technology have led to safer and more efficient patient care. Dr. Kalant also shares his excitement for potential advancements in AI and tissue engineering, envisioning a promising future for the field.
How have you witnessed the field of oral and maxillofacial surgery evolve throughout your career, in terms of surgical techniques, technology, and patient care?
I have seen a tremendous number of advances in surgical techniques, materials, practice management, and patient care. Regarding practice management, when I first started, practice scheduling was done in a paper scheduling book, daily fees were logged on a pegboard, and there were no computers, scanners or fax machines.
I remember when we obtained our first fax machine. I thought it was the greatest invention in the world. Things have developed rapidly over the years, all for the better. Cell phones that were available were extremely expensive and did not have a broad range. I had a calling card that I used at pay phones to call into the answering service when paged. Imagine driving down the highway, getting paged, and having to frantically look for a payphone, either on the expressway or having to pull off to find a gas station that had one.
With all these advances, patient care has become much easier. Electronic charting has made the flow more efficient. Patients can fill out their registration forms online, have text messages sent to them via cell phone to remind them of appointment times and electronic billing has streamlined our collection protocol.
What were some of the major challenges faced by oral and maxillofacial surgeons in the early years of your career, and how have they been addressed or changed over time?
When I trained back in the 1980s, the area of maxillofacial surgery was advancing exponentially through the dedication of our forefathers. Those surgeons dedicated their careers to advancing our specialty to where we are today. Many younger surgeons are not aware of the restrictions we encountered, including managing pan-facial trauma, craniofacial deformities and extensive reconstructive procedures, as well as having hospital admitting privileges and performing history and physical examinations. I remember hearing stories from my attendings actually having verbal and physical confrontations with other surgical specialties in order to obtain the privileges we take for granted today.
Today’s residency programs are equally staffed with talented and dedicated surgeons continuing to increase the scope of our specialty. I have practiced a full scope of oral and maxillofacial surgery my entire career and never had any issues with obtaining hospital privileges for any procedure I showed competency in. With this being said, I feel it is important for younger surgeons to continue performing these procedures, and it saddens me to see so many pushing away from this part of our practice.
Can you highlight any significant advancements or breakthroughs that have occurred in the field of oral and maxillofacial surgery during your career?
When I completed my residency in 1986, we were still using wire osteosynthesis to treat maxillofacial
trauma and orthognathic surgical cases. Rigid fixation was just beginning to evolve into the maxillofacial field. Dental implants were introduced in 1984 to the United States, with a multicenter study being formed to investigate their efficaciousness. I placed my first implant in 1987. There were no specific bone grafting techniques nor a consensus on the surface preparations for implants. Some were pure titanium, others had hydroxyapatite coatings, and some had plasma-sprayed surfaces.
Over time, we have evolved into an understanding that pure titanium implants offer the best success. Regarding bone grafting techniques, sinus graftings were just being performed as well as onlay grafts. Allogenic bone grafts and Xenografts were also being introduced. Collagen membranes of all different types and sizes, including resorbable and non-resorbable were being fabricated. The use of platelet-rich plasma and now platelet-rich fibrin has become an essential adjunct in bone grafting techniques. Of equal importance has been the introduction of bone morphogenic protein for more extensive reconstructive procedures and custom titanium mesh trays for ridge augmentations.
The revolutionary implant-supported fixed/detachable prosthesis has offered patients a change in their quality of life. The field of temporomandibular joint surgery also became an area of controversy as well as great advances. The proplast disc implant was introduced back in the 80s and unfortunately caused significant postoperative problems and was eventually taken off the market. This made way for other forms of grafting, including ear cartilage, dermis grafts as well as silastic membranes, all with their share of less-than-desirable results. Temporomandibular joint arthroscopy was introduced in the late 80s and early 90s as well as the arthrocentesis procedures. Probably the greatest breakthrough in temporomandibular joint surgery was the development of the total joint replacement prosthesis. Today, there are two available, Biomet non-custom prosthesis and the Stryker (TMJ Concepts ) custom prosthesis.
In the area of imaging, the 2D Panorex was the workhorse for many years in my practice. In the mid-2000s, the CBCT was introduced to the dental field and over the years has become perfected. In conjunction with 3D printing technology, orthognathic cases as well as dental implant cases can be treatment planned more efficiently and predictably.
How have the treatment approaches for common conditions or procedures and oral and maxillofacial surgery evolved over time?
Regarding orthognathic surgery, the use of 3D imaging and planning has improved predictability and stability. Now, with custom-fabricated rigid fixation plates, the surgical time has been reduced. This aids with the patient’s recovery, as well as shortening the postoperative hospital stay. The 3D planning has taken a three to four-hour presurgical workup to less than half an hour, with much more accuracy with the planning as well as the fabrication of the surgical splints.
In your experience, what are some of the key considerations and advancements in pain management and anesthesia techniques within oral and maxillofacial surgery?
The management of anesthesia and pain control has evolved tremendously from when I started practice. The pulse oximeter was introduced near the end of my training. This allowed for more predictable monitoring of a patient’s respiratory function. The introduction of the end-tidal CO2 monitor adds another layer of safety for in-office anesthesia procedures. The ECG monitors are more compact and efficient, many which come with the above monitors as part of the system. The AED has been a great addition to our emergency armamentarium. Advances in intravenous anesthesia medications have changed the delivery of office-based anesthesia.
During my training and early years of my practice, the standard intravenous medication protocol included Valium, Demerol and Brevital. For those who never have had the experience with this anesthesia protocol, be thankful. We are now fortunate to have more efficient medications, including Versed, fentanyl, propofol, ketamine and sufentanyl. There are other medications on the horizon which will be beneficial. Postoperative pain control management has also taken a paradigm shift. The use of narcotics has been limited and non-narcotic medications including Toradol, ibuprofen/acetaminophen regimen, and long-acting local anesthetics such as Exparel are showing promising results.
Have you observed any change in patient demographics, expectations or treatment preferences in oral and maxillofacial surgery over the years, and how has it influenced the way you provide care?
Regarding change in demographics, with three office locations, we have the opportunity to treat a diversity of patients. This is exciting since many patients have not had access for quality surgical care.
Over the 37 years of practice, the most frustrating aspect has been the insurance industry. As we all know, their reimbursements have continued to decline, and maximum benefits have not increased. Unfortunately, patients have become more insurance-driven when making decisions for their care and tend to shop around more. With this being said, we do participate in several dental-managed care programs. However, my standards have not changed nor will they in the future regarding patient care.
The Internet has altered patients’ expectations regarding the healthcare industry in general. The adage “a little knowledge is dangerous” has proven to be correct. We’re more scrutinized as well as questioned regarding treatment outcomes. Patients have come to believe that everything should be perfect, and no alteration of their perceived treatment outcome should occur. This has made it extremely difficult to continue to practice in this ever-growing litigious society.
Are there any specific emerging trends or areas of research and oral and maxillofacial surgery you find particularly exciting or promising for the future?
I can only imagine what the future brings for our profession. I’m excited to see where AI may offer new treatment and diagnostic opportunities. I feel there will be advancements in the field of implant and reconstructive surgery. Tissue engineering for autogenous hard and soft tissue growth, including teeth. If the next 35 years show the same growth potential as the previous 35 years, one can only imagine how our field will change.
Dr. Kalant is a graduate of Loyola University School of Dentistry. He served his residency in oral and maxillofacial surgery at Loyola University and Hines V.A. Medical Centers. He has been in private practice for over 35 years performing a full scope of surgery. In addition, he was assistant clinical professor of surgery at Loyola University actively involved in surgical resident training. He is a Diplomat of the American Board of Oral and Maxillofacial Surgery. He is a fellow of the American Association of Oral and Maxillofacial Surgeons, the American College of Oral and Maxillofacial Surgery, American and International College of Dentists, and American Society of Temporomandibular Joint Surgeons. He has been a member of and held offices in many professional societies. His areas of interest and expertise include dental implantology, orthognathic surgery, and surgical management of temporomandibular joint disorders. In his free time, he enjoys cooking, golfing, and spending time with his family.