Dentistry Uncensored with Howard Farran
Dentistry Uncensored with Howard Farran
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1489 Oral Surgeon Sherman A. House, DDS, on Surgical Emergency Preparedness : Dentistry Uncensored with Howard Farran

1489 Oral Surgeon Sherman A. House, DDS, on Surgical Emergency Preparedness : Dentistry Uncensored with Howard Farran

10/29/2020 3:00:00 AM   |   Comments: 0   |   Views: 61
Dr. Sherman A. House is currently in his second decade as a healthcare provider, and is a Hospital Dentist and Assistant Professor of Oral and Maxillofacial Surgery at the Meharry Medical College in Nashville TN. Prior to his career in dentistry, Dr. House was a Fireman and Emergency Medical Technician in Washington State. Concurrently, he was an armed guard for several West Coast Armored Truck companies. He holds undergraduate degrees in Law Enforcement from Skagit Valley College, and also Biology and Philosophy from Gonzaga University. He completed his Doctorate of Dental Surgery at the Meharry Medical College with Honors in Nashville TN.

VIDEO - DUwHF #1489 - Sherman House


AUDIO - DUwHF #1489 - Sherman House


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**Please excuse any typos as this was digitally transcribed.

It is just a huge honor for me today to be podcast interviewing Sherman House DDS is currently in his second decade as a health healthcare provider and is a hospital dentist and assistant professor of oral maxillofacial surgery at the Meharry medical college in Nashville Tennessee prior to his career in dentistry dr house was a fireman and emergency medical technician in Washington state concurrently he was an armed guard for several west coast armored truck companies he holds undergraduate degrees in law enforcement from Skagit valley college and also biology and philosophy from Gonzaga university the editor of dental town magazine tom Jacobi his kids all go to Gonzaga university um he completed his doctoral dental surgery at the mahari medical college with honors in Nashville he earned a hospital dentistry certificate as a chief resident from the metro general hospital in Nashville after a decade in private practice dr house joined the faculty of the mahari medical college in the oral surgery department where he works as an assistant professor and attending DDS he dr house also teaches a tactical combat casualty care based first responder course called hemorrhage arrest course to lay people law enforcement and military professionals hopefully he'll put that on dental town someday he also teaches open enrollment wound closure and dental emergency management courses to lay people and other allied health care providers that lack direct dental experience he is happily married to an attorney and yoga entrepreneur and they have one 14 year old boy in his free time dr house enjoys playing rugby practicing Brazilian jiu jitsu i take it you're a horse gracie fan yes yeah and cycling um he's uh my gosh um wow what what did he uh um an exciting um well diverse background i was looking at your website i don't want to get too off course here but i was found your civilian defender uh he's got a website called civiliandefender.com before we get into oral surgery and teeth and all that what is the civiliandefender.com um well thanks for having me Howard first off civiliandefender.com is a website that i started um probably about five years ago six years ago and um i guess people would call it a blog now i always just call it like an essay site because i don't put stuff up there um you know with um you know Gregory and regularity i just kind of put stuff up there when i have something useful to say and then i also use it to promote a lot of my open enrollment classes and that i teach so a few years back when i was well you know i haven't always been in dentistry you know I’ve had kind of a varied experience in my past and and um a lot of that involved um you know being an armed professional one kind or another and so that website is kind of a an amalgamation of all of the things that I’ve learned through training and experience you know over the past 20 some years that i try and you know pass on to my students and the readers so you you were born up in the state of Washington near Canada yeah correct yeah my dad was a naval aviator and um and you know so i was born at the naval air station on Whitby island wow so um um so you've been in uh military uh so so that's where the the roots of that um um civilian defender come from right correct yeah yeah i mean you know i when i originally um left high school you know i had every intention of you know being a police officer um and um ended up kind of sort of pivoting and going into the ems um but I’ve always had kind of a a um interest you know in public safety and and and service public service that that is uh that is very interesting um my gosh um so but um from your civilian defender to oral surgery is it um it sounds like you've always been a hands-on um surgery wound surgery suturing um sure has it really changed a lot in your lifetime i was hearing on the news it was on the news uh maybe a couple of years ago that now there's some chemical pack they pour in a wound and then it sets up and coagulates has there been a lot of technological advances in your career uh for these uh civilian wounds and and uh stuff like that yeah you know unfortunately probably one of the most beneficial side effects of the global war on terror has been you know the advancements that have been made in trauma medicine that have kind of trickled down into civilian uh emergency medical services and yeah there's like um you know quick clot combat gauze things like that that are you know available like on amazon or you know at rei even you know you can buy these things if you're uh you know like cyclist or or mountain biker you know if you have um you know uncontrolled bleeding uh you know a tourniquet and some wound packing you know with a hemostatic in it is what saves people's lives and it happens very regularly now so um you you got a 14 year old child i i want you to put your dad hat on first because we we have a reoccurring problem in dentistry um everybody talks about when they talk about the 12 dental specialties number one is always oral surgery highest paid everything and endodontics and then and then it's perio pediatric ortho prosthetic anesthesia oral facial pain oral medicine oral pathology and the bottom is dental public health and whenever i talk to a dental public health person they say one of the you know eight percent of the emergency room visits are odontogenic in origin and they always say the major problem is that someone will go to a dental office and that dentist went all down the road a cosmetic dentistry bleaching bonding veneers and invisalign and they can't pull a tooth or do a root canal and and i mean my gosh i hate to be rude but you're really not a doctor if you can't treat a wound pull a tooth get them out of pain and i couldn't ima you're a cycler could you imagine wrecking on your bicycle they take you with a take you to a hospital a broken leg and they go ah sorry Sherman we don't do legs we just do fingers and toes i mean and when i talk to them um you know there's two paths at a dental school one is the most needed most profitable and it's blood and guts it's i can pull this tooth and start a root canal and half the class says nah nah i want to do the bleaching bonding veneers and i say why you got 400 000 student loans and it's fear it's just fear so put your dad hat on what would you say she's in dental school and she she pulled it too she did a root canal and she's like you know what i could live three more lifetimes and never do that again how do you psychologically pump up a kid because i know after they do a hundred extractions and a hundred root canals they're they're past it but crossing that chasm how do you get someone afraid of blood and guts to pull some teeth and start some root canals and and do your public health dentistry service and and stop throwing them all in fact when dennis tell me don't you when people say we're not a real doctor i said well you're not a real doctor because if you crash your bicycle on a Sunday the ambulance is working they're taking to the hospital they're all working you couldn't you could find three mermaids and four unicorns in phoenix on Sunday before you found a general office open and then eight and a half percent of the emergency room visits blah blah blah so how do you get a young child in dental kindergarten school to get over the fear of blood and guts well um i i do it a couple different ways and i always tell people you know when people say that you know you're not a real doctor thing i say like no I’m a real doctor like i do surgery every day on people's heads and what could be more important than somebody's head you know you're less than three inches from their brain and six inches from their heart so yeah pretty important um but you know with students that we have you know in the clinic at school every day and i work in the um in the dental schools uh you know outpatient oral surgery clinic um most of the day and you know we have probably between three to five third or fourth year dental students that you know get vasovagal and pass out um every week and um and that's either from you know the extra layers of ppe and the and the heat exhaustion you know that people are experiencing now with all the extra covert precautions or you know intermittent fasting um or one thing or another that that you know results in them kind of getting hypoglycemic and and a little wobbly um so you know i i get students other students to kind of sort of always say like galvanize themselves or gird up their loins to be able to deal with people passing out because that's one of the most frequent you know in inter-office dental emergencies that we deal with is you know syncope and um so that's kind of like one thing that i hit everybody else on and so they get to see like what it actually looks like to put somebody uh into the Trendelenburg position you know and you know see what it looks like to get a high flow o2 onto somebody that's that's passed out and get them you know back to where they're functioning and alert and aware um the other thing is is that you know i i try and get people over the idea really quick that you know um dentistry is a is a bloodless uh specialty you know or subspecialty i mean there's there's nothing bloodless about it you know even on the most uh atraumatic you know orthodontic extractions that you might do on primary teeth for a teenager or a child you know there's still going to be a tiny amount of blood even with you know no flap and um and you know very little uh manipulation but there's always going to be some blood and some people you know are geared for that kind of thing and some people um aren't but yeah i agree with you 100 i think that you know i know that we don't require people to do you know a residency to go into practice and i i really think that so many of the students that i see would benefit greatly from you know a gpr or an aegd not because they didn't get a good dental education or wherever they went but they need the basis in dealing with um when when procedures don't go well you know like when there's complications when there are emergencies and things that fall outside the realm of conventional dental curriculum and so those are the things that i try and prepare people for and and i always encourage the d3s and the d4s like to think about doing you know a hospital dentistry program uh or an aegd if they're not really into you know dealing with the medically medical complexity stuff so much um just because i think it's that important and these days you know i always enlist the help of you know other medical specialists in guiding you know treatment plans for especially medically complex patients and i conduct myself in such a way that you know i want those physicians and cardiologists and whoever they might be um to think of me as you know a sub-specialist just like they think of themselves and um and i teach by students you know if you and residents you know if you conduct yourself um in that way then that's how you'll be treated and i i i kind of get miffed you know when i see the um you know social media has done a lot to promote the purely cosmetic and almost gimmicky side of dentistry and you know people ask me all the time like hey what kind of whitening products should i use and i said you know like i honestly have no idea like there's people that deal with all that stuff and I’m not that guy like I’m the guy that if you want to um you know you're you're interested in getting a couple teeth out but you also have hemophilia like I’m the guy that you're gonna come to you know so um that's that's kind of my take on those things but i agree with you 100 i mean I’ve been the guy before on you know trans continental uh uh airplane flights you know when they've said is there a doctor on board you know and I’ve raised my hand and stood up and you know rendered aid to people um just like i would any other time um so yeah i agree with you 100 i think it's the emphasis that needs to be put on being able to treat people um in an emergent state or how you find them is absolutely absolutely critical and as kind of an addition to that right now at mahari um where i work we're trying to put it uh you know there's everything is so partitioned um having to do with coda um as far as hours that are allotted to certain subjects but I’m trying to squeak an extra four hours in so that i can get the residents and the students um four hours of tactical combat casualty care based training so that you know if they're at a peaceful demonstration and and you know violence breaks out and someone has life-threatening arterial bleeding or uh you know I’ve had two patients in my practice in the past that have had gunshot wounds that needed immediate treatment and they came to the first place where they thought they could get some medical help and they luckily come into my place they came to the right place um but yeah i think that that kind of of uh training is is absolutely essential because you will not um you know you will respond to the way that you were trained and if you haven't had that training before you are you are not going to do it and I’ve got some uh roots to um you and my hairy and all that stuff you can't even make this up this is so bizarre but my two oral surgeons at my school umkc which by the way umkc um caesar sabotage just got elected become the ada president-elect he's a umtc graduate of uh 1987 and he'll be the first Cuban American the first Hispanic American to be the president ada but when we were at umkc the two oral surgeons were Charles Williams and Brett Ferguson and now uh uh his daughter uh daphne Cassandra Ferguson that's uh that's um Brett Ferguson’s daughter right i I’m not positive about that i know that we have daphne Ferguson young that that works um that's the director of the gpr clinic but I’m not sure if that if if he's related or not Charles Williams though um i know him um for sure he was actually my professor uh of oral surgery when i went through dental school and he also was the guy that interviewed me when i came to cherry but i was bringing up Charles Williams um and it was two things that come to mind there was a um girl and uh the uh the class that that was an assistant and um her name was uh Susan Susan um maybe her name was Susan white and um i would see Charles Williams and Brett Ferguson these big old manly men and i thought oral surgery was about um you know muscle and all that and then i watched this little Susan girl you know who just she would just sit there and she wasn't sweating she wasn't grabbing hard and manly taught me everything about leverage but when you said about the peaceful demonstration i got a strongly worded lecture from Charles Williams and changed my course in the oral surgery department um someone was um you know they'd gotten a fight or an altercation or a gunshot or whatever and when they're working in case I’m asking about all this stuff and he stops and goes look um right now they're in the oral surgery department and they need an oral surgeon they don't need a judge a jury a preacher their mom their dad whatever and you just need to stay in the zone because if you start thinking about all that stuff you'll you know your your surgical skills will go down and he said when you're in a um when you're in the oral surgery department let's do oral surgery and i i don't i don't want to know who did what who started the fight what they're demonstrating you know whatever you just get our job done but my gosh i i thought uh Charles Williams uh was uh and brett ferguson were just uh the two most amazing people at the school you dropped the name coda I’m afraid a lot of people don't know what that um coda means oh that's the uh committee on dental accreditation okay um your last uh one of your posts on uh dentaltown um is actually what we were talking about you said um she went to the er last night the er doc gave her some percocet blah blah blah blah blah and then you're showing these pictures of something that's just such a mess i i couldn't imagine that this patient went to the emergency room and their best idea is percocet and what i think strange about hospitals is you go in there they can remove a tumor out of your brain they can do a bypass they can amputate your diabetic foot and then when they look in the mouth they just hand them pen vk and vicodin is that changing is um i mean it seems to me the infrastructure at American hospitals is wrong if i could you know take out a bullet and a tumor and cut off your foot but i can't i mean this picture you have on here i mean it's like are you kidding me that a doctor looked in that mouth and gave her percocet antibiotics uh is something structurally wrong with hospitals when they can't do an entire body part yeah i think there is and you know one of the great things about being here you know is metro general hospital is on the campus of maher you know we're one of the same um so when you know a dental chief complaint comes into the er they call you know the hospital dentistry department or the oral surgery department to you know go in and do a consult and get to the bottom of it and so we have a little bit different approach here but a lot of the emergency rooms that are in Tennessee um that aren't us they do that you know they'll give somebody a maybe a toradol shot and um and some ivy pro sorry and some uh some antibiotics or some clindamyas and maybe some amoxicillin and send them on their way and just say oh go ahead and follow up with a dentist but you know i I’ve seen a few of those people that have been um you know patients that are there when we open the doors at 7 50 in the morning and um you know they they're a fascial space infection so they you know miss the pick up a lot on on some of the odonogenic you know and even orthognathic issues that um is yeah it's it's kind of strange you know it's it's weird to me that if you have a hospital dentistry resident you know they'll do rotations in the er where they're where they will you know suture wounds work up patients do codes you know full-blown uh respiratory arrest or cpr codes full resuscitations but we never have you know emergency room physicians that like you know that are residents that come through and you know learn how to shuck teeth or cut a flap or drain an abscess or do any of the number of things that we do on a regular basis i don't know who teaches some dental blocks but one of my friends that's a an emergency room physician in in spokane Washington he said that a dental block is one of the highest reimbursed procedures that they do so that might have something to do with it as well um another thing i wanted you to weigh in on is um there are sometimes they and you know because this has been a constant random mind for a long time that um you know um a real doctor has to do blood and guts they have to be able to exit onto they have to get a patient out of pain they just got to do what they got to do and a lot of times they um they let the um better be the enemy at best right now they need a doctor they need to get out of pain and they start thinking things like well I’m not an oral surgeon but a lot of them come back with a specific that i want you to address they'll say well i would have if i was in Meharry but i need a 22 cal i need a coward i mean i mean some of these people need like 50 different forceps to approach oral surgery and then there was a guy there one of our teachers that taught with uh brat and Charles was uh matthias horrigan and he said and he used to get so mad he hated um instruments and he said look i was an oral surgeon in korea and we had a 150 a 151 a small large elevator and perihouse we had five things yeah and he said i pulled every single tooth in korea with those five instruments and then on the other side of the spectrum is somebody's not gonna get out of pain because they don't have one of the 50 forceps so my specific question to you is how many forceps does a dentist need to be able to walk into an operator and say I’m going to pull that tooth come hell or high water how many do they need um i generally in the room when I’m working i'll use a 150 a 151 and a three um a one a one fifty a one fifty one and a twenty five horn yeah and um so four so four forceps yeah i i mean you know i can use an 88 uh if if i have them or three if i have them but like they i don't you know unless they're there i don't i don't really even think about them and and uh kind of going along with what you were talking about with dr matthias um you know when i i worked for a time as a contractor for the army national guard and um you know you'd get to a location um with a portable operatory setup and you know your your armamentarium was very very spartan and it wasn't unusual to have exactly what he said you know you had a a you know a number nine molt periosteal elevator maybe a 77 r to 77 l um and a 150 a 151 um and a 23 and a blade handle and you know if you needed anything else past that i mean you had a surgical hand piece of course um but if you needed anything past that you know you're gonna get a uh uh we don't have that you know like what do you think this is like we you know it's not an instrument store here this is what we got everybody else did it with this you're like oh okay so you know you only have to do a few thousand of those before you kind of get the moves down and then you go back to your you know regular office and go why we got a lot of stuff here in you know each one of these uh autoclave bags are these uh instrument kits that's just kind of taking up a lot of space so you know stuff ends up going on ebay another thing I’ve noticed um since i got out of school is a um you know we used to take the um the um um the periosteal and we just used to detach the tissue and a lot of the young dentists have said to me um when they're watching they're saying well you know you put a lot of time on that um that area but i mean the tissue's not really holding it against the bone but um again uh dr Williams dr horrigan dr ferguson they always said and i want to um that hydraulics and what i mean by hydraulics is you know if you put the empire state building in a test tube you could just have a little pencil in the bottom and lift up the empire statement i mean leaves hydraulics and he used to always say you know um when you do that periosteal all the way around that and really get it good you start the inflammatory process and it starts inflaming and it starts loosening up and and now I’ve seen that turn into proximators where if i go around with the periosteal then i go around with approximate i mean you could almost play with that thing long enough to where it'll just start coming up out of the mouth are you a big proximator fan or not really or is it too slow or what are your thoughts on that uh i mean if I’m doing something where I’m really concerned with ridge preservation then i will but a lot of the time i can get away with just you know using conventional instruments and still not having you know having a minimal amount of damage to the to the ridge um and as far as socket preservation goes and a lot of times you know you graft uh immediately following but yeah i i always there was a time where i i can't remember i had an associate ship and they did have approximators and i experimented with those for maybe a couple months um on you know several hundred extractions and and you know the idea of of you know either creating space or severing periodontal ligament fibers you know to you know work to luxate a tooth is is great in theory i know periodontists love them um but i always kind of think of that as a as like you know the sniping rifle of of oral surgery and you know you can get uh a lot done with um you know with with just a a regular 77 um and um and just a little bit of uh flick of the wrist and and just knowing exactly where to put it and that's one of the things that i think a lot of students get kind of twisted in their minds is that they aren't working you know against the root surface and the bone they're trying to work the elevator between two teeth and you know they're ending up um getting one out for sure and getting the other one half of the way luxated and so that happens uh uh you know occasionally um in the clinic where i'll say okay this is how we luxate and watch where this goes and you know going along with that like where you said that um you know people will use the excuse well i would pull i would have pulled this tooth but i didn't have you know x y and z available to me or i didn't have a hand piece available to me you know that i would say probably eight out of ten of the cases that we have in the outpatient oral surgery clinic where the student you know will request i need a handpiece in here and some supervision when i go in there i look at what the you know the current state of the patient and i don't use a handpiece at all i just use a little bit of creative elevator work and um and and just pop it right out going going back to that um pulling out i went tell the kids also you know when we're talking about you know you go around the periosteal you're loosening up the ligaments and soft tissue but you're starting the inflammatory process and when you're elevating and there's nothing happening or whatever and then you get more frustrated because now you're getting beep for a hygiene check oh my god that's perfect put everything down let mother nature start swelling and flaming and all that go do a hygiene check go to the bathroom eat a cheese it whatever and then you'll come back and if you're out of that room for five or ten minutes you will see exactly what I’m talking about when you left it wasn't budging and then and then when you get a hygiene check you went into panic mode thought well now i got to get out in two seconds let mother nature do the work and then you come back and you'll see what swelling and inflammation does um you know it's um it's just a it's a it's a beautiful uh thing um i want to ask you another controversy um i i wanna um this dentistry on center i don't like talk about anything everybody agrees on um a lot of these kids again I’m staying focused on the kids because that's really you know the only value of knowledge is if you can um share it and you know we should always be trying to take what we learned on our you know 70 laps around the sun and hand it to the next generation um but they're they're sitting there they're afraid that if they pull that too they they're always looking at the extreme well that that roots in the sinus and i i don't want to get a sinus exposure but then you hear people say that 99 of sinus exposures nobody even knows it uh you're going to see it and um and then the other thing they're afraid about it's by this nerve that they're you know they're afraid they're going to hurt this nerve or whatever that most all the nerve injuries is because you broke off this little two three millimeter root tip and your ego just can't let it go so now you're down there digging and drilling bone and you just make a mountain out of a molehill and a lot of these older guys like matt horgan used to always say he said you know what if you left that damn thing down there three months later it'd work out like a splinter but you had to go in there and cause a pair so so i know that's a lot of questions but I’m afraid to pull this maxillary first molar because i'll get a sinus exposure and I’m afraid to pull this mandibular molar because it's too close to the nerve sure and that is going to make her decide I’m not doing oral surgery so talk about that sure so you know you're always going to have bad outcomes like despite your best efforts you could have the the cleanest surgical technique and form and you know sometimes the patient is just medically non-compliant and you're going to have a bad outcome and that's not malpractice and that's where a lot of the students these days get kind of you know wrapped around the axle is it's that's not malpractice malpractice is when you you know have made a a grave mistake that you should not have made but you did it anyway and you kept pressing on and caused some kind of damage so yeah that's that's kind of the thing about it and you know a lot of times what i will do is if i always tell people if the root tip is the size of a bb or smaller and you know which is 17 caliber so so you know like what 4.5 millimeters uh in diameter it you know if it's if it's uh that small sorry 3.5 millimeters um if it's that small and there is no you know periapical radiolucency or or abscess or something that makes you think that there's some type of pathology in the bone leave that thing in place if there is pathology you know in the bone then a lot of time the bone is is kind of spongy and squishy and corky and you can flip that little piece out of there you just have to be able to visualize it and then as far as the sinus exposure thing goes yeah i mean there's plenty of people that have you know um the the apices of of premolars and molars that are you know well within the sinus and you can take those things out with uh no concern at all and if you do get a sinus exposure the trick is is you have to know how to close it and it's not a difficult thing to learn how to do and you also have to know the parameters what you're looking at so the way that i recognize you know if there's been a sinus exposure and how i teach um students to do it is to you know just use their 27 gauge local anesthetic needle and feel up into um you know the the socket where those teeth were you know previously residing and just kind of palpate with the needle tip and if you poke through into the schneiderian membrane you know with um with a 27 gauge needle it's not going to do anything of note and you know what you're looking for is a hole that is you know larger than two millimeters um you know a hole that is less than two millimeters you just close it up like you would any other extraction socket if it's you know two to four um you can usually get away with you know some some gel foam or um some type of biologic um and then past that you're gonna have to do some type of you know if it's like a six millimeter um exposure you're gonna have to do you know some type of you know a buckle advancement type flap or um a buckle fat pad or you know something like that to be able to to get something like that closed and have it stay closed and not turn into an oral intro fistula um but yeah a lot of times people will come in our students will come in for you know with one of their student pool patients and have um you know some one of my professors used to call it the lone ranger you know standing there that's a the lone you know two three or fourteen or fifteen and and no adjacent neighbors and say like oh boy you know even though this person has severe perio you know that last one third of that root structure is holding on for dear life and it's gonna bust a big piece of bone off with it and if it does you know it's not the end of the world so i you know have people you know cut a full thickness flap so that they've got good exposure on the bone and then just go real slow and and i always call it the 15 and 15. you know i'll push to the buckle and count in my head you know one mississippi two mississippi to 15. and then push back towards the palatal for another 15. and it usually only takes about three cycles of that and you can get just about any tooth in their mouth out atramatically and with a minimum of sinus exposures um another problem with um again I’m trying to focus on the um you know public health is about availability accessibility affordability and i want to talk about that demographics that you know i i see people talking on dental town they'll say well i wouldn't go to i wouldn't go to Nashville there's too many dentists there and I’m like whoa whoa there's 168 hours in a week i bet there's too many dentists monday through thursday eight to five and a half on friday but i bet there's not a single dentist in town on um you know after 6 p.m or saturdays and sundays whatever but a lot of these people say um you know there's so many new prescription medications out there and it's just endless and and americans are four and a half percent of the world's population take half the prescription pills and they just look at these health histories and they start going into fear mode complications side effects um how how do you get your mind around the health history um you know with all these medications and interactions and you know what is what is your simple do you have an app is there a website how do you get around that um i do a couple things so i implemented at mahari a thing i call the sample history which is also the same algorithm that the American heart association teaches for acls now and it's one that we actually use in the pre-hospital care setting you know even as as early as the uh 90s early 90s we were using that when i was still working in the field and basically it's it's subjective allergies medications past medical history past surgical history past social history last uh meal and then events leading up to the event that they're presenting to today and um so yeah i use that as a guideline and i have created a sheet you know that the students fill out for every consult and every patient that comes through my clinic or through the gpr clinic and with using that you know you get all the patients medications and you get all of the patients medical history that they disclose and you know i i teach people all the time you know it's convenient that my last name is house and you know hugh laurie made a uh heck of a killing with you know house md and i always tell people you know i tell students that that you know they'll they'll bring a patient in and they'll give me this history and i can see out into the clinic like where that patient is and i'll say you're telling me that that person doesn't smoke cigarettes never takes a drink of alcohol and does not use any recreational drugs and they'll say yes that's correct and i'll say okay come on and then i walk in the room and i go all right when was the last time that you used drugs and they go um about two hours ago in the parking lot when i got to the school and I’ll say okay well thanks for being honest with me but you know uh cocaine would preclude us doing anything today as far as oral surgery so we're gonna need to have you stay clean for a few hours or a few days and then we'll get you back and get you reappointed and it goes fine but a lot of times the students they aren't really like interested in being a detective and and sometimes you really have to be a detective and kind of drill down on these things and one of the things that i try and reinforce to them and i'll tell them is you know you're coming here into this clinic that I’m running and you want me to sign off on you to be able to go uh execute and complete a surgery on a patient you know that you don't that's a stranger to you effectively and you don't know everything about every medication that they're taking and every medical condition that they have and these aren't things that are necessarily obscure you know these are things that we see all the time like um you know dvt uh have a history of dbt and they're on plavix now or you know it's a person that has congestive heart failure you know and they're on a beta blocker and they're on a diuretic and they're on an antihypertensive of some sort and and then maybe also you know like a coumadin or one of the new generation anticoagulants and you know they'll i'll say you know with this patient and their blood pressure being 190 over a hundred if you if i said yeah let's go ahead and do this full mouth extraction of their remaining 14 teeth if i let you just run and do this three hours later when you're completing this procedure they might have exsanguinated in the chair uh or gotten really close to it i said and then we have to like take them from here and wheel them over to the emergency room and admit them to the hospital and they're going to be in the unit and that's not acceptable so here's why you have to be johnny on the spot with these things and understand the implications of of what we're doing which again is surgery on somebody's head and understand where that can go wrong and where things can go off the rails and if people are giving you this information or you can see it you know with your own eyes you have to be able to assimilate that information and figure out where the train can possibly go off the tracks and then prevent that from happening and sometimes that's as drastic as saying we're not going to do this procedure today at all until i speak with your physician or we do some blood work or or some some lab work so that we have a little bit more uh information and actionable intelligence so that we can make an educated decision regarding your surgical care and you know a lot of times that's not what students want to hear because they're trying to you know get this patient edentulous so they can get them to the pros clinic and and you know get a get some dentures in them but you know i also have to uh act in the in the best interest of of the patient of course so that's the the priority is we're trying to make everybody go home safe at the end of the night another stressful thing is pre-meds i swear if you go to a group practice and there's four dentists they all think there's four different pre-med protocols for it and it doesn't help when they're always changing it and changing it and changing it we're yet right now with the pre-meds okay so for um for cardiac stuff pretty much the only thing that i'll pre-medicate for unless the physician orders it you know and sends a letter in which case i'll tell them you go ahead and prescribe whatever you feel is appropriate and I’m fine with that if they don't or the patient you know is maybe years out or you know as a poor historian or hasn't followed up or whatever the case may be if they've had valvular surgery uh you know either replaced with um a porcine valve or a mechanical valve then i will always um prophylax them appropriately with the 2007 uh American heart association guidelines you know which is um you know basically a gram of amoxicillin or 600 milligrams of clindamycin the other pre-med is um and this is a dispute in many group practices where someone will say well that that's too infected to touch and they're swelling and we need to put them on antibiotics for a couple days and then the other guy's like well you know what to be the best thing is to get that tooth out of there and get all that pus out of there and blah blah blah blah blah and you got two good doctors who are old and they they see this two different ways how do you weigh in on that um i think i always think that it's it's easier for our body to begin to heal itself without the infected um the necrotic material there and the way i think about that is is you know if you came to me and you said Sherman look i got a huge sliver in my hand today doing yard work what do you think of that and i'll say like wow look at that like it's it's there's pus coming out of it you know it's red it's hot it's angry Howard let's give you let's give you a couple grams of uh of keflex and um you know we'll wait about three days or so wait till this thing gets real hot and angry and then we'll pull this sliver out on monday how's that sound uh you know and and the thinking past that is usually has to do with um the the um that you know the the acidity of the tissue and being able to achieve profound anesthesia so a lot of times people will say well if this tooth is really hot and there's a lot of you know acidotic tissue there and it's really [ __ ] then what we'll do is you know indeed it stitch a drain in and then we'll get him back a few days later to extract the tooth and that's you know I’m okay with that that's that's that's a kind of a you know a long walk for a light snack but it's it's okay um one of the ways that i'll usually do it is get around the acidity of the tissue by changing up my local anesthetics is something that has a pka that's more amenable to uh you know a lower ph and i can usually get profound anesthesia by either doing that or just going more superior with my block and if i do that then i can get them profoundly numb and then i'll do the ind suture the drain in place and take out the the you know the fugitive tooth all in the same visit so i really don't like people to you know leave with something that is you know effectively a lit stick of dynamite with an unknown length of fuse hanging out of their mouth um the young kids that are still in dental kindergarten school um they're going into the fall season now where you know it's uh halloween then thanksgiving then christmas um is it an old wives tell or do you think we have a lot more emergencies and drama in the holiday season um than uh in other times of the year i think it's absolutely true yeah and i always joke and i say i think i misspoke before i think i said a a one gram of amoxicillin but it's two um just to be clear but um yeah i always say that uh the number one you know cause of dental emergencies during the holiday season um which i count as starting in you know right about now mid-october um is food injuries and you know whether it's you know i haven't eaten a laffy taffy since last halloween and then i eat a laffy taffy and and um you know rip some some fillings out you know or break some cuffs off the teeth or um you know people at thanksgiving always seem to be like gnawing on bones and something a battle happens so yeah i definitely think that um it's a situation of half karma and then also you know when it's least expected you're elected um so you know when you are got the station wagon packed up and you're ready to you know close your office in december and leave town for 10 days um that's when that emergency is going to just show up through the door and yeah i think that that the uh the holiday emergency is a real thing and i think it's going to be worse this year than it has been probably ever in years past because there's been such a you know i don't know for lack of a better term like a cease and desist placed on preventative care and you know treatment planning um now you know there's so many things that i see in our clinic every day that the patient was made aware of and treatment plan you know in mid 2019 or or early 2020 that you know with coveted kind of shutting everything down sort of just nipped that in the bud and and these people never got definitive care and now we see these teeth that were you know had a small periapical radiolucency um you know back in february now they're coming in you know and eyes swollen shut or you know we've got swelling down into the neck um things like that so things that could have been fixed um easily before you know I’ve now turned into major problems and i think that that's going to be a bigger issue this year because people were just like man I’m not working i can't afford it i don't have time like you know I’m working two jobs and driving for uber eats and i don't have time to get to the dentist and now this kind of thing is going to to you know really sneak up on him and and then you know i mean it's a national thing you know dentists are half closed for the month of december so uh it's just the way it spills out on the calendar so yeah i think that i do think that that is true that they they are always emergencies are always worse around the holidays and i think this is going to be the worst one we've seen yet and and another thing i i want to i want to tell you kids think outside the box i mean um i coach I’ve coached people for 30 years where um they um they came out with a bunch of student loans they don't have they didn't come from a family with money they don't know what to do and i say um okay well the stats are 11 of the towns in america don't have one dentist obviously these are small towns of a thousand or two but i have done this and and successfully several times where i tell a kid well just go find the mayor of that damn town and tell him you'll go to this town of 1200 people because remember whatever the small town is it's a thousand the draw is another thousand so you need a dentist for every two thousand so a city of a thousand that doesn't have a dentist it's got two thousand people and they've literally said well if you go to the first street in maine half the buildings are closed and empty or whatever and the mayor gave them a building you know so well you can have that building so now you got free landing building and then the bank in the town well hell yeah they're going to give you a signature loan you live there sure um but the the um i mean you're just um i mean you have no competition um i i just think it's a great way to go but one of the problems in that small town is you're kind of um if you're the only dentist that town there's probably no emergency center there's no hospital and you get a lot of stuff and then um I’ve lived i practiced for the full spectrum when i in the 80s the doctors were the bad guys because grandma's dying of cancer and they won't give her morphine or pain med and and why are you worried about grandma being a drug addict when she's 80 years old dying of cancer you you you doctors are too mean so we were the bad guys in the 80s so we started giving a lot more opioids and pain meds yeah and now now we're the bad guy and we can't go back and one of my one of my I’m going to ask you about this because i know you um were um worked in a small uh rural gp practice for a while um my rule just avoids a lot of problems is i tell them i can't give you any pain medication unless i did something so if you really want pain med well then you're in a lot of pain so let's pull the tooth or do the root canal but I’m just not going to give you antibiotics and a pain med because you got to go drive for uber eats in two hours i mean if it's really an emergency um is that is does that work for you is that a good in out or is that um yeah and and you know one of the things that i have seen you know both anecdotally in person and then also there's a good basis in the literature to support is um the use of you know tylenol and um ibuprofen you know complex together um and and there's people that you know alternate them and there's people that take them or you know practitioners that recommend taking them together i think that's a great way to go and you know we see um corrections patients you know from facilities all around Tennessee um two days a week and you know those people aren't prescribed narcotics like narcotics don't exist in um state prisons that's you know that's why a lot of people are those folks are there in the first place so um you know we do full mouth extractions we do orthognathic surgery um and on a regular basis it's like I’m talking like you know 40 cases a month um on corrections patients and they're treated with you know tylenol and an nsaid of some sort and with great effect and um so i think that that there's a definite argument to go towards that there's a lot of offices here you know in Tennessee where opiate abuse is a huge problem um and they've gone you know uh narcotic-free completely and and that's what they do is is you know the the combination of the tylenol and the handset and i think that's okay too um but I’m with you i always tell people i do not give um narcotic pain medication unless I’ve spilled your blood and the only way I’m doing that is like you said um with you know some type of intervention and so that's you know my lie in the sand i also check we have a database here called the Tennessee controlled substance monitoring database and anybody that i contemplate writing um a controlled uh substance to i run through that um just to make sure that they're not in a pain management program already and um a lot of people are so it's it's i don't want to get on the state's radar for any of that yeah i just want to make one comment about the opium um war and a lot of people think and how we're in the middle of a pandemic and all that kind of stuff um did you all forget the opium wars in china as you know a century ago i mean when people say it's a new thing I’m like yeah if you've never read history i mean some of the reports when the british got to uh china that a third of the entire country was just growing and smoking opium and all that stuff i want to go to another drug because like you alluded to earlier they'll tell you if they're on penn vk or coumadon or whatever whatever but they're not going to tell you they're on meth and that's another big one um if if you know um he's young he's nervous about oral surgery and he's afraid that maybe this person's on meth um what are you thinking when you have a toothache and you're going to go in there and do an extraction and you're thinking it's not on the chart but this guy might be a meth addict what's running through your head um i look at it I’m looking more for systemic stuff I’m not just isolating it to what i see um intraorally because you know i mean um you know rampant decay secondary to drug use of any kind is almost inextinguishable indistinguishable from um like someone that has a three or four liter a day mountain dew habit you know and mountain dew was invented in Tennessee so there's a lot of people here that take full advantage of that and um it's not unusual to go into an operatory here to meet your patient and they've got two one liters of mountain dew one in each hand one is empty that they spit their you know tobacco juice into and the other one is full of mountain dew that they're drinking um and when you look at these cases that you know the way that i determine is you know a lot of times just by their behavior um because people that are you know methamphetamine addicts or regular users they definitely have a pattern to their mannerisms and their behavior and their affect and the way that they speak and interact with you and and that's you know they also have a lot of times you know there will be hygiene issues and everything else so um you kind of have to consider the whole um patient of course like you do for everything but you have to be specific and look for those indicators that might make you think that something is afoot now i'll tell you i have seen a tremendous amount of patients that are on suboxone or subutex or you know some version of that for the purposes of opiate cessation and that drug in and of itself you know where you maybe wouldn't normally see um the rampant decay that you see um in people with um that are using methamphetamine you know you imagine this person's on opiates so there is you know a parasympathetic enhancement there and and you will see these people you know have xerostomia so because they have xerosomia they're um unlike the the you know the methamphetamine people that are drinking the mountain dew and the monsters you know maybe these people were doing that as well but a lot of times you'll see the same kind of decay um but it'll be um in a in a not generalized fashion and with speaking specifically about the subutex film or suboxone film you know it's a dissolvable sheet um almost like those um listerine breath saver strips you know that were kind of popular a few years ago at all the conventions you know it's that treated with a drug people put it into their buckle mucosa and it dissolves and i don't know what it's made out of um but it sure does a number on you know teeth on the people that I’ve seen use it and it always seems to be um you know close to major salivary ducts so um you know you'll see it uh just rampant decay um you know anywhere close to the stenson's ducts and then you know in the um sublingual as well so uh it's odd and um you know i i think just by getting a really thorough medical history and then you kind of have to compare it if you have a person that has generalized decay and odd behavior and sores on their face and on their arms and on their hands and they're 16 years old and you're looking at no restorative teeth in their mouth and thinking you know full mouth extraction and dentures um that's a you know i i would say it's safe to err on the side of caution that even if they told you that they're not uh a drug illicit drug user you kind of have to um assume that they are until proven otherwise and of course you can also get a lot of that from from vitals too you know you can get uh you know pretty impressive hypertension just off of cigarettes and and energy drinks but you can get a really impressive number off of methamphetamine plus monster energy drinks plus cigarettes so you know blood pressures that would be um you know considered an acute hypertensive crisis under some situation so yeah i i always um have you know really highlighted to the students like what this person's telling you and what i see when i look at them those stories don't coincide so there's a there's a piece of the puzzle here that we need to look into further a lot of times you know i'll tell people like look like I’m not calling you know the metro police to come over here to get you like i could really care less about what you do in your free time what I’m trying to do is best guide your health care so that i don't give you a medication that's going to cause an interaction that could result in your death so please be honest with me and then usually they'll go okay well in that case yeah i smoked crack cocaine or i did you know a couple hits of ice like two hours ago before i drove in i said okay great thank you for telling me we'll uh you know delay the procedure for a couple days and get you back in when you're sober and uh get it done um i want to go back to mountain dew because that that was a very interesting product um during prohibition uh the bootleg was mountain dew so so when they brought mountain dew to the market that was already the brand name uh but what's interesting is they use citric acid instead of phosphoric acid and i know um a lot of people um say well coke has a lower ph than a mountain dew coke has ph 2.5 mountain dews 3.1 it's not really that um they call it titratable hydrogen ions long story short um citric acid can donate three hydrogen ions whereas phosphoric acid can donate one and it's just a uh it's just a it's just a bad com combination and they uh you start mixing that stuff I’m gonna go with some uh um um some more specific questions you promised me an hour of your life I’m 10 minutes over can i go into some overtime sure um any any thoughts or tips on the um the dreaded dry socket and is it still we were told it was three variables woman or smoker woman birth control pill so two of them is woman birth control is that still a thing or is that because because I’m at the age where a lot of the stuff i learned 30 years ago like even the three laws of thermodynamics now there's four i mean yeah uh rant on um dry sockets i i okay so the first thing i always tell students is the longer that the periosteum is exposed to the air the better so if i can get a procedure you know you know open shut and sutured in 90 seconds or less then I’m happy patients happy the chances that i see them back for a post-operative complication is is very very low the other thing along with that is that i always tell people like absolutely no smoking absolutely no drinking through a straw and absolutely no spitting and those three things i think go a long way towards it and in my experience it's probably 90 of the time when i have somebody that has a dry socket it's they're a smoker so to kind of hedge my bets towards that direction i will you know always work to get primary closure um on on a tooth like that and then um on a smoker and then i'll often like put gel foam um actual or surgical like in the socket as soon as i do it just to make sure that that stays planted there um another thing about access to care affordability availability I’ve been told point blank well you know I’m working at this um this um um well it might even be a volunteer deal it might be saint vincent de paul something or you know some church and they'll say yeah but um i i would have had to have a cbct and i kind of cringe because i sit there and think okay well we didn't even i remember when the greatest new thing in oral radiology was on the panel where they put a r on one side and l on the other and i thought that was the greatest thing that ever happened in radiology because the patient looked at says is that my right side can you i mean when is a cbct when is it the standard of care when when can you not pull a tooth um and be that um emergency room doctor get him out of pain pull it to without having a cbct the only time that i really like even think about those is um as far as you know from the public health aspect is if i see something that is like really obvious um large pathology on the um on the pan and if it is something where i can actually like palpate um you know expansion in the arch if it's something i can you know palpate expansion in the arch or something that where where it kind of hits me with uh you know this is some type of pathology then i'll say hey let's go ahead and get a cone beam you know we have one across the hall um just to sort of rule that out and see where this is going because you know it doesn't make any sense to um you know yard out a couple teeth if you could also do that and you know enucleate um assist or um you know we see a pretty good amount probably uh probably half a dozen a month like dentist cysts uh probably half a dozen a month okc's um you know the the kind of and and um amioblastomas as well so you know we see them and um that's kind of when we look to to get some advanced imaging but probably 98 of everything we do we do off of a pan with right left markings on it i want you to address this um there are um when you lecture around the world um irrigation protocols that that's what i love the most when people say they love architect what whether what they're really saying to me is you know every human lives in a home and it's neat that all 8 billion people need a home and they all make it different down to the details of the bathroom the sink the plumbing and i notice when I’m in some other countries after every extraction they have a very exorbitant protocol like first they'll rinse with uh they'll rinse the sock with paradox then they'll use hydrogen peroxide and you know um do you is is post surgical irrigation part of your protocol it is yeah i we rinse um and irrigate with paradix um just about i mean i mean every every time we do a procedure and i think that that's especially for our population you know our population medically indigent um a lot of polypharmacy patients a lot of systemic illness a lot of immunocompromised people so anything that we can do to kind of um put the odds in their favor to allow their bodies to do you know a better job of of catching up to repair and remove any further pathogens i think is is beneficial and now the new thing is bone grafting and there's a lot of people that it's it's convincing these young dentists that if you extract a tooth you got a bone graft what's your thoughts on bone graft when to be or not to be when are you bone grafting um if the if I’m going to be absolutely placing implants in the future then i think that it bears some use you know somebody the other day uh i saw was routinely bone grafting for third molar extractions you know which just seems like i mean you know um nickel and diming somebody you know charging 250 dollars per site for a graft for something that if you just left it alone for six months it's gonna fill in and and be absolutely normal and what are we grafting for like you know there's so much bone um you know in the in the proximity of the mandibular thirds especially on the buccal that it's it's not going to make a difference in the world whether you graft that site back or not so if we're really concerned about ridge preservation um and or and socket preservation and and putting something there you know in the immediate future then all graft but um you know in the public health setting you know we can't justify the cost and um and patients certainly aren't going to pay it you know we have patients that gripe about getting a tooth out for you know an exam an x-ray and extraction for 70 dollars so you know if we said yeah we could do that we could also graph the site back for you know 150 or 200 dollars um most people would you know scoff at us and stomp out the door um piezo unit is that standard armamentarium or or is that a must-have or or what um i i haven't used one you know in in institutionally i mean I’ve used used them before in um in private practice but i don't think it's uh an absolute no i don't think that it's something that you you have to use no yeah i i agree it's uh it's a it's it's a nice thing um but you don't have to have it um a lot of the surgeons um and we're both bald heads i uh i'll bring that to your attention um man when you got a bald head and you're banging into that overhead light and then uh you know things like that are you still using the old-fashioned overhead light and banging your bald head against it or are you using a um you know a a surgical headlight I’m probably about 50 50 if if I’m going to do something planned i wear a light if I’m gonna do something spontaneously you know to to you know get a student out of the ditch or a resident out of the ditch then i'll just go in and use the operatory light but enough i'll tell you enough students and residents have them now that a lot of times i can be like point your faces over here and just have them you know hold their uh over my shoulder or you know close to the proximity and those leds you know they have got such a tremendous amount of of spill that you can um see very very plainly what you're what you're trying to see but um yeah that's that's how i do it and i i want to tell you dennis said in 32 years I’ve had two of my dental assistants become dentists and you know what the only thing they both had in common well they were both girls um they were assistants they were girls but um when i would be doing surgery they'd always be bumping their head and and then when i and sometimes i just like have to take my hand up there put my hand on their head and just like push their head back in so i want to tell these dentists when when you got a dental assistant it's actually banging her head on your head she's so into this i mean she's trying to see and and i'll i'd say to him i said you know elaine you bumped my head five times and she goes i know i it's hard to see can you move your head back and I’m sitting here thinking uh I’m the dentist but i mean but that that so it's when they're really fighting to see uh that's a really good thing um another thing um um put your dad hat on um some of these people um when they're coming out of school they they they just always think they have to section every tooth before they even start doing anything um so rant on sections when what makes you think I’m gonna section this first as opposed to luxating it and working it that way my big thing is i'll i'll take into consideration the history of the patient uh you know and and you know their overall uh health and exam but i also look at ankylosis like ankylosis is one of those things that you know can really really um make a you know a relatively straightforward extraction you know into a real humdinger the other thing with ankylosis and you know kind of goes along with it is endodontically long-standing endodontically treated teeth you know that don't have a periapical radiolucency if you end up having to take those out um a lot of times it's a fight and you know if it's if it's a say a 19 or a 30 you know that's been there for 25 or 30 years maybe it's got silver points in it even and you're like um you know having to go and get it and it's ankylos like section is going to be the least traumatic way to to get it out of that patient now I’m going to get you in trouble I’m going to ask a question so controversial there's no way you could answer this without pissing at least half the the people um england did a study about i you know five or ten years ago they were they were looking at iv sedation deaths and they're rare but they did call out the dental community that even if it's only one out of a million the dentist were you know two out of a million and i find what i think is very interesting is um looking at you know we're all the same species we're all treating the same decay we're all the same patient they all eat sugar regardless of what you think when you're little I’m like we believe when we were little that in india they were all vegans that ate the best oh my god when i went over there and lectured i mean when you go to the dentist house you were met with grandma with a whole tray of sugar cookies in fact I’m almost ready to say that the india might eat more sugar than americans i mean um it's all the same thing uh but um you know they they do things uh slightly different and uh in america you can't go in a hospital and do the iv and the bypass you can't do the iv i mean in every hospital in america it's separate it's like you do the iv surgeon do the surgery the only place i see it is mainly in dentistry joan rivers is a class example she just went in to have a little nodule done no big deal but the one of the most famous comedians of the time died from iv sedation i notice there's only two publicly traded dental car uh there's uh three two in australia there's one three hundred uh smiles and and pacific smile and then singapore has one q m and i I’ve met with all three of those founders and in order for them to go public the the the broker said no iv sedation under 18 over 65. because they looked at the risk analysis they said no you know 18 and under no way 65 between 8 under 18 over 65 is was the majority of the mortalities as the way wall street brokers saw it um so the question is when i hear these dentists say oh I’m gonna go to this weekend course in a hotel and I’m gonna start doing iv sedation I’m like god dang so for many many years and still to this day in fact i just had dinner with them uh um a couple of nights ago um these oral surgery um these these medical malpractice they send me their month end claims right anytime it's the max you know one million three million they all have the same thing in common there's an iv and it didn't go well um i just don't believe in it i i think if you want to do dental hell it's even a specialty dental anesthesiology but I’m telling you you're talking to a lot of dentists right now who do iv sedation while they're doing uh the the dentistry what what are your thoughts on all that yeah i mean I’m i am a fan of iv sedation just because i think that there's a lot of patients that just can't tolerate um you know even enteral sedation or um or you know local anesthetic just just you know straight up local anesthetic and getting getting work done now granted most of the ones that i do you know are relative to exidentia cases um i don't really have much to do with iv sedation um with you know restorative or endo or anything like that i have friends that do that but i i don't fiddle with that um so you know i think you can be very there you know there's a few different ways like a lot of people that um are experienced with iv sedation you know hit the patient with you know a big huge uh bolus of opiates and benzodiazepines and and anti-medics get them you know real snowed and do the work no problem uh and that probably works good for you know 75 of the patients and you'll always have um you know a certain percentage that falls outside of that where regardless of the amount of drugs that you give to them it's just combat ineffective like you're not doing any good at all and you end up aborting the procedure and it just turns into you know bad feelings and refunds and everything else so i think you have to be really really cautious with your iv sedation cases i don't like to do iv sedations on anybody that is above an asa class too if it's somebody that's an asa class 3 then a lot of times then we will take them to the operating room at the hospital and do that you know in the full surgical suite with an anesthesiologist and run it that way um but you know of course that boils down to the economics of it too and you know working at a school um like i do you know there is a bit of a a a break than it would be you know in private practice or at a surgery center or private hospital or something like that but um yeah i mean i think that i i think kind of like many um expensive ce courses that are available in dentistry you know iv sedation is like a 12 000 or 15 000 course you know for the for the 60 hours or uh what the requirement is a lot of times people do that and they go okay we're going to set up the whole practice you know based around iv sedation model or you know i invested all this money into a cereal and cereal training now we're gonna you know base the practice all around that and it kind of turns into the you know when all you have is a hammer everything starts to look like a nail and you start trying to do you know iv sedations on somebody who's a little bit nervous and has you know some buckle pits and an mo on 14 that needs to be done and and they're just anxious you know and you do it because uh it increases the profitability of a of a you know otherwise low productivity procedure but at the same time you know could you manage that just as well with some you know atrocitation hypnosis and some nitrous oxide and maybe a little you know uh benzodiazepine the night before for for anxiolysis i mean i think you can um I’ve worked on you know thousands of special needs patients using exactly that and you know these are people that are you know not you know normally amenable to that kind of thing and it works fine it just depends on on how you treat them and i always call it like using the jedi mind trick you know if you if you have the capability to do it and you're good at it um i think that it's best to use the uh just kind of like we use the minimum amount of radiation possible we should use the minimum amount of sedation and local anesthetic that's possible it just doesn't make sense to like hit everybody with everything all the time and then just kind of you know ride the averages and hope that you're going to be able to you know dodge that bullet that's coming your direction at some point um and have the case that's just going to be um you know somebody that ends up having a a bad outcome um it could have been handled you know easily by a less invasive method um another um thing from this coronavirus um pandemic now there's people saying that after you pull a tooth you can't give the patient the tooth it's a biohazard uh it's not following osha but the pace it wants there too i mean it's a body part you know um where where are you standing in on that now I’ve never really been a big fan of that just because a big fan of what giving away the you know teeth that i extract yeah just because um i think there actually is a regulation against um that in Tennessee but aside from that what i don't like is even if i like took it you know wiped it down with bleach and then autoclaved it you know in a small bag and you know signed my name on it wrote the patient's name and date and i give it to them they'll open it up roll it around in their fingers touch every pen and clipboard in the office and the door knob on the way out and that just kind of grosses me out and so just from a hygiene you know you know hygienic perspective i just don't like that and that just it just doesn't sit well with me um but i mean aside from that like philosophically I’m not opposed to you know giving patients their their body parts back as long as it's um you know i do it to kids sometimes especially you know if it's if it's a little kid or some ortho extractions or something like that but in general um i don't well I’m I’m gonna play devil's advocate on the ivy sedation because you know i have four kids and um my gosh when uh you you go in the emergency room in the middle of the night and you decide you need an iv epidural they just paid someone and they show up out of nowhere um there are you know if you're not granted I’m in a big city phoenix is about a million people but the metro is 3.8 million and you can page an anesthesiologist you know to your office um i and and um i don't know i would do that um um one last thing i know it's late there it's uh 5 30 here what time is it Nashville is it 7 30 7 30. yeah yeah oh by the way i think that's interesting where um um did you see the position position statement on the uh American academy of sleep uh medicine they're getting ready to change the um um daylight savings coming up and i thought it was pretty cool how the daylight savings time position statement by the American academy of sleep medicine says you guys should eliminate this and I’m telling you the research has cleared the bell we were we've been living on circadian rhythms forever by the way the dinosaurs um didn't go extinct we still have birds and they've been flying around on circadian rhythms since the asteroid deal and they're the academy of sleep destiny i thought i thought it was very good but i imagine in the middle of a pandemic an election an economic collapse racial tensions i don't think daylight savings is gonna make it high up there but one last question i see um is um about you again i'd love to see variants i think dentists are all smart they all were trained in math applied math is physics applied physics chemistry applied chemistry biology applied biology's dentistry but but in the oral surgery community you guys use a lot more electrical hand piece drills and the guy and the dentist are using air um and in fact there's there's dentists who um you know they'll know that you caught them or something they'll say oh yeah man i pull my gazillion teeth a month and i'll say what would electric handpiece you have they're like so um they're doing it you know they're doing it i mean there's you know they're removing bone with a high speed moving bone back there how bad of an idea is that or or is it oh you know what what are your thoughts on that because of air embolism possibilities and stuff sure as long as you're using a rear exhaust hand piece i don't i don't it's not an issue i mean i i have um uh i use an electric but i also have some backup like um nsk brand you know rear exhaust surgical hand pieces you know that have a contra angle uh head on them that are designed to be used for oral surgery i don't think they spin it you know the same rpms that like an operative handpiece would spin at and they're also um they also have a uh um a spindle in them that will stabilize a longer you know a surgical length burr um better and so you know as long as you're doing that i think that's fine I’ve seen a case with my own eyes while it was happening of an air embolism on when i was a dental student it wasn't a patient that i was doing the work on it was a patient that i was watching you know had the work done on and while this was was occurring i noticed that this patient's eye like periorbital tissue just started to swell up like like a a cartoon like it was it reminded me of uh of that scary monster martial artist at the end of big trouble in little china you remember back in the 80s like it just instantly started to inflate and um and i you know hit the the guy on the shoulder and i was like stop like you know stop and you know just like you'd read about the textbook she had subcutaneous emphysema um and you know was immediately sent to an oral surgeon for follow-up and it all turned out fine um but the moral of the story is is i think it's a lot better to just not get there in the first place if you're going to do surgical extractions that necessitate the use of a pneumatic handpiece make absolutely positively sure that it's a rear exhaust handpiece and you know i always tell people they'll say is this a rear exhaust handpiece and i'll say like hold it up in front of you step on the step on the rheostat then they do and i said do you feel the air hitting you in the face and they say yeah and i said that's the rear exhaust so uh if you have that i think you that you're okay but you know i i really um having used pneumatics and now having used electrics I’ve really been spoiled by electrics and i think that you know there's millions of of uh well not millions probably thousands of of hosts on dental town about the benefits of using electrical hand pieces and all the stuff that applies for operative also applies for uh oral surgery and exidentia and i think that um you know electric hand pieces are just so great i love just the control you know and having a true uh you know 40 000 rpm available to me to cut bone um with inline irrigation just makes everything so quick and so easy and so predictable and you know when you cut a flap you know you see guys like you know ben johnson and jason auerbach you know bloody tooth guy doing these great gopro surgeries on their instagram pages you know using both pneumatics and using electrics and you know the result the end result is the same but the effort involved and the feel for the operator i think i really enjoy electrics as opposed to to the pneumatics well set um and just a little um thank you so much for this one last question um a decade ago you're in Nashville it was flooded it was devastating um um is that um all um repaired and and behind you or are you is there still damage from that from 10 years ago the flood by and large most of that stuff was repaired you know the the mall uh you know you've been to I’m sure the opry land before there's dental meetings that happen there you know by the dozen every year um you know that place was destroyed you know it was under like i think about 10 or 12 feet of water that's all you know been restored and is completely back to normal um i can't say though that you know we had a tornado that came through here approximately around march 2nd of 2020 that that really caused a ton of damage throughout the state of Tennessee not just here um but also in donaldson some of the outlying suburbs of Tennessee and even as far east as cookeville and baxter um which are you know kind of up the mountain um heading towards the cumberland plateau um and um oh sorry the upper cumberland and um the um um you know then immediately two weeks later you know the covid stuff started happening and so a lot of the rehabilitation and rebuilding efforts you know instantly got shot shut down because of that so we do have a lot of the city and a lot of the area up around harry in north Nashville that is still in a you know huge amount of disrepair and businesses you know closed forever um you know first because of the tornado and then you know not being rebuilt and gone because of coven so yeah the the the flood is a distant memory but the the tornado and is still uh very recent here you know that opera land usa there's two things got to say about number one i remember the first time i ever lectured there i called the front desk like five times because i just loved hearing them say operling usa might help you and it just it was just so cool but anyway oh my god i always my mom's to get away trips when she wants to get away i send her to operland usa she loves sitting in that indoor deal and then she loves um and the other ones in Tennessee uh chattanooga there's a uh there's a um a hotel that's in a train car and okay oh she just thinks that's cooler and stuff but when i go there i don't stay there i always on just stay at dolly parton's house and uh you know that's my uh that's my home getaway but hey thank you so much for coming on the show and if you ever got time to do an online ce course um it'd mean the world to me because uh you're you're so knowledgeable on it and again it's the you know the the red-headed cheps style of all the uh dental specialties is dental public health and it's just embarrassing when eight and a half percent of our patients end up at the emergency room while doc's out there you know on uh on a three-day weekend at the you know on a four-wheeler and um and um we need to get to a minimum level that if you go to a dental office and you're in pain someone there can triage you you know you know because the emergency room i mean they can't even take a pa they i mean you might as well just ask them uh why your car won't start uh you know they're just they're not equipped for it and dennis got to get to the level of basic public health triage and i think um my god my favorite procedure is an extraction i mean it's instantly out compared to a two-year invisalign case i mean god i mean it's just like hitting a home run i mean it's right there you just saw it happen um i think oral surgery is the most instant gratification and orthodontics is my god it's so uh it's so long and time consuming but Sherman thank you so much for coming on the show i was an honor to podcast you and i hope i didn't keep you up past your bedtime no no problem at all thank you for having me Howard all right have a great day you too take care you
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