Question for practicing periodontists

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Gentledental1

Truly, I'm not trolling when I ask this, I'm just curious. I was having a conversation with a co-resident (OMFS) of mine about periodontists doing surgical third molar extractions. We also recently experienced a complication ourselves where our patient aspirated a root tip from a third molar we were pulling. So I know how we handle that complication, but how does a periodontist (or any other dental provider for that matter) deal with this complication? Do you just send the patient to the ED and tell the patient to tell the physician what happened? Do you go to the hospital with them and try to tell the ED physician what you want them to order? Just not sure how someone without hospital privileges deals with these types of complications.

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I, also just for curious want to know how yourself handle that? Please advise. Tx
 
I, also just for curious want to know how yourself handle that? Please advise. Tx

Was that a question for the OP? I would order a stat CxR, perform my own H&P, admit them to the hospital if it was in their lungs, order and monitor their cbc/cmp/abg/vitals, consult ENT to do a bronchoscope if necessary...Etc. Thats why I'm curious what a periodontist would do. I don't think they'd dump it on OMFS since it can be time critical to treatment. I believe in an emergency setting its appropriate for them to quickly get the patient to the ED. What I'm wondering about is what their next step is.
 
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A periodontist would most likely be more careful so a root tip is not aspirated. Prevention is key for anyone performing a third molar extraction. They would most likely have a relationship with an ENT so like in the post above they could a bronchoscope if it was needed. May be focusing on what you should be doing (ext root tips safely) and not what others are doing (dental work ) will help your future practice.
 
A periodontist would most likely be more careful so a root tip is not aspirated. Prevention is key for anyone performing a third molar extraction. They would most likely have a relationship with an ENT so like in the post above they could a bronchoscope if it was needed. May be focusing on what you should be doing (ext root tips safely) and not what others are doing (dental work ) will help your future practice.

I applaude your zero complications approach to surgery. My question was directed at those of us that do experience complications during surgical procedures. I believe you did answer my question anyways, so you'd call your ENT buddy and tell him to go to the hospital to manage the patient. Fair enough.
 
Was that a question for the OP? I would order a stat CxR, perform my own H&P, admit them to the hospital if it was in their lungs, order and monitor their cbc/cmp/abg/vitals, consult ENT to do a bronchoscope if necessary...Etc. Thats why I'm curious what a periodontist would do. I don't think they'd dump it on OMFS since it can be time critical to treatment. I believe in an emergency setting its appropriate for them to quickly get the patient to the ED. What I'm wondering about is what their next step is.
Thank you Dr. for your expertise advice.
 
Was that a question for the OP? I would order a stat CxR, perform my own H&P, admit them to the hospital if it was in their lungs, order and monitor their cbc/cmp/abg/vitals, consult ENT to do a bronchoscope if necessary...Etc. Thats why I'm curious what a periodontist would do. I don't think they'd dump it on OMFS since it can be time critical to treatment. I believe in an emergency setting its appropriate for them to quickly get the patient to the ED. What I'm wondering about is what their next step is.
How do you know if the tooth is in the lung? Don't you need to have a chest Xray to find out? If my ortho patient accidentally swallows a metal orthodontic band in my practice, I wouldn't call my OMFS because I am not sure if he/she can do anything to help my patient. I don't think my OS's facility has the right equipments to handle such complication. First, I'd make sure the patient's airway is OK. Then, I would inform the patient's parents that there is a 50% chance that the orthodontic band could go to the lung. Then, I'd ask them to drive to the hospital for the chest x ray. And I just let the doctors at the hospital manage the complication if the molar band is in the patient's lung. That's how I was taught at dental school.

If I were a general dentist and performed dental extraction, I would probably use a 2x2 gauge to minimize the chance of tooth tip aspiration.
 
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How do you know if the tooth is in the lung? Don't you need to have a chest Xray to find out? If my ortho patient accidentally swallows a metal orthodontic band in my practice, I wouldn't call my OMFS because I am not sure if he/she can do anything to help my patient. I don't think my OS's facility has the right equipments to handle such complication. First, I'd make sure the patient's airway is OK. Then, I would inform the patient's parents that there is a 50% chance that the orthodontic band could go to the lung. Then, I'd ask them to drive to the hospital for the chest x ray. And I just let the doctors at the hospital manage the complication if the molar band is in the patient's lung. That's how I was taught at dental school.

If I were a general dentist and performed dental extraction, I would probably use a 2x2 gauge to minimize the chance of tooth tip aspiration.

I think this is the point the OP is trying to make. That even with a very real/possible complication you're dumping your mess for someone else to clean up...which anyone would agree is pretty poor form.
 
I think this is the point the OP is trying to make. That even with a very real/possible complication you're dumping your mess for someone else to clean up...which anyone would agree is pretty poor form.
Complications happen in any health field. We, dentists, often have clean up the anesthesiologist's mess by restoring the missing anterior teeth because the anesthesiologist knocked them off from doing oral intubation.
 
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Complications happen in any health field. We, dentists, often have clean up the anesthesiologist's mess by restoring the missing anterior teeth because the anesthesiologist knock them off from doing oral intubation.

Why just ORAL intubation?

And I think he meant urgent/emergent sequellae that must be dealt with in a timely fashion...not elective sequellae.

In three years in the hospital I haven't seen a single avulsed anterior secondary to a traumatic intubation...if you are seeing them OFTEN you need to have a sit down with the anesthesiology department that is giving you all these referrals
 
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Complications happen in any health field. We, dentists, often have clean up the anesthesiologist's mess by restoring the missing anterior teeth because the anesthesiologist knock them off from doing oral intubation.

Thats actually a really good point. But to make it an equivalent analogy, that would be like having the anesthesiologist tell the patient to follow up with their dentist and that be the end of it (in reality thats probably what happens, but it doesn't make it right). Its also not exactly the same since aspirating a tooth can be life threatening while the anterior teeth restoration is cosmetic. I know complications happen, my question was about how a non-hospital based specialist that is practicing surgery handles a surgical complication. I agree that its all about risk minimization. Obviously all general dentists and specialists are qualified to pull teeth. But when you consider risk stratification, the rate of complications are very little for non-surgical simple extractions. However it seems there is a trend amongst periodontists to want to perform complicated surgical extractions in the back of the mouth. So the risk stratification goes up quite a bit and I was wondering how they compensate for that increased risk.
 
The periodontists/dentists/orthodontists/pedodontists will manage the tooth tip aspiration complication the same way the OMFS's do, that is to refer to the patient to the hospital and let the experts (radiologist, ENT etc) handle the such complication.
 
The periodontists/dentists/orthodontists/pedodontists will manage the tooth tip aspiration complication the same way the OMFS's do, that is to refer to the patient to the hospital and let the experts (radiologist, ENT etc) handle the such complication.

Actually, an OMS would not just "refer" (dump) the patient at the hospital. It would/should admit the patient and get other specialties involved to solve the problem, unlike the other dumps.
 
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A periodontist would most likely be more careful so a root tip is not aspirated. Prevention is key for anyone performing a third molar extraction. They would most likely have a relationship with an ENT so like in the post above they could a bronchoscope if it was needed. May be focusing on what you should be doing (ext root tips safely) and not what others are doing (dental work ) will help your future practice.

Perio would be more careful, it would only take 90 minutes and 17 sutures. Glad to see perio has the big balls about third molars now. I would be amazed if you could describe a "bronchoscope" without the help of Dr. Google.

And for the record, I'm not against perio doing thirds. Just against perio acting like they are the experts at it.
 
I admit I don't know what a "bronchoscope" is. I am just an orthodontist. Even if you, unlike the periodontist, knows what the bronchroscope is, what difference does it make? You are not going to be the one who manages the complication....the ENT does.
 
The periodontists/dentists/orthodontists/pedodontists will manage the tooth tip aspiration complication the same way the OMFS's do, that is to refer to the patient to the hospital and let the experts (radiologist, ENT etc) handle the such complication.

Thats not how OMFS is trained to handle their surgical complications.

I admit I don't know what a "bronchoscope" is. I am just an orthodontist. Even if you, unlike the periodontist, knows what the bronchroscope is, what difference does it make? You are not going be be the one who manages the complication....the ENT does.

The difference is in how and who is managing the patient. The proper way to deal with this, since it is your patient, is to coordinate their care whether you provide the treatment or not.

All that I expected a periodontist to come forward and say is:

-I would refer the patient to the emergency room since I don't have admitting privileges
-I would call the ED ahead of time and inform them of what was coming in, and that I would meet the patient there
-I would be present to discuss the case with the physicians who are going to have to order imaging and prescribe treatments to fix my complication
-I would request who ever ends up following the patient to allow me to come in and round with them each morning so I could check on my patients well being every day they're in the hospital

These measures seem like the bare minimum from a non-hospital specialist performing surgery.
 
Actually, an OMS would not just "refer" (dump) the patient at the hospital. It would/should admit the patient and get other specialties involved to solve the problem, unlike the other dumps.
Warning: For those of you, who are not OMFS, you should not perform surgical extractions in your practice because you don't have the hospital privilege.
 
All that I expected a periodontist to come forward and say is:

-I would refer the patient to the emergency room since I don't have admitting privileges
-I would call the ED ahead of time and inform them of what was coming in, and that I would meet the patient there
-I would be present to discuss the case with the physicians who are going to have to order imaging and prescribe treatments to fix my complication
-I would request who ever ends up following the patient to allow me to come in and round with them each morning so I could check on my patients well being every day they're in the hospital

These measures seem like the bare minimum from a non-hospital specialist performing surgery.
That's exactly my point. Every dentist, not just periodontist, would do what you listed above when complication happens. And that's how every dental student is taught at school.

From my experience, the OMFS, who works at the dental chain offices, manage complications very similar to what a nonOMFS dentist would handle. They call 911, monitor the airway while waiting for the paramedics to arrive etc.
 
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I admit I don't know what a "bronchoscope" is. I am just an orthodontist. Even if you, unlike the periodontist, knows what the bronchroscope is, what difference does it make? You are not going to be the one who manages the complication....the ENT does.

Charles I think you're taking this personally, when no one was trying to attack you.

But there IS a difference. When an orthodontist "REFERS" his patient to OMFS for extraction or uncovering, that orthodontist may not be able to DO what he referred out for, but he understands ALL the concepts behind the procedure. That is a legitimate referral because you are still the captain of the ship dictating treatment simply carried out by another specialist.

Same thing when a general dentist has a sinus perforation beyond his scope. He refers to OMFS, and even though he isn't performing the procedure he knows what is being performed and why.

When an OMFS has a root tip aspiration he is referring that patient for specific treatment that he can write the orders for and manage because he has done rotations through medicine and ENT and anesthesia. Sure radiology takes the CXR, and if necessary ENT does the bronch, but the OMFS knows the reasons for doing all these procedures and either could or did write the orders for them. He is actively involved in that patient's care, even if he isn't performing all the work. Same as you are when you refer to an OS for your extractions.

It is a different situation when something goes wrong and you DUMP the patient (telling someone drive to the emergency room is DUMPING the patient), that isn't a referral, you are no longer in control. The patient's care lies far outside of your scope, and you have created a problem that you have absolutely no clue how to fix.

And the question is, when does the risk of co-morbidities you cannot handle become too high to perform an intervention?
 
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Warning: For those of you, who are not OMFS, you should not perform surgical extractions in your practice because you don't have the hospital privilege.

Um, I actually agree with this, but I think you and I have different definitions of surgical extractions.
 
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Warning: For those of you, who are not OMFS, you should not perform surgical extractions in your practice because you don't have the hospital privilege.

If you don't/can't handle the complications, don't do the surgery. Most extractions, including surgical extractions, have a very low complication rate. Complications jump up when you talk about fully impacted third molars. If you can't handle the 1% of the time it goes wrong, you shouldn't be doing it, then dumping that 1% on the ER.

A DA would never give a "friendly referral" to an MD anesthesiologist after one failed intubation (which probably happens <1% of the time too).

To be proficient in a job, you need to be able to handle the case start to finish, not just the lucrative parts.
 
I applaude your zero complications approach to surgery. My question was directed at those of us that do experience complications during surgical procedures. I believe you did answer my question anyways, so you'd call your ENT buddy and tell him to go to the hospital to manage the patient. Fair enough.

If someone wanted to refer and pay me for something, I have been trained in and do everyday, is it really dumping a patient onto them?
When a dentist has difficult extraction is he dumping the patient onto someone else? No, they are helping each other out.
What is the difference between God and an oral surgeon?
God does not think he is an oral surgeon.
Why do oral surgeons not care when I ext a third molar but do when a periodontist whom has 3 yrs more training does?
Everyone makes fun of dentist, the dentist make fun of periodontist, the medical doctors make fun of oral surgeons. I have heard tooth fairy quite often during school and after from my MD friends. In reality don't worry what joe blow is doing, do what you do and do it well. We are all a big team helping people with their oral health. No one cares you can ext 4 impacted 3rds in 10 min, or you go to 6 yrs of extra hell than the rest of the dental community. Extracting teeth is not very difficult. May be focus on learning how to help the next lady give birth or what ever you do during med school and stop caring what a periodontist is doing when they follow the standard of care extracting a tooth.
 
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This argument is getting a little crazy but I'll say this...

"When an OMFS has a root tip aspiration he is referring that patient for specific treatment that he can write the orders for and manage because he has done rotations through medicine and ENT and anesthesia. Sure radiology takes the CXR, and if necessary ENT does the bronch, but the OMFS knows the reasons for doing all these procedures and either could or did write the orders for them. He is actively involved in that patient's care, even if he isn't performing all the work. Same as you are when you refer to an OS for your extractions."

-The ENT, radiologist and pulmonologist are going to treat that patient who aspirated a tooth in exactly the same fashion whether a general dentist, periodontist or oral surgeon referred the patient. Just because an oral surgeon has rotated through the different departments does not make them any more of a pulmonologist than the general dentist. Better versed in the medical fields - yes. But,the physicians will write their own orders after gathering the necessary information from the OMFS or dentist. As an oral surgeon, if a pulmonologist referred a patient to me for wisdom teeth removal or facial reconstruction, I'm not going to listen to their opinion on the matter too much.

"If you don't/can't handle the complications, don't do the surgery."

-It all comes down to this. If you can't handle the dental and/or head and neck complications, don't do the surgery. But aspiration of a tooth is a risk both general dentists and oral surgeons take on and will be dealt with by entirely different medical specialties. It's not like the pulmonologist is going ask for your professional opinion. It has passed the head and neck and into an area he/she is very well versed in and may ask for information in a different way, but that's about it. Will the doctor possibly have more respect for your training and knowledge in the medical field? Absolutely, but that doesn't change the care that will be provided.
 
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This argument is getting a little crazy but I'll say this...

"When an OMFS has a root tip aspiration he is referring that patient for specific treatment that he can write the orders for and manage because he has done rotations through medicine and ENT and anesthesia. Sure radiology takes the CXR, and if necessary ENT does the bronch, but the OMFS knows the reasons for doing all these procedures and either could or did write the orders for them. He is actively involved in that patient's care, even if he isn't performing all the work. Same as you are when you refer to an OS for your extractions."

-The ENT, radiologist and pulmonologist are going to treat that patient who aspirated a tooth in exactly the same fashion whether a general dentist, periodontist or oral surgeon referred the patient. Just because an oral surgeon has rotated through the different departments does not make them any more of a pulmonologist than the general dentist. Better versed in the medical fields - yes. But,the physicians will write their own orders after gathering the necessary information from the OMFS or dentist. As an oral surgeon, if a pulmonologist referred a patient to me for wisdom teeth removal or facial reconstruction, I'm not going to listen to their opinion on the matter too much.

"If you don't/can't handle the complications, don't do the surgery."

-It all comes down to this. If you can't handle the dental and/or head and neck complications, don't do the surgery. But aspiration of a tooth is a risk both general dentists and oral surgeons take on and will be dealt with by entirely different medical specialties. It's not like the pulmonologist is going ask for your professional opinion. It has passed the head and neck and into an area he/she is very well versed in and may ask for information in a different way, but that's about it. Will the doctor possibly have more respect for your training and knowledge in the medical field? Absolutely, but that doesn't change the care that will be provided.

Do you have a lot of experience in the hospital? As a resident, have you had the chance to do a lot of referrals and work with specialists while managing your patient? From your statement it certainly doesn't sound like it. It sounds like you're saying that since we have no possible way to influence treatment, dumping them on the ER is the only possible option and what happens happens.

OMFS can admit patients to hospital. They can write their own orders. They can get consults from other specialists and still decide the care.

Since you've probably never worked in a hospital, when you admit a patient they're your patient, you can request consults, but those specialists don't dictate what will happen unless you give the go ahead.

I admit the patient, he doesn't go to the ER if I don't want. I write an order for a CXR. Radiologist gives his opinion that the tip may be in the lower portion of the right inferior lobe. He recommends pulmonology consult. I write a consult for pulmonology. They recommend a bronch. I write the order for the bronch.

And even if the patient isn't admitted by the OMFS it's a professional courtesy when working in the hospital to still facilitate the treatment. When you ask for a consult, you don't just turn the patient over to the other service, you follow up and do all the footwork...you optimize the patient and do as much as you can before another service is contacted.

What you described is why people are calling you "tooth fairy" (well probably one of many reasons)...you just refer and assume there's nothing you can do a let the real doctors take care of the problem.

But I would like to know how much time you've spent in the hospital that you are able to have any contribution to this convo?
 
This argument is getting a little crazy but I'll say this...

"When an OMFS has a root tip aspiration he is referring that patient for specific treatment that he can write the orders for and manage because he has done rotations through medicine and ENT and anesthesia. Sure radiology takes the CXR, and if necessary ENT does the bronch, but the OMFS knows the reasons for doing all these procedures and either could or did write the orders for them. He is actively involved in that patient's care, even if he isn't performing all the work. Same as you are when you refer to an OS for your extractions."

-The ENT, radiologist and pulmonologist are going to treat that patient who aspirated a tooth in exactly the same fashion whether a general dentist, periodontist or oral surgeon referred the patient. Just because an oral surgeon has rotated through the different departments does not make them any more of a pulmonologist than the general dentist. Better versed in the medical fields - yes. But,the physicians will write their own orders after gathering the necessary information from the OMFS or dentist. As an oral surgeon, if a pulmonologist referred a patient to me for wisdom teeth removal or facial reconstruction, I'm not going to listen to their opinion on the matter too much.

I'll agree with what was said above, your statements make it seem like you have never worked in a hospital before. When a patient has a consult from a specialist, that specialist doesn't take over and ignore input from the referring provider...it is expected of a referring service to give a very good account of the patient, the morbidity, what treatment has been performed so far, what the differential diagnosis is, and what further treatment course has so far been proposed. No service wants to inherit another provider's mess and take the reins from there without input and communication with the original provider.

When I get a H+P back from a cardiologist on a patient going in for GA, I don't disregard cards opinion or advice on the patient simply because he has never done anesthesia before, I read everything he wrote and consider it alongside what my own training has taught me. He knows the heart a lot better than I do, and he probably knows the patient a lot better than I do. To completely ignore him because he's never bolused prop before would be careless and brash. The same thing goes for a dentist/omfs referring for a possible dental aspiration. The ED physician is damn good at triaging and stabilizing a patient, but to expect him to understand the minutia and possible sequela of this occurrence is impractical.

If the OMFS elects to have that patient go through the ED, then of course the ED physician will have the final say on treatment from that point until admission, but if you think that an ED physician isn't going to appreciate the expertise and continued care from the OMFS on THEIR root-tip aspiration you just don't know what you're talking about.

I think part of the reason some of us are getting worked up by this thread is that we're a little ashamed of you guys saying "send them to the ER and let the experts handle it"...we should be the experts.
 
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This argument is getting a little crazy but I'll say this...

"When an OMFS has a root tip aspiration he is referring that patient for specific treatment that he can write the orders for and manage because he has done rotations through medicine and ENT and anesthesia. Sure radiology takes the CXR, and if necessary ENT does the bronch, but the OMFS knows the reasons for doing all these procedures and either could or did write the orders for them. He is actively involved in that patient's care, even if he isn't performing all the work. Same as you are when you refer to an OS for your extractions."

-The ENT, radiologist and pulmonologist are going to treat that patient who aspirated a tooth in exactly the same fashion whether a general dentist, periodontist or oral surgeon referred the patient. Just because an oral surgeon has rotated through the different departments does not make them any more of a pulmonologist than the general dentist. Better versed in the medical fields - yes. But,the physicians will write their own orders after gathering the necessary information from the OMFS or dentist. As an oral surgeon, if a pulmonologist referred a patient to me for wisdom teeth removal or facial reconstruction, I'm not going to listen to their opinion on the matter too much.

"If you don't/can't handle the complications, don't do the surgery."

-It all comes down to this. If you can't handle the dental and/or head and neck complications, don't do the surgery. But aspiration of a tooth is a risk both general dentists and oral surgeons take on and will be dealt with by entirely different medical specialties. It's not like the pulmonologist is going ask for your professional opinion. It has passed the head and neck and into an area he/she is very well versed in and may ask for information in a different way, but that's about it. Will the doctor possibly have more respect for your training and knowledge in the medical field? Absolutely, but that doesn't change the care that will be provided.

You have no idea what you are talking about. Keep dumping on the ER like you always have. At least you seem so poorly informed that you don't even know it's a dump.
 
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Many valid points in this thread (but definitely not from everyone). I disagree with the definition of dumping in the sense that as an OMFS you don't have to admit to your service as long as you actively follow and provide advice to the primary service that admits your patient. Ideally you would admit the patient to your service. In some instances, the hospital you have admitting privileges or you as the medical provider may not be covered under the patient's medical insurance. In this case, helping them get through the ED triage quickly and efficiently and then definitively treated would be good form.

Regardless of what you do (admit, follow, or dump) this doesn't change the fact you are about to get sued. But that is a different discussion.

OP - you sure you weren't trolling?
 
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Truly, I'm not trolling when I ask this, I'm just curious. I was having a conversation with a co-resident (OMFS) of mine about periodontists doing surgical third molar extractions. We also recently experienced a complication ourselves where our patient aspirated a root tip from a third molar we were pulling. So I know how we handle that complication, but how does a periodontist (or any other dental provider for that matter) deal with this complication? Do you just send the patient to the ED and tell the patient to tell the physician what happened? Do you go to the hospital with them and try to tell the ED physician what you want them to order? Just not sure how someone without hospital privileges deals with these types of complications.

Me personally I would just refer to the MFOS. I also have stopped doing S/RP because of the potential for infective endocarditis and now refer all of those cases to the cardiologist.

MFOS…..
 
I'll chime in here as this one is too good to go let go…

I'd start with a KUB personally. Odds are they swallowed it. A CXR may or may not show it in the GI tract. If you don't see it on KUB, then shoot CXR. I'm of the opinion you should find it regardless of where it is. I wouldn't d/c the patient to the ED. You can't guarantee follow up. If the bronchospasm on the way you're SOL. Get your paramedics to your office.

Regarding perio dumps. I just plain don't get it. Taking thirds out is simple. The complications aren't. I've had 2 Friday afternoon admissions to our service by traveling periodontists with buccal space infections. I told the patients they ought to sue the crap out of the periodontists not because of the infection, but because of patient abandonment.

It's real simple:
- Perio can't treat odontogenic infections that will arise
- Perio can't manage nerve injuries
- Perio can't treat mandible fractures (one out of 16k mandibular thirds result in angle fx)
- Perio grafts thirds sockets which should be an crime

If you tell me that you don't have these complications you're a f'ing rookie. Those that don't have complications don't operate.

Regarding sedation in the state of Florida, 60 hours didactic with 3 hours of dummy airway work and 20 "observed" cases with fentanyl and versed gets you an IV sedation permit. This is joke. As an OMFS resident, I have over 350 GA cases managed in OR including a few trauma cases with 10+ units of blood products administered with an attending that stuck his head in the room for 20 minutes while I was lining up. Additionally, I'll have over 300 sedations in our clinic for in office procedure stuff. The periodontists and their IV sedation are going to ruin the operator administered model after they start killing people. Oh wait, I forgot you don't have complications. Board certified OMFS mortality rate in office is around 1 in 350,000. I'd love to see the in office perio mortality rate.

Perio should stick to implants and gingival related procedures.

My 2 cents.
 
Lets face it...

After reading through this thread its easy to identify that many dentists want to pick the low hanging fruit & not deal with complications. It's not isolated to this thread, though. I've found that it's a negative theme that is common throughout the profession.
 
I'll chime in here as this one is too good to go let go…

I'd start with a KUB personally. Odds are they swallowed it. A CXR may or may not show it in the GI tract. If you don't see it on KUB, then shoot CXR. I'm of the opinion you should find it regardless of where it is. I wouldn't d/c the patient to the ED. You can't guarantee follow up. If the bronchospasm on the way you're SOL. Get your paramedics to your office.

Regarding perio dumps. I just plain don't get it. Taking thirds out is simple. The complications aren't. I've had 2 Friday afternoon admissions to our service by traveling periodontists with buccal space infections. I told the patients they ought to sue the crap out of the periodontists not because of the infection, but because of patient abandonment.

It's real simple:
- Perio can't treat odontogenic infections that will arise
- Perio can't manage nerve injuries
- Perio can't treat mandible fractures (one out of 16k mandibular thirds result in angle fx)
- Perio grafts thirds sockets which should be an crime

If you tell me that you don't have these complications you're a f'ing rookie. Those that don't have complications don't operate.

Regarding sedation in the state of Florida, 60 hours didactic with 3 hours of dummy airway work and 20 "observed" cases with fentanyl and versed gets you an IV sedation permit. This is joke. As an OMFS resident, I have over 350 GA cases managed in OR including a few trauma cases with 10+ units of blood products administered with an attending that stuck his head in the room for 20 minutes while I was lining up. Additionally, I'll have over 300 sedations in our clinic for in office procedure stuff. The periodontists and their IV sedation are going to ruin the operator administered model after they start killing people. Oh wait, I forgot you don't have complications. Board certified OMFS mortality rate in office is around 1 in 350,000. I'd love to see the in office perio mortality rate.

Perio should stick to implants and gingival related procedures.

My 2 cents.

Regarding the highlighted above, I'm glad that you mentioned that. I believe that the sedation "training" for Pedos is similar to what you described--and many of them practive IV sedation in their offices independently and make a killing in so doing. That's ridiculous.
 
Regarding the highlighted above, I'm glad that you mentioned that. I believe that the sedation "training" for Pedos is similar to what you described--and many of them practive IV sedation in their offices independently and make a killing in so doing. That's ridiculous.

Not just ridiculous...............it's terrifying.
 
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Not just ridiculous...............it's terrifying.
Regarding the highlighted above, I'm glad that you mentioned that. I believe that the sedation "training" for Pedos is similar to what you described--and many of them practive IV sedation in their offices independently and make a killing in so doing. That's ridiculous.
Do you have any statistics comparing dental providers in this regard? Not trying to agree or disagree, just trying to better understand the facts relating to this issue.
 
Do you have any statistics comparing dental providers in this regard? Not trying to agree or disagree, just trying to better understand the facts relating to this issue.

Don't have any specific data about other providers. OMFS is unique in that most are covered by OMSNIC which tracks the sedation stuff. It's apples to oranges in training and capability. The problem is your patients physiology doesn't care about your training and it goes haywire no matter who you are. If you're not trained to second nature like OMFS or DA, then the patient is receiving inferior care.

The continuum of conscious vs deep vs GA should be discussed with the anesthesia comments.

Conscious -- responds to verbal and physical stimuli and maintains physiologic protective mechanisms (cough, maintain airway etc)

Deep -- doesn't respond to verbal or physical stimuli and maintains physiologic protective mechanisms

General -- doesn't respond to anything, no airway protection

OMFS operates in the deep end of the spectrum routinely with sedation. Perio/Pedo/Dentist/anyone not OMFS or dental anesthesia doesn't have a permit to operate in the deep/general playing field. There's no operator out there that sedates patients for anxiolysis that doesn't WANT to have them not moving. What I'm getting at is moving targets to physical stimuli = conscious sedation and non-moving targets = deep/general AKA out of your scope of training. This is going to be the thing that get's you in trouble. To make your target not move to stimuli, which is what everyone WANTS, means you're relegated to one drug typically -- fentanyl. Enough of that on board to make you not a moving target = apnea and big problems for the "I intubated a dummy in my 60 hours" crew. Did I mention that not moving was out of your training and scope?

This is what will kill it all. Instead of worrying about perio doing thirds or endo doing implants, AAOMS should be hammering the public about our anesthesia training and how we're not weekend warriors. If you can't sedate, then you can't take out most thirds or do a lot of the more invasive grafting. If you think you can do everything under local, I'll take your kids full bony impacted teeth out with local....yea right you wouldn't let me do that....put your patients health and well being first and your wanna be OMFS ego and pocket book second.

Regarding exact numbers, I have no idea as to the comparison. I'll say that the anesthesiologist do it worse than we do when it comes to sedation mortality. That is well documented. In their defense, I'm not sedating a guy with a bleeding polyp with an EF of 20% in my office which would drive complications up -- but I have in my anesthesia training. If you have to google EF, then quit sedating people.
 
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Don't have any specific data about other providers. OMFS is unique in that most are covered by OMSNIC which tracks the sedation stuff. It's apples to oranges in training and capability. The problem is your patients physiology doesn't care about your training and it goes haywire no matter who you are. If you're not trained to second nature like OMFS or DA, then the patient is receiving inferior care.

The continuum of conscious vs deep vs GA should be discussed with the anesthesia comments.

Conscious -- responds to verbal and physical stimuli and maintains physiologic protective mechanisms (cough, maintain airway etc)

Deep -- doesn't respond to verbal or physical stimuli and maintains physiologic protective mechanisms

General -- doesn't respond to anything, no airway protection

OMFS operates in the deep end of the spectrum routinely with sedation. Perio/Pedo/Dentist/anyone not OMFS or dental anesthesia doesn't have a permit to operate in the deep/general playing field. There's no operator out there that sedates patients for anxiolysis that doesn't WANT to have them not moving. What I'm getting at is moving targets to physical stimuli = conscious sedation and non-moving targets = deep/general AKA out of your scope of training. This is going to be the thing that get's you in trouble. To make your target not move to stimuli, which is what everyone WANTS, means you're relegated to one drug typically -- fentanyl. Enough of that on board to make you not a moving target = apnea and big problems for the "I intubated a dummy in my 60 hours" crew. Did I mention that not moving was out of your training and scope?

This is what will kill it all. Instead of worrying about perio doing thirds or endo doing implants, AAOMS should be hammering the public about our anesthesia training and how we're not weekend warriors. If you can't sedate, then you can't take out most thirds or do a lot of the more invasive grafting. If you think you can do everything under local, I'll take your kids full bony impacted teeth out with local....yea right you wouldn't let me do that....put your patients health and well being first and your wanna be OMFS ego and pocket book second.

Regarding exact numbers, I have no idea as to the comparison. I'll say that the anesthesiologist do it worse than we do when it comes to sedation mortality. That is well documented. In their defense, I'm not sedating a guy with a bleeding polyp with an EF of 20% in my office which would drive complications up -- but I have in my anesthesia training. If you have to google EF, then quit sedating people.

South,

Thanks for your comments. Re: the bolded above--that's a fairly bold statement itself. Could you explain further why you think that is true?

thanx
 
Not speaking for him, but I believe that he would mean that in the hospital where you are treating much sicker patients, the mortality rate is higher. Because of patient selection, we have a very low mortality rate (1 in 350,000 I believe). Unfortunately, anesthesiologists don't have the ability to turn away and send an ASA III or IV patient to a hospital setting due to his cardiac issues. The difference in the ability to differentiate patient selection and the concerns with certain patients (Thyromental distance <6, Mallampati IV, Neck stiffness, etc.) is the giant step between "proper training" and "weekend courses".
 
If you have to google EF, then quit sedating people.[/QUOTE]


Strong work. Let me see hmmm 20% maybe I will ask Jeeves or wikepedia about EF and if that is an acceptable number. No wait 100% is normal. Nope 100% is not normal. No one ejects 100%.. Damn Jeeves.

My 2 cents which is now worth a dollar with all I write about anesthesia. OMFS and DA should be sedating only. Not weekend warriors or Perio. I don't think pedo should sedate. I like anesthesia coming to their office for those little kids. Little kids will get you in trouble if I have to put money on mortality in an office. Those little guys go down hard when they do. But hey a little Halcion, Nitrous, more yummy po meds that taste like bubble gum. oh well soon they will stop crying. Pulse ox???? Do you even own one? I met a dentist who would PO sedate the hell out of patients with no monitoring, just scary. When you don't know what to be worried about then there is no worry. More is better? NO.....

Folks the DA and Anesthesia community is itching and working their way into OMFS offices for multiple reasons and we need to protect our speciality to sedate. Soon it will be gone if things are not closely monitored. Now I must go in tomorrow and hook my patient up to the CO2 monitor which is crap. Damn machine still beeping due to low ETCO2. No crap its not a closed system. Well glad regulations are present to protect that patient as he mouth breathes and my machine beeps...beep...beep. While weekend class keep popping up for sedation education. Urghhhh.
 
A convo I had recently...

Dentist: I do oral sedations
Me: What do you use? PO midazolam and meperidine?
Dentist: No, I use versed and demerol.
Me: So you know how to bag a patient?
Dentist: Bag what?
Me: Well can you start an IV to administer emergency drugs?
Dentist: Why would I need an IV?! I'm giving them drugs by mouth only

I wish this was eliminated as the ASA are already breathing down our backs
 
I knew a periodontist who bragged of using a rubber dam for his extraction. Of course he had a surgical cap and little booties on too.
 
A convo I had recently...

Dentist: I do oral sedations
Me: What do you use? PO midazolam and meperidine?
Dentist: No, I use versed and demerol.
Me: So you know how to bag a patient?
Dentist: Bag what?
Me: Well can you start an IV to administer emergency drugs?
Dentist: Why would I need an IV?! I'm giving them drugs by mouth only

I wish this was eliminated as the ASA are already breathing down our backs

This stuff is the most unethical occurrence I've seen happen in healthcare. They cannot be stopped fast enough.
 
Aspiration is a risk for all dentists. We have to keep in mind the standard of care. The standard of care is detained by what a reasonable dentist with similar training would do. So, the OP initial post is really irrelevant as it compares two different tiers of training. Yes, an OMS will utilize their hospital privileges when necessary. A general dentist does not have the same luxury nor the same responsibility. The standard of care is different. For example, A general dentist who is seating a crown and loses it down the patient's mouth will refer the patient for a Chest x-ray. Pending results they will direct the patient to relevant specialties with referral notes, etc. does this mean that a general dentist should not be working in the mouth where aspiration of dental materials/products etc can occur? Of course, risk as aspiration is much higher when a patient is sedated.

It is baffling to me that many anesthesia providers recognize that anesthesia is a spectrum while discounting the value of mild and moderate sedation. The comments and tone here certainly indicate sentiments that "IV sedation=deep sedation GA" and "nobody wants their patient moving." Route of sedation does not determine level of sedation. Conscious patients never die (they must first become unconscious) and stress reduction increases safety for treatment. Moderate sedation is very, very safe, effective in stress and anxiety management, and it can be taught and learned to a competent and safe level within 100 hours and 20 patient experiences. That is not my opinion; that is organized dentistry's opinion and published by the ADA.Sedation and anxiety management should be available to all dentists who seek out approved training and abide by guidelines currently in place.

Opinions based on fear with no data are not really useful and fail to improve the profession and patient experience. There is no data on Moderate sedation deaths but I have heard of a few. Most dental patient deaths related to sedation/anesthesia occur with children, deep sedation, and excessive dosing with oral sedation.

How many patients avoid the dentist due to fear?

EtCO2 monitoring is over the top-especially, imagine on a conscious patient!
 
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Aspiration is a risk for all dentists. We have to keep in mind the standard of care. The standard of care is detained by what a reasonable dentist with similar training would do. So, the OP initial post is really irrelevant as it compares two different tiers of training. Yes, an OMS will utilize their hospital privileges when necessary. A general dentist does not have the same luxury nor the same responsibility. The standard of care is different. For example, A general dentist who is seating a crown and loses it down the patient's mouth will refer the patient for a Chest x-ray. Pending results they will direct the patient to relevant specialties with referral notes, etc. does this mean that a general dentist should not be working in the mouth where aspiration of dental materials/products etc can occur? Of course, risk as aspiration is much higher when a patient is sedated.

It is baffling to me that many anesthesia providers recognize that anesthesia is a spectrum while discounting the value of mild and moderate sedation. The comments and tone here certainly indicate sentiments that "IV sedation=deep sedation GA" and "nobody wants their patient moving." Route of sedation does not determine level of sedation. Conscious patients never die (they must first become unconscious) and stress reduction increases safety for treatment. Moderate sedation is very, very safe, effective in stress and anxiety management, and it can be taught and learned to a competent and safe level within 100 hours and 20 patient experiences. That is not my opinion; that is organized dentistry's opinion and published by the ADA.Sedation and anxiety management should be available to all dentists who seek out approved training and abide by guidelines currently in place.

Opinions based on fear with no data are not really useful and fail to improve the profession and patient experience. There is no data on Moderate sedation deaths but I have heard of a few. Most dental patient deaths related to sedation/anesthesia occur with children, deep sedation, and excessive dosing with oral sedation.

How many patients avoid the dentist due to fear?

EtCO2 monitoring is over the top-especially, imagine on a conscious patient!


A lot of what you said is true...but you describe sedation as very black and white, when it is not.

As you mentioned depth of anesthesia falls along a spectrum and there aren't clear cut doses/meds that get each person to the same point. The problems occur when a dentist who is trained in moderate/conscious unintentionally takes their patient to deep sedation...to the point where they are no longer protecting their own airway reliably.

And given recent data on fast vs slow acetylators, it's difficult to know how much drug will take a person to a given level on the spectrum. In training as a DA we put 5-6 kids/adults to sleep everyday...it is astounding how different their medication requirements are using the same meds patient to patient. The first 3 year old will need a given amt of remi/prop to tolerate a procedure and the next one at the same weight will need 3 times that number.

As an anesthesiologist when my patient moves to a deeper level of sedation, i can handle it because i'll do well over 1000 cases during training...but you cannot expect the same from someone who was trained to handle a patient only to a certain depth after 20 pts (or whatever the requirement is)

So my point is that, a lot of dentists are trained to handle sedation to a certain point, but it is very easy to move beyond that point and fall out of your scope of training...which accounts for the two cases in hawaii in the last 6 months. In an ideal world we could take a patient to the depth we wanted consistently without fear, but patients aren't ideal and some of them are going to fall deeper down the spectrum than expected, and without someone trained to handle that it leads to morbidity and mortality.

I'm not against dentists/peds doing sedation, i think it's necessary, but given the fact that in the two years i've been a resident 5 healthy people have died at the dentist (and those are the ones that made it to the media...if you think there aren't deaths and trauma that go unreported and settled out of court you're naive) i think the system and guidelines needs to be re-examined
 
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Aspiration is a risk for all dentists. We have to keep in mind the standard of care. The standard of care is detained by what a reasonable dentist with similar training would do. So, the OP initial post is really irrelevant as it compares two different tiers of training. Yes, an OMS will utilize their hospital privileges when necessary. A general dentist does not have the same luxury nor the same responsibility. The standard of care is different. For example, A general dentist who is seating a crown and loses it down the patient's mouth will refer the patient for a Chest x-ray. Pending results they will direct the patient to relevant specialties with referral notes, etc. does this mean that a general dentist should not be working in the mouth where aspiration of dental materials/products etc can occur? Of course, risk as aspiration is much higher when a patient is sedated.

It is baffling to me that many anesthesia providers recognize that anesthesia is a spectrum while discounting the value of mild and moderate sedation. The comments and tone here certainly indicate sentiments that "IV sedation=deep sedation GA" and "nobody wants their patient moving." Route of sedation does not determine level of sedation. Conscious patients never die (they must first become unconscious) and stress reduction increases safety for treatment. Moderate sedation is very, very safe, effective in stress and anxiety management, and it can be taught and learned to a competent and safe level within 100 hours and 20 patient experiences. That is not my opinion; that is organized dentistry's opinion and published by the ADA.Sedation and anxiety management should be available to all dentists who seek out approved training and abide by guidelines currently in place.

Opinions based on fear with no data are not really useful and fail to improve the profession and patient experience. There is no data on Moderate sedation deaths but I have heard of a few. Most dental patient deaths related to sedation/anesthesia occur with children, deep sedation, and excessive dosing with oral sedation.

How many patients avoid the dentist due to fear?

EtCO2 monitoring is over the top-especially, imagine on a conscious patient!

I understand what you're saying but an appeal to authority is a logical fallacy. What is going on in dentistry, with regards to sedation, is unprecedented. Why not raise the bar as a profession rather than subject patients to potential harm? Conscious sedation is serious esp when not every pt is an ASA class 1.

To add to the above posters point I've taken pt to a level of sedation, unintentionally, that I needed to protect their airway with just a few mg of IV MS and phenergan. In most other pt that combo would not do anything to lower their level of consciousness or compromise their breathing. It's impossible to anticipate how every pt will react to medication.
 
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So my point is that, a lot of dentists are trained to handle sedation to a certain point, but it is very easy to move beyond that point and fall out of your scope of training...which accounts for the two cases in hawaii in the last 6 months. In an ideal world we could take a patient to the depth we wanted consistently without fear, but patients aren't ideal and some of them are going to fall deeper down the spectrum than expected, and without someone trained to handle that it leads to morbidity and mortality.

It appears that the 2nd case was from someone board-certified in dental anesthesiology
 
Yes the 2nd case (of the two most recent in HI) was an MD/DDS oral surgeon.
Sublimazing: not sure where you got the idea from my post that sedation mad the spectrum of anesthesia is black and white. I certainly do not believe it. I agree with you that we don't hear about other deaths that occur. The five deaths you heard about were likely involving oral sedation with pediatric patients and a single operator/sedationist AND teen/adult patients undergoing deep sedation under the care of an oral surgeon with and without MD anesthesiologists.
Of course all of the bad outcomes are tragic and do not always indicate lack of training or poor training.
Re-examining must be done constantly, I agree with you 100%. The training programs for moderate sedation continue to evolve and change and improve. A couple of the more popular courses are taught by leading dentist anesthesiologists, Ken Reed and Stanley Malamed. Whether or not changes need to be made- I do not believe changes need to be made. You will have to see how the courses are taught and the techniques that are used. You will soon be one of the leaders in the field of anesthesia in dentistry so keep looking into the facts and the data. Anecdotally, my premiums for malpractice did not increase $0.01 after I got my permit for moderate sedation. I was surprised but they told me: "we just haven't seen losses there."
Yappy, I am not a big ADA fan-especially after the blocking of DA specialty. The application was very strong and from an objective standpoint, met all the criteria. But that is a separate issue. So, I only threw out the ADA guidelines as one piece of the puzzle. They were in fact drafted by "leading experts in anesthesia," right? I am not sure what you refer to when you ask about patients being subjected to harm. Are you talking about the 25 gauge needle in their face? The 200,000 rpm diamond bur cutting away part of the patient's most sensitive and pain-prone body parts (ok I might be going a bit over board here...)? Maybe just the mental anguish and exhaustion they go through to get in the chair? Or are you referring to the risks of anesthesia? Or just moderate sedation? Local anesthesia?

You are right that every patient will respond differently to all drugs and I am sure you will take comfort knowing that anyone trained in sedation is aware ;) I believe your concerns will be alleviated when you learn how training is completed and the drugs and techniques used.

For example: in your case. How many mg did you give, morphine? How much phenergan? Why was the sedation indicated? Why did you choose those drugs?
 
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Yes the 2nd case (of the two most recent in HI) was an MD/DDS oral surgeon.
Sublimazing: not sure where you got the idea from my post that sedation mad the spectrum of anesthesia is black and white. I certainly do not believe it. I agree with you that we don't hear about other deaths that occur. The five deaths you heard about were likely involving oral sedation with pediatric patients and a single operator/sedationist AND teen/adult patients undergoing deep sedation under the care of an oral surgeon with and without MD anesthesiologists.
For example: in your case. How many mg did you give, morphine? How much phenergan? Why was the sedation indicated? Why did you choose those drugs?


You're right, tragic outcomes can occur regardless of training. And I also believe you're right with malpractice premiums as I've only heard an increase with the operator/anesthetist model.

I think there is a severe lack of evidence based outcomes regarding sedation amongst dentists, so a lot of what we all say and think (including myself) is based on personal opinion and not hard facts. A closed-claims analysis like the ASA has would be tremendous for our field, but i don't know that we'll ever have one.

You're entitled to your opinion, I'm entitled to mine...at least we're both concerned with patient safety.

@osteotomy01 i still cannot find info that the oral surgeon was a board certified DA...as there are less than 300 of them in the country, it would surprise me if this was true.
 
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I thought he was a dual degree oral surgeon, can you link the website that shows he's a board certified da?

It seems as though he took his website down. But this is what it said before, maybe I am misinterupting this:

"Dr. John D. Stover is one of the few triple board certified physicians in the entire state of Hawaii and is one of the state’s top-performing cosmetic surgeons. He is certified by the American Board of Cosmetic Surgery, the American Association of Oral and Maxillofacial Surgeons, and the National Dental Board of Anesthesiology. Dr. Stover is a member of the American Medical Association, the Hawaii State Medical Society, and the Hawaii County Medical Society, and he is a fellow of both the American Academy of Cosmetic Surgery and the American Association of Oral and Maxillofacial Surgeons… Dr. Angelo Cuzalina, an internationally recognized breast surgery expert, performs all cosmetic breast surgery in our Waimea surgical suite under general anesthesia and on an outpatient basis."

And lets not have everyone point fingers at anyone or even accuse the operator-anesthetist model. It was only a couple years ago we had the case in Maryland with an OMFS taking out thirds on a HEALTHY ASA I teenage girl that died under the care of a separate MD Anesthesiologist. And of course everyone instantly placed blame on the OMFS.

http://www.baltimoresun.com/news/ma...o-olenick-settlement-20130403,0,3496441.story
 
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