Stanley F Malamed is a dentist anesthesiologist and emeritus professor of dentistry of the Herman Ostrow School of Dentistry of U.S.C., formerly the University of Southern California School of Dentistry. He is author of three textbooks: Handbook of Local Anesthesia; Medical Emergencies in the Dental Office, and Sedation: a guide to patient management. Dr Malamed has authored more than 160 papers in scientific journals and authored 15 chapters for other textbooks. Additionally, Dr. Malamed has authored interactive videos (DVDs) on (1) Local Anesthesia Technique and (2) Emergency Medicine
VIDEO - DUwHF #971 - Stanley Malamed
AUDIO - DUwHF #971 - Stanley Malamed
Listen on iTunes
Howard: It is just a huge, huge honor for me today to be podcast interviewing Stanley F. Malamed, DDS., Dentist, Anesthesiologist, a Meridis Professor of Dentistry at the Herman Austro School of Dentistry of U of C. Formerly, the University of Southern California School of Dentistry. He is a dentist anesthesiologist, and a Merdis Professor of Dentistry. He is author of three textbooks that we’ve probably all read; Handbook of local anesthesia, Medical Emergencies in the Dental Office and Sedation, and A Guide to the Patient Management. Dr. Malamed has authored more than one hundred and sixty papers in scientific journals and authored fifteen chapters of other textbooks. Additionally, Dr. Malamed has authored interactive videos, DVD’s on local anesthetic technique, emergency medicine. Seriously Stan, and happy birthday; today is your birthday and you’re celebrating it with me on a podcast. Is this just going to be your most amazing birthday ever?
Stan: Absolutely the best birthday I’ve ever had, Howard.
Howard: If you go into implants there’s several legends, there’s brandmark, there’s mesh. You go in to all of the nine specialities, there’s several people at the top, but my God, in dental anesthesia you own the whole space; it’s just you, you’re the judge, jury and the executioner in the entire field. I’ve got to congratulate you; that’s amazing. In fact, the was first Horace Wells, then there was William Thomas--Horace Wells with pioneering the use of nitrous oxide, then there was William Thomas Green Morton in 1819; the first guy, dentist used ether, and the Alfred Einhorn came out with Procaine in 1905. I think the only name they will ever mention for your entire lifetime will just be Stanley F. Malamed. I mean, kudos to you buddy, how does that feel?
Stan: It feels good.
Howard: I don’t want to bring up any old dead horses, but I remember when Septocaine came out, a couple people said it was paresthesia, and they kept beating that horse for ten years, but I always noticed one thing; when anybody entered the debate, they only quoted you. I hate to ask that question again, because it’s ten years old, but they still talk about that on social media all the time. What’s the definitive thought on Septocaine?
Stan: My opinion, and just as a proviso, as a disclaimer, I’ve been a consultant for Septodont who make Septocaine. Now, having said that, I try to be as unbiased as I can, and I have been in my career. I’ll tell you right now that Articaine, the generic name Articaine, was introduced in the States in June of 2000, so about eighteen years ago. It is now the number two most used local anesthetic in dentistry in this country. It is number two in the world; over 600 million cartridges of Articaine are sold annually.
Howard: 600 million?
Stan: Yeah. Worldwide there are almost 2 billion dental cartridges manufactured every year. The number one drug is Lidocaine, about 1 billion cartridges. Articaine is number two at six hundred million. Now, the question about paresthesia; it’s been around since a little before 2000, and there is no definitive evidence whatsoever that there is a higher risk of paresthesia with Articaine than other local anesthetics. If you want to look at sheer numbers annually in the United States as to the number of cases of paresthesia reported; number one is Lidocaine, but Lidocaine is the number one drug used in the United States, so you’d expect to see that. But, there’s no--all the reports are anecdotal, it’s reports in the literature. In fact, it became a cottage industry in medical legal areas where plaintiff attorneys were online, there was one web site called, “lingualnervedamage.com,” they were trolling for people. I’ve been involved in probably thirty to forty medical legal cases as an expert witness defending Articaine, and knock on wood, but we win virtually all the cases. And there’s very simple reasons for this, number one; the nerve that is most often affected when it comes to paresthesia is the lingual nerve. Let’s talk about this; 90% of all the cases of paresthesia in our profession occur in the mandible. Half the work we do is in the maxillary arch, half is in the mandible. 90% of the cases, the paresthesia occurr in the mandible. Of those, between 70-90% only involve the lingual nerve. Let’s look at this from a logical point of view; if a drug is neurotoxic, they’re saying that Ardicaine is more neurotoxic than other local anesthetics, it damages nerves. Why don’t we see cases of paresthesia in the maxillary arch? If the drug is neurotoxic, it damages nerves. Articaine is now being used in medicine, there are no recorded cases of paresthesia outside the mouth. If it’s neurotoxic, you’d expect to see paresthesia elsewhere in the body. In the mandible, I’m going to use a generic term called mandibular block. When you’re giving a mandibular block, you have 1.8mls of anesthetic in your cartridge, you’re probably going to give the vast majority of that volume, maybe 1.4, 1.5mls when you go down to bone for the inferior alveolar nerve. And you're going to give a little bit of anesthetic to get the lingual nerve, right? If you’re giving a lot for the inferior alveolar, and a little bit for the lingual, you would expect to see a higher percentage of cases of paresthesia involving the lip and the chin, the inferior alveolar nerve. But 90% of the cases involve the lingual nerve. What’s the most likely cause? Mechanical trauma; needle touching nerve. And this is especially the case, and I think every dentist whose given lots of IA blocks, mandibular blocks has had this happen. Putting a needle in, patient jumps, you pull out and ask them what happened, “I felt an electric shock.” “Where?” “In my tongue.” That is by far the most likely cause of the paresthesia. Again, there’s no evidence whatsoever. If you do animal research, and it’s not the same as human beings, but if you dissect out the mental nerve, this is done in Brazil, dissect out the mental nerve on rats. Meaning kill the rats. And if you expose the mental nerve to lidocaine, to articaine, and to epinephrine, only the epinephrine is the one that produces the paresthesia. There’s no evidence whatsoever. Like I said, the drug, dentists all over the world love the drug, it works, it diffuses through soft tissue better, you don’t miss as often, it’s a preferred drug in pediatrics, it’s a preferred drug with pregnant patients, it’s the preferred drug if a person is nursing. There is so many advantages to that medication, but there’s no evidence whatsoever, none.
Howard: It’s so funny how fake news can spread. What do they say? Fake news spreads around the world in one second, but the truth takes years to go back around.
Stan: Isn’t that great, that term never existed how many years before Trump; fake news.
Howard: And also, you made a deal, you said you wanted to have a disclaimer that you’re a consultant for Septocaine. I still throw dentists under a bus for that, because it’s an obsession only American dentists have. I could say the same thing to every American dentists, “Well, I don’t need any dentistry done, you work for yourself, you’re just selling me a crown and root canal.” And when I go to Europe, when I go to the IDF meeting in Cologne Germany, which I think is the greatest meeting in dentistry, it’s every other year. The dentists there, they want to talk to the owner; they figure, “Well hell, if you’re the owner, you know more about this company than anybody in the world,” but the American’s say, “Well I’m not going to trust that guy, he’s trying to sell it, I’m going to go talk to some dentist who doesn’t know shit about this product, and they’re experts in like a hundred different products.” But the Europeans are like, “Well, yeah, if you spent your whole life making this, you're the guy I want to talk to.” So, it just comes down to trust. I don’t know why dentists think everybody should trust them selling dentistry, but they can't trust anybody selling all the stuff that we need to do what we do. And I’ve done that, my dental office just turned thirty years old, and once a decade I do that. I give a shot, they jump out of the chair, and they’re numb. I think I’ve done it three times. The longest one lasted was feeling tingly for like a year before it was all gone, the other two were just a month or two.
Stan: Most paresthesia goes away. The treatment is tincture of time; the body heals itself.
Howard: I like that, I’ve never heard that.
Stan: You’ve never heard of tincture of time?
Howard: No, that’s awesome.
Stan: When somebody asks you where you get it, you say, “It’s on the shelf next to elbow grease.”
Howard: That is awesome, I’ve never heard that. I almost don’t know, I always thought of you as local anesthesia, but you’re as big in medical emergencies and sedation. You’re really a triage of local anesthesia, medical emergency, sedations, how did you go from anesthesia to medical emergencies to sedation; is that all in one category?
Stan: Well, let’s put it like this; we’re going to be talking about emergencies in theory, starting at a local but here’s what happens. I did a survey in 1993, it was published in JABA, of 4 thousand dentists in North America and their experiences with medical emergencies in their office. I had 43 hundred dentists, every state in this country, six provinces in Canada, and 94.9% of them said that at least on one occasion in my dental career I had in my office a medical emergency. Now, the average career was fourteen years, and I gave them a list of emergencies and the total number of emergencies was over 30 thousand, so that worked out to be about seven emergencies per doctor, over their fourteen year career. What does it mean? It means that you’d have one emergency every two years. Of those emergencies, fainting; syncope, was number one. It was over half of them, so that means that every four years you would expect to have a medical emergency in the office that is other than fainting. Okay, so the bottom line is; stuff happens. Now, in the emergency list we had number one by far fainting, number two was angina; angenefectorist, chest pain, we had asthma, hyperventilation, the so-called epinephrine reaction, and seizures. Those emergencies are called stress-related. What I use in my lecture is a good example; fainting is the most common medical emergency. Happy people don’t faint; scared people faint. Got it? Okay, so sedation, if somebody is scared, sedate them. Right now, the DOCS people with the oral housley on Triazolam, that’s a big thing. I’m a firm believer that nitrous oxide should be available in every dental office. Those are the two most common techniques that we use. But if you take away a patient’s fear, Mr. Macho, the dude who is scared of getting an injection is not going to faint. And nepolectic, when they’re scared--see, an epileptic when they’re scared can faint. And asthmatic can faint. A person with angina can faint. But they’re more likely to have a seizure, or an asthmatic attack, or chest pain. Take away the theory of preventing medical emergencies; that’s number one. Number two, the most common time when medical emergencies happened was during the injection. The most fearful thing--I give lectures to every specialty group except for one; orthodontics. Because orthodontist never miss injections, because how often do they give them, right? But the point is, you can be an implantologist, you can be the best periodontist, pediatric dentist, oral surgeon; you’ve got to give good pain control and that is the starting point for everything we do in dentistry. You know, Dentaltown covers everything; you guys, you’ve done podcasts with Joe Massad, prosthodontist, endodontist, but it starts with good pain control, and if you don’t have good pain control, guess what? It hurts. And it hurts, scared people faint, they can hyperventilate, asthmatics have asthmatic attacks, bad things happen. Now, the next part of this was that 22% of all the emergencies that occured in my survey occurred during the dental treatment. In other words, the patient, in the mind of a scared dental patient, the worst part of this whole procedure is the injection, the shot, use that term, okay? The patient gets the injection, they get numb, and let’s say it’s the mandible, the lip is numb, the tongue is numb and the patient is thinking to himself, and usually it’s him, the fainter is usually a macho dude, ‘The worst is over, I can relax now.’ So, you pick up your hand piece, and let’s say you’re doing a restoration on tooth number thirty, or you’re doing an endo or an extraction. In your practice you probably have this also, where you have good lip and tongue signs, you start cutting on the tooth, and you get down to dentin and the patient jumps; they feel pain. Soft tissue anesthesia as we always know, is never a guarantee of focal. What happens? The scared patient, the one who has bad pain control, poor pain control, medical emergency happens. The two things that are tied into most medical emergencies are ignoring a patient’s fear, and not having the pain control. That’s a triage; in other words the triad that we talked about. My book on sedation, my book on local anesthesia, good sedation, good pain control, and you’re preventing a lot of of the medical emergencies. In fact, if you added up the numbers it comes out to be about three quarters of all the medical emergencies in dentistry are preventable, by not ignoring a patient’s fear, and by having good pain control.
Howard: That’s nice. Again, I practiced thirty years, and I’m really, really lucky. Less than one mile away from me is a fire department, and once every ten years I’ve had to call the fire department for a fainting, and one of the three times is actually my office manager.
Stan: Sure, ten percent, in my survey, ten percent of the emergencies occured in non-patients. In other words, it might have been the parent or the grandparent in the waiting room, and the dentist or the hygienist or the receptionist, exactly.
Howard: I remember in dental school, my best friend was--
Stan: You went to dental school?
Howard: In oral surgery, and it was the first time he’d ever seen an extraction, and I’m looking at the extraction, I’m watching it, and all the sudden I hear this thump, it felt like a refrigerator fell over and he was laying on the floor, and busted up his teeth. So yeah, non-dentist.
Stan: Yeah, absolutely.
Stan: Blood scares a lot of people.
Howard: Back to medical emergencies, I’m going to go back in a minute, so what is your current assessment of how dentists are treating medical emergencies today? The one thing that really blows my mind is the case in Hawaii where the pediatric kid, and they left her sitting up in a chair. It seems like you see some of these cases, like, they didn’t even do basic 101, it’s like, “Are you kidding me? How did you get out of dental school and do that?”
Stan: I’ve been doing this for forty-four years now, and you want to believe that you’re making and impact. We teach our students CPR. In most dental schools they have courses on medical emergencies. And it’s kind of a weird thing, it’s good and bad; the good thing is that medical emergencies really are very rare in dentistry. That also makes it a problem in that you get, what’s the word, you assume it’s not going to happen, you get, what’s the word I’m trying to find? You assume it’s not going to happen. So when it does happen, and then people panic because it never happens. I heard about a story, this is the dentist saying to his staff, “I heard a story that Dr. Jones down the hall had a problem, a medical problem last week. No, knock on wood it doesn’t happen here, but when it does happen here and you're not prepared, that’s the kind of thing in Hawaii, where disasters happen.” I’ve been involved in cases like that too, where a sixteen year old girl got an injection from a dentist and fainted, and the dentist, she left the girl sitting up. Got the ammonia, got the oxygen, but the girl was sitting up. When eventually they called the paramedics, the girl wound up being brain dead. It was a simple thing that would have helped this sixteen year old girl. They did everything right except position the patient properly. I think one of the problems is that we don’t see--the good problem is we don’t see medical emergencies, which often is a negative in the sense that we don’t get practice in doing it. A lot of dentists don’t keep up with their training.
Howard: You know, the generals always say that the first casualty of war is the battle plan, and they really study the reaction because they say when the first shot is fired, 99% of the people dive behind a bunker, and one guy will actually stand up and do the plan, so it’s just kind of human nature, probably 99% are going to panic. I don’t want to slight everything you're doing, but most of my staff training is, I just tell them all the time, “We’re .9 miles from a fire department, and whenever we call them they’re here in five minutes.” When I first even, I said, “If you ever even think something is going on; it’s free. Just dial 9-1-1, we pay taxes, it won’t cost us a penny.”
Stan: Here’s the fallacy to that; you’re .9 miles away...if that fire station is not out doing something already; what if they’re on a fire call? The station is empty, where’s your backup station, how far away is it?
Howard: It would be about four miles.
Stan: The USC School of Dentistry is directly across the street from a fire station, and that fire station, we call 9-1-1, that fire station across the street from our dental school is not our station; our fire station is about five miles away, so that station that’s right across the street doesn’t respond to us. You make these assumptions that I’m only .9 miles away. When I give my course on medical emergencies, the name I give it is called “Ten Minutes to Save a Life.” The reason for that ten minutes is, in the United States overall, if a person makes a 9-1-1 call, the ambulance will arrive on the scene in about ten minutes. In your case it might be faster. I give cases up in North Dakota, I give courses, I won’t say the middle of nowhere, but quite honestly, in the middle of nowhere. Doctors have driven three, four, and five hours to come to the course. Where they are, the ambulance will take thirty, forty minutes. You can’t make the assumption that everybody has an ambulance right around the corner because that’s not the case. The other thing is, I’m here in Las Vegas, you’ve probably been to Las Vegas. I’m looking down at the strip right now, have you ever tried to travel half a mile by car on the strip in the afternoon? No, the ambulance is stuck in the same traffic that you are. That’s again, the bottom line is; train your staff. There are four parts when I teach emergencies, there are four things I teach. Number one is; the most important step in preparing for the office is basic life support; CPR training for everybody who works in the office. Most states make it the dentists and hygienists and maybe the assistant. They’re assuming the people who work chairside, work with patients, need to be trained. But, I was given the example, what if I, Stanley Malamed come into the office at 7:00, I’m a dentist, I come in at 7:00 in the morning, my first patient is at 7:30, and the only person in the office with me at 7:00 in the morning is my receptionist. There’s no state that requires the receptionist to be trained in CPR. If I, Dr. Malamed, who is good at doing CPR, if I have a cardiac arrest at 7:00 in the morning, and the only one there is my untrained receptionist, guess what? I’m dead. One of the things I always teach is; make it mandatory. Anybody who works in your dental office should be trained, number one, the most important step. Number two is developing a team, people know what to do. Number three is having an emergency drug kit, and number four is basically, “How do you handle medical emergencies.” But, everybody, I would feel secure if I knew that everybody in my office could keep me alive. It’s selfish, but you know what? I’m the old guy in the office; I’m the one most likely to need the assistance.
Howard: I actually got a tattoo on my back that says, “Do not resuscitate.” That’s when you know your life’s not doing too good. Tell us about your last book; medical emergencies in the dental office. You’re on your seventh edition, that is amazing.
Stan: That is amazing. I started writing these books back in 1978, and it’s amazing, it’s been forty years, holy mackerel. The emergency book just came out, seventh edition. I’m doing the seventh right now of my local book, Local Anesthesia, I have six editions of Sedation book. I’ve been really fortunate, and they’ve been published in thirty-nine different languages too, so I’ve been very, very fortunate.
Howard: I’ll tell you, a great marketing thing, I still think a great market is these millennials online, so University of Phoenix online is growing ten times faster than Arizona State University. We put out four hundred and eleven online courses and they’re coming up on a million views. If you did an online CE course, I would pay you, bribe you, whatever it took, but if you did a one-hour course on your sedation book, your medical emergency book, and your local anesthesia course, I think it would sell books in two hundred and twenty countries.
Stan: Well, we can talk about that, I wouldn’t mind that.
Howard: Yeah, I would love it. To have you put a course on our website, talk about adding so much prestige and the information is so amazing. I just think it would be the greatest. It would be my birthday today if you said yes to that.
Stan: Let me ask you this question; let’s say I do stuff like for Joe, and he does stuff online, he sells it to different groups like ADA and other people, is there any kind of a conflict if I do it with you, or is that just competition?
Howard: Yeah, there’s no conflict.
Stan: I wouldn’t think so, but I wouldn’t want to, if I’m working with him or somebody else, I don’t want to do anything that might be a problem.
Howard: No, I’m actually one of those old-fashioned economists who loves competition and I think American cars were horrible when the Japanese and the Germans weren’t allowed to sell their cars here. I still, do you know--you and I have been road warriors for years lecturing, do you know that I finally got to fly first-class for the first time in my entire life at my last seminar? I mean, Americans think they have first-class, it’s just a wider business seat that reclines two inches. First class is when the chair flattens out like a bed, but since the American Pilots Association has got congress to ban all foreign carriers from flying domestic flights, you have horrible service, horrible airlines, horrible everything and the only thing that fixes it is competition, and I love competition. Whenever someone starts telling me that person is making money, I’m like, what do you believe in, communism? We should all work for free? That doesn’t work. When people say, “Well, I don’t like competition,” I think they’re crazy. And dentists think they’re in a competitive environment. Did you see the chart that came out today on the Las Vegas number of taxi rides in the two years? It’s dropped.
Stan: It’s going straight down.
Howard: Yeah, it’s gone straight down, and Uber has gone straight up.
Stan: Oh, Uber and Lyft have killed them, yeah.
Howard: And it’s like, that is competition. What is New York trying to do? They’re trying to pass a law to ban Uber. Really, that’s the future?
Stan: I was born and raised in New York. To buy a Taxi medallion at one time was a million dollars. Taxi drivers would mortgage everything to get that medallion. The medallion is now worthless; they can’t sell it because Uber and Lyft have killed them.
Stan: It’s good and it’s sad for the Taxi drivers, but everybody loves Uber and Lyft because it’s so convenient, so easy to do .
Howard: This is dentistry uncensored; I don’t like to talk about anything everybody agrees on, I like to go right for the jugular vein, talk to controversy. One of the biggest controversies in sedation is that in every city in America, in the hospital, I can’t do the cardiovascular surgery and the anesthesia, they don’t allow you to do the sedation, and the anesthesia. Britain, it was several years ago, and I don't’ know if it was five years, ten years ago, showing studies that the anesthesia as a specialist had a much higher survival rate after a million people than oral surgeons. So, why do we see this? And Joan Rivers, remember New York, Joan Rivers, my question is; if it was my four children, or my four grandchildren, i wouldn’t let a doctor do the anesthesia and the surgery. I would demand a board-certified anesthesiologist. Is that just unnecessary regulation that raises the cost of goods and services, or do you agree?
Stan: In the United Kingdom it’s been almost fifteen, twenty years where you can’t do both. They had what’s called the poswillo report. But, in the United States, you call it the operator anesthetist. Now, what we’re dealing with primarily is not sedation; we’re dealing with general anesthesia, that’s where the problems come in. Nitrous oxide Howard, your patient is talking to you, there’s no problem with the operator doing the dental procedure and that patient is still conscious. The people who are using Halsy on Triasalan for oral sedation, there is no problem with that. We do intravenous sedation, which basically is the same level of sedation as nitrous oxide, in those three situations the operator is the--and the word is not really the anesthetists for that comparison, it’s the sedationist--when you get to general anesthesia, that’s what we’re talking about right now. It is a controversy, and the only people who are really doing the operator anesthetists are the oral surgeons. They are a very powerful group. How do I say this...we had many years ago, we tried to get dental anesthesiology as a recognized specialty, and it went through all the committees of the American Dental Association two, three, and four times and they agreed; we should be at the House of Delegates, each of the two and three times it was voted down. It was voted down because one specialty group spent a lot of money to have the people vote against it. We’ve given up on that, but again, it is a specialty. Dentists, anesthesiologists, we are specialists and they do the anesthesia and you do the dentistry, and we have a very good safety record. It’s the other specialty, which I won’t say again, that does the operator anesthetists, and that’s where some of the disasters are happening.
Howard: But, I’m a dentist, but I’ve also got an MBA from Arizona State University, and my oral surgeon, Dr. Greg Edmonds, ten years ago brought in anesthesiologist just for workflow, productivity, a dentist doesn’t do his hygienist, I can’t believe dentists are afraid of dental therapists, because as soon as they come out, they’re all going to get a job at a dental office doing the fillings, because the dentist doesn’t want to do the cleanings or the fillings. And, Greg Edmond says, “My God, I can take out so many more sets of wisdom teeth because I’ve got an anesthesiologist for ten years doing all the anesthesia.”
Stan: You know the operating room; the anesthesiologist puts the patient to sleep, the surgeon walks in and goes to work. We don't’ do that, we for some perverse reason, we don't’ want to delegate, and I think delegating is good; I’d delegate everything if I could sit down and read a newspaper and have somebody do the work for me. But, yes, I’m here in Vegas, so I have a couple of friends who are dentist anesthesiologists, who have been hired by oral surgeons, there’s a progressive group of oral surgeons here, just like the one Dr. Edmonds you’re talking about, that they will bring the dentist anesthesiologist and put their patients to sleep while that oral surgeon is finishing up the other patient, then walks into this room and can do the procedure. Absolutely, it’s so much safer because you can concentrate on doing the oral surgery while there’s another person sitting there keeping the patient alive. Basically what we’re doing is we’re keeping the patient alive while you’re operating on them.
Howard: So, do you think it is a good, back to business, do you think it’s a good business decision or a high-risk business decision for a general dentist to offer, “We can put you to sleep, anesthesia, we offer general anesthesia, but the dentist doesn't’ do it, but he contracts--because, I’m in Phoenix where dentist anesthesiologists will come to your practice and do the anesthesia, but if you did, say you did one case every Friday from age twenty-five to sixty-five. That would be fifty cases a year over forty years, do you think that that is, like Joan Rivers, she went in for a simple procedure and died, and I’m sure--
Stan: But, that was--
Howard: That was what?
Stan: That was a disaster, the whole thing. I’m not sure, rumors were that the anesthesiologist left or something.
Howard: So, that was just a perfect storm of stupidity? But, back to the business decision, if a young kid walks out of U of C, and they were going to have a business for forty years, do you think the attractiveness to build your business by offering sedation and having a board-certified anesthesiologist come into your practice whenever the case arises is a good thing? Or, do you think that it’s a high-risk thing and you should stay away from that?
Stan: No, number one, I think it’s a good thing and it’s not a high risk thing. And the reason is that we’re treating patients who are medically fit. I don’t know, what we call the ASA one or ASA two. ASA one is a perfectly healthy--ASA stands for American Society of Anesthesiologists, and it’s a physical evaluation system. ASA one is, review the history, heart, lungs, liver, kidneys, central nervous system, they are healthy; ASA one. ASA two has a mild medical problem. Those are the patients we do GA on; we don’t treat the severely medically compromised because the risk is too great. Patients who are more medically compromised, you put them in the hospital and you do general anesthesia, but when it comes to outpatient, it’s the healthy patients we treat. The age group you’re talking about, anywhere from teenagers on up to the sixties and even seventies, if they’re ASA one and two, they’re very good risk patients. To have the dentist anesthesiologist there doing the anesthesia and having the dentist doing the dentistry, the risk rate is minimal.
Howard: Plus, I have a bad bias of this because when I got out of school thirty years ago, they were mostly sedating with narcotics, it took time for the stuff to wear off, the drugs today are just a lot more safer and reversible, would you agree with that?
Stan: Absolutely, the drugs, if you go back when I graduated dental school in 1969, so I’m ten years ahead of you, more than that, the drugs we had were the barbiturates, things like Nebutrol and Pentothal, and even using them for sedation; the patient when they would recover from sedation would be groggy for the rest of the day. Now we have drugs like Midazolam and Diazepam, but mainly Midazolam, which used to have a brand name called Versa, many people know it by that name. And, it’s a drug that’s like Valium, it’s a sedative, but it produces amnesia. So the patient, even though they’re awake and talking the entire time during the procedure has no memory of anything. So as far as your patient is concerned, they’ll say, “When I woke up, the first thing I remembered.” But when they say, “I woke up,” the implication was they think they were asleep. And they weren’t; this is a sedation that’s almost like nitrous oxide, where they’re talking to you but they have no memory. That’s a marvelous medication, and the recovery from these drugs today is much faster. And, we don’t use narcotics as much anymore, we don’t. Because they’re not really good sedative drugs. The narcotics are for pain relief, but in dentistry we have the best drugs in the world for pain relief, we have local anesthetics.
Howard: It is weird, because I’ve had IV sedation twice for a colonoscopy and I have zero recollection of after. In fact, here’s the weirdest story, the first time afterwards we went and ate at the iHop, I have no memory that we even went to the iHop.
Stan: Yeah, well you probably got that drug Midazolam. Absolutely, because my first colonoscopy, I remember the nurse starting an IV and telling me, “I’m going to give you 5mg of the drug,” the next thing I remembered is, “You can go home.” That’s it, thank God, you don’t want to have a recollection of what’s going on when you’re having a colonoscopy.
Howard: I know, I remember when I had my first one I said, “A man is about to go where no man has ever gone before.” Hey, we always hear Profonol in the news, I think it was because of Michael Jackson--
Stan: Yes, Propofol.
Howard: Because of Michael Jackson. He took that, no one had ever heard of it, and now it’s a household name, and I’ve noticed that the anesthesiologist I was talking to said that as much as he loved Michael Jackson’s music, he’s still very upset about that deal because so many of his patients ask him, “I don’t want that.”
Stan: Exactly. Well, what happens, first of all, I mentioned Pentothal and drugs like that, the old barbiturates that are no longer used, the patient would wake up and be hung over for the rest of the day. Propofol is the new, it’s not a barbiturate, but it’s the new drug like that. And, it’s a rapid-acting, but short-acting drug. So, what happens is, the term we use is the patient is, “street-ready,” faster. They’re ready to be discharged from the office more rapidly because they’re mentally much more clear, rather than having hours and hours of being hungover, they feel better rapidly. Now, the drug again, what happened with Michael Jackson, and I forget the name of the cardiologist but, he hired a cardiologist who has no training in anesthesia to be his private physician, the guy made lots of money with Michael Jackson, and Michael Jackson had a problem going to sleep, so he would give him Propofol, which is a general anesthetic drug. You give him Propofol intravenously at night so Michael Jackson could go to sleep. On the night of the incident, and this is the equivalent of, he gave him the IV drug, put him to sleep, and left. Well, it’s like an anesthesiologist, if anesthesiologist walked into a surgery, and put their patient to sleep and walked out of the room, the patient is going to die. Because the anesthesiologists job is, once that patient is asleep is to keep them alive; maintain an airway, monitor vital signs. So this guy, this cardiologist, and I have lost of slides when we discuss Propofol about this, he was legally allowed to use the drug because he’s a physician. You can use any drug you want, if you’re a licensed dentist or a physician, but he didn’t have any training. And after the death occurred, there was--any anesthesiologist everywhere in this country, pro bono, for free, wanted to testify against this guy. Because he literally killed him; the drug is what killed him, but the person who killed him was the person who gave the drug because he had no idea what he was doing. And the drug has a bad rep for that reason; it is known as the Michael Jackson drug, exactly. It’s a great medication.
Howard: That’s one of the major disagreements between me and my eighty year old mother, she thinks Frank Sinatra is the greatest singer, songwriter that ever lived, and I always tell her, “No mom, it’s Michael Jackson.”
Stan: My mother-n-law is a hundred years old and four months; a hundred years, plus four months. Mentally sharp as anything, and Frankie is the guy.
Howard: And it’s so funny that you’re from New York, because everybody who from the east coast has barbiturates, and everybody from where I’m from in Kansas has Barbiturates.
Stan: Same drug.
Howard: Same drug, yeah. Also the Northeasterners call it hy-gee-en-ists. Whereas in Kansas it’s hygienist.
Stan: Hygienists, yeah.
Howard: You’ve got three books, and today we put them out on Dentaltown Facebook, we pushed them out on all the social media, but go through your three books; who is your target audience with these three books? You’re talking to a lot of dentists today, you’ve got a book, Local Anesthesia, you’ve got a book, Medical Emergencies in the Dental Office, and you’ve got a book, Sedation; a Guide to Patient Management, and they’re all just covered with five-star reviews, and the comments under them are, “You are the God of all three of those subjects.” So, go through those three books and tell my homies who should read them, what they’d learn, what they’re about?
Stan: Okay, the other reason would be to come take my lectures, because I lecture on this stuff. But, here’s the thing; local anesthesia is for the dentists and hygienists. Very simply, those are the ones that administer drugs. There is so much more new that is happening in local anesthesia; we have the nasal spray, no needles needed. We have a nasal spray to give maxillary non-molar teeth numb.
Howard: What’s that company, St. something?
Stan: St. Runades. The drug, Cobinaise is the name of the drug, and it’s a nasal spray. Think about this; how many needle phobics there are?
Howard: And they’re always the one with tattoos all over their body.
Stan: Isn’t that amazing? When we do IV sedation and people faint, it’s the tattoo person, it’s bizarre. But, when they got the tattoo, they were probably stoned.
Stan: That might explain it right there. But, the book on local is mainly for the people who use local. The book on sedation obviously is for those people who use sedation, which I would hope would be every graduate from dental school, because again, nitrous oxide, oxygen, to me is the--I call it the stoddard technique Howard. You learned it in dental school, you should be using it. And the book on that has pieces for everybody. You want to get that entire staff trained. In fact, when I get invited to go to meetings, once a year most dentists I use have a meeting for the entire office. Emergency medicine, the receptionist, the front office people, it’s designed for everybody.
Howard: I think I’ve seen you at the Arizona State Dental Association Meeting, several times, three times?
Stan: Yeah, multiple times, yeah.
Howard: You mention DOCS at the very beginning, DOCS people, is that a good program to learn sedation, do you like that program, what are your thoughts on DOCS? They’re a big brand.
Howard: It’s dentistry uncensored, buddy!
Stan: I know that. Here’s the thing; they’re teaching dentists to treat fearful patients, which is great; love it, no problem at all. Because there are a lot of dental phobics out there, so they’re getting people into the office, and I think there’s nothing wrong with that. They’re using a drug, Triazolam, Housion, that’s a very safe drug, okay, so far so good. But, when it comes down to some of the things that are being taught, people who do anesthesia like myself, and you’re in Arizona, Ken Reed? You know Ken Reed from Tucson?
Howard: Ken Reed?
Stan: Ken Reed, R-E-E-D.
Howard: Yeah, he’s in Phoenix though, isn’t he on Camelback.
Stan: Tucson, he’s in Tucson, but he does a lot of cases up in your area.
Howard: Is he the one who went to Harvard?
Stan: No. He’s not smart enough to go to Harvard.
Howard: Okay, get me Ken Reeds now, maybe I’m confused and there’s another Ken. But anyway, Ken Reed in Tucson.
Stan: But the point is this; anybody like myself who teaches anesthesia have problems with some of the things they’re teaching, and yes, it’s a safe drug when used properly, and I’m talking about, these are the things I have been told. This is not--they wouldn’t put this in writing, but a quote such as, “You can give a person a bowling ball sized Triazolam, Houseum, and it won’t hurt them. No, people die from Triazolam overdose, they die from Triazolam overdose from doctors who have taken it in the DOCS course, because the doctors use it wrong. They don’t understand the concept of; you can’t--there’s a certain limit as to how much medication you can give. So, yes, they’re doing a good job in getting dentists to treat fear. They’re using a safe drug, but some of the concepts are a little bit against the...they’re sort of not kosher, they’re not up to par if you will.
Howard: So what training would you recommend?
Stan: Number one, oral sedation as a technique, it’s a crap shoot, and let’s just talk about this. If the average dose of Triazolam is .25 milligrams, okay? Why is it .25 milligrams? You’ve heard of the bell-shaped curve, normal distribution curve? If you gave a hundred people .25 milligrams of Triazolam, 70% of them would have the desired clinical effect; that’s the middle of the bell-shaped curve. 15% of them on .25, that’s not enough. Now, the problem with that is, you gave the drug an hour before they’ve come into the office, and you gave them .25, and it didn't work. What are you going to do, give them another dose of the drug and wait another hour? Okay, that’s the problem with oral medication. The other 15% on the other side of the bell-shaped curve, the so-called hyper responder, .25 is way too much. And that patient comes in, and they’re overly sedated, they won’t keep their mouth open, you can’t treat that patient. So, what I’m getting at is; oral sedation, it’s a crap shoot. You give a patient the dose and you cross your fingers and you hope the drug is going to work the way it’s supposed to. Now, I’ve been talking about nitrous oxide as the starter technique; with nitrous, since it works within thirty seconds, you titrate. You don’t give everybody 40% nitrous oxide, you start out with 10%, you wait about thirty seconds to a minute. If it’s not enough, you give them 10% more, 10% more, so you’re giving everybody the amount that they need. YOu're not going to overdose, you’re not going to underdose a patient; it’s safe. And, the same is true with IV sedation. People are afraid of IV sedation because they don’t understand it, but with IV sedation you titrate. You may need, Howard may need 6 mg of Midazolam, Malamed may need 3mgs to get the same level of sedation. But if you titrate, nitrous, you titrate IV, those are safe techniques. With oral sedation, it’s a crap shoot. You give a drug, you cross your fingers, and you hope it’s going to work. There’s no safety involved in that at all.
Howard: Podcasters are usually very young. I always tell my audience, “Shoot me an email, Howard@dentaltown.com, tell me your name, how old you are, what country you live in,” about 25% are in dental school, the rest are under thirty. I get like one guy a week that says, “I’m fifty-five, two, or whatever.” But anyway, I remember a lot of people are self-medicating. Marijuana was go to jail stuff when we were in school, but what do you think about, I still think a lot of people are not reporting to their dentists that they have a few belts of whiskey before they come, and now some people are getting stoned before they come, what kind of problem is that for these young kids?
Stan: If a patient came in--if I had a dental office, and a patient came in who is obviously under the influence of a drug, whether it’s alcohol, or whatever, I wouldn’t treat them. I wouldn’t treat them. Basically, if they were definitely under the influence, so other words, sometimes you can’t tell, but they definitely look like they’re stoned or they’re drunk, no. If that patient comes in with drugs in their body, and even with local anesthetics, even though there’s minimal risk of what’s called the drug-prog interaction, but if they come in stoned or high, I’m not going to treat them. Now, but what about the patient who you can’t tell, right? I’m sure we’ve all treated patients who’ve smoked a little marijuana or had a drink or two. If you're using local, there’s no problem. But if you start sedating patients, that’s where the problem comes in, because whether it’s marijuana or alcohol, they’re depressing the brain. If you're sedating a patient, you're depressing the brain. So, let’s go back to what I said a couple of minutes ago; if you are sedating, a patient comes in unbeknownst to you, has taken a pill, or has smoked a joint, or has had a couple of shots of alcohol, if you titrate nitrous, titrate, it’s okay. Because you're going to wind up at the same sedation level you would have been without having medication on the board. No doubt you’re going to get there sooner. If you give IV sedation to that patient, it’s okay; you’re titrating. But the problem comes in with oral sedation, because you’re going to give them fixed dose of lets say .25, and .25 may have been okay for that patient if they hadn’t taken whatever drug they took before, but if they took a drug earlier, and they have a level of sedation already from that medication, and you give them your .25, they could go too far. So again, a technique of sedation where you titrate, nitrous, intravenous, would be safe. A technique like oral sedation where you can’t titrate, you're giving a fixed dose, would be less safe; simple.
Howard: I know, earlier I was thinking of Reed Day, Dr. Reed Day on Camelback in Phoenix, but you’re talking about Dr. Kenneth Reed, so my brain. Why did you mention Kenneth Reed?
Stan: Well, Ken is a dentist anesthesiologist like I am. Ken and I have worked together for almost twenty years right now, and we teach IV sedation courses together, we’ve given courses on local anesthesia, medical emergency, he’s a good guy. And, he does mobile anesthesia in Arizona, even though he’s based in Tucson, he does a lot of cases up in Phoenix.
Howard: So it’s a safe business decision; you can safely say that if I had someone like Kenneth Reed coming in every Friday for forty years, the economic benefits of attracting people that are afraid of the dentist who actually need all the dental work. It’s like a cat chasing their tail; the more they’re afraid of the dentist, the less preventive they get, so they need all the root canals and deep cleaning. So, breaking the fear, and it’s all in their head obviously because if you’ve had one million tattoo shots, but you're afraid of a shot in your mouth, it’s all fear. Most of that is irrational. I’m going to ask a question that sounds kind of crazy, but I actually hear dentists talking about that; now that medical marijuana is being legalized, and in fact Canada is going to vote on it for the whole country in June, some people are saying, would it be a smart deal to offer an edible, to say, “Hey are you afraid of the dentist? Come in my office thirty minutes before, eat a peanut butter cookie, or a marijuana brownie,” do you think that’s something we’re going to see in the next five, ten, twenty years, or do you think that's a really bad idea?
Howard: I really and truly believe we are going to see that in the future and thee reason is number one it’s I’ve always I’ve never had a problem with marijuana being legalized never you know the problem with marijuana is the same problem that happened back in the late 1700’s with Ether and nitrous oxide. Ether and Nitrous were discovered around 1976, but Horace Wells as you brought up earlier today, didn’t use until 1844 but in that seventy year period, those two drugs were party drugs ether people got high on nitrous and when Horace Wells did his demonstration in Harvard University with nitrous oxide, he was laughed out of the room because how could this, first of all in those days, the lowly dentist coming before the medical profession talk about nitrous oxide when these medical students in the audience had probably gone to a party yesterday and gotten high on it. So now what we’re looking at in the year 2018, is we’re saying, “Here’s marijuana,” which is a drug that people get high on, how can this drug possibly have any real therapeutic use, but it does. It’s been around for a long time for nausea when you have people on chemotherapy and they have nausea, it’s been used for that, and it is a damn good sedative. And, I think in the future, somewhere down the line it has to happen. It’ll be legalized everywhere eventually and I think, yes. And doses right now can be strictly--you can dose it properly. You buy a marijuana brownie, I’m winking now, so I’ve been told, but it’s got on the label, the dose of this is one fiftieth of the brownie. In other words, if you can give a precise dose of a medication like that, whether it’s a brownie or a cookie or whatever form of it you want, yeah, I would have no problem with it right now. Because I think that it’s a joke that it hasn’t been used earlier for medical purposes. It’s politics, you know?
Howard: Yeah, when I was in college, I thought that the laws were exactly backwards; all I remember in college is if the boys drink the hard stuff like Jack Daniel’s and Vodka, there were fist fights, car wrecks, property damage, police called. If they just drank beer, they wanted to go out and find women at the dance, so they went and go dancing and find women. But, if they smoked pot, they all stayed home and ordered Dominos and watched movies. And, I looked at all the mayhem after nine years of college and thought, “Man, they should legalize liquor, and hand out free marijuana every Friday at 5:00 just to control the university.
Stan: Right. And you’re more forward thinking. People are coming around slowly, but if you think about it, it’s the coasts that start first. Here we go with the colour of the states, but it has to spread to the middle of the country, and it’s much more conservative.
Howard: I know, I was born and raised in Kansas and if they caught you doing a DUI, it was like, “Well, he’s a country boy.” But if they found a bag of weed, now you were like a prisoner and a criminal and locked up, it was just crazy. Horace Wells, he became addicted to that stuff, in fact, he actually died from suicide when he was only thirty-three.
Stan: He committed suicide, absolutely. All the famous people were on anesthesia, Horace Wells, the father of anesthesia, he became addicted to chloroform. He was arrested for throwing acid in the face of a prostitute, and he was put in jail. They allowed him to go home to get his shaving kit, came back to jail, and under the influence of ether or chloroform he slit his wrists. And then the guy who gave the first injection for a local was William Stewart Halsted, gave a mandibular block, a medical doctor. Cocaine with epinephrine. Became an addict of cocaine. To get him off his cocaine addiction, this is like the year 1900, they gave him morphine. They didn’t understand addiction. A lot of these famous people in anesthesiology were in fact drug addicts. And the reason is, the way research was done in those days was on yourself. You didn’t do studies like we did here today. There was probably some poor sucker out there who was experimenting with a thing called Strychnine. We’ve never heard of him before because the drug killed him. So, the ones who picked the right drug, the lucky ones, are the ones that are famous.
Howard: And who did Dr. Salk give the first polio vaccine to?
Stan: It was himself.
Howard: Himself, and the next ten were all of his grad students.
Stan: The live virus; it was a live, attenuated virus.
Howard: Amazing. When I got to school, it was a different time. You could buy spray cocaine. People who had oral surgery and they couldn’t swallow and all that. I knew a dentist back when I went to school who was, when I was in dental school, an older guy who was ordering that stuff, and he ordered it initially for patients who had oral cancer surgery and tongues removed and all that stuff. The next thing you know, he was spraying that, it was 99.9% pure aerosol cocaine. So, that’s riddled with that.
Stan: If cocaine weren’t a schedule one drug, or two drug, whatever it is, it is the best topical. Absolutely the best, and it’s great, it numbs up soft tissue and it also vasoconstricts. It would be the ideal drug for intraoral topical anesthetic. Unfortunately it’s cocaine; ain’t going to happen.
Howard: So, it’s just not going to happen because the abuse potential is just too high.
Stan: Absolutely, yeah.
Howard: I’m forward thinking on the cocaine thing too, because when you go to Latin America--what is America’s number one problem? Obesity. And, what was coca leaves used for These long hikes, these long trails, they would chew coca leaves and everybody in Peru that you talk to says that every fat person in America should be chewing coca leaves. And it would be just a tincture of cocaine, it wouldn’t get you high or anything like that. Just like there’s a little bit of caffeine in coffee, there’s a little bit of caffeine in chocolate, but if there were just a little bit of cocaine in bubble gum...when you talk to dentists in Peru, they think it would make a major material impact on obesity in the United States, but because of the name cocaine, the chance, it’s just not going to happen.
Stan: Like I said, it’s the same as marijuana; it has a stigma to it. If it turned out to be a marvelous drug, it would never happen, because the stigma against cocaine is so great, absolutely. I’m with you Howard.
Howard: I can’t believe, we just hit an hour man, that is unbelievable. Is there anything I didn’t ask that I should have asked?
Stan: Not really. We sort of didn’t talk about medical emergencies most of the time, but that’s alright, I think we covered really where you wanted to go; we covered sedation, we covered emergencies a little bit.
Howard: I just want to make one final question, because I know you’re in Vegas, I know it’s your birthday, you’re with your wife, she’s probably gambling, she’s probably lost your house and car by now while you were doing this interview. You probably lost your pension, your 401K, what was that movie where the girl goes down and gambles, and loses everything, that comedy? Do you remember that?
Stan: Yeah, the Million Dollar Proposition I think it was, right? She meets the rich guy, makes her a proposition, they go to Hawaii? I can’t think of the name of the movie.
Howard: But, there’s only three publicly traded dental offices in the world; two are in Australia, one Three Hundred Smiles, and Pacific Dental, and the other one is in Singapore called Q&M, and I thought it was very amazing; they are not as a publicly traded entity, and wall street doesn’t like risk and all this stuff, they will not do any anesthesia eighteen and under, sixty-five and older, they say all the problems are eighteen under, sixty-five or older, they don’t want the liability of someone--like a pediatric dentist, someone putting down a two-year old kid and then it doesn’t wake up, even though it was a board certified--but anyway, do you agree that all the accidents are under eighteen and over sixty-five?
Stan: Under eighteen? No, I could give you lists of patients in their twenties and thirties and forties, but a lot of the cases are in younger children. We’re talking about three, four, five, six-year olds. The Hawaii case is one of those examples.
Howard: Tucson had, Yuma, Arizona has had two in the last five years.
Stan: Really? But, I’m saying, it’s usually--eighteen is no, it has to be under that. Because eighteen, you’re teenage already, they’re mature, there’s no problem with that. But, we always say people who are under six and over sixty-five are at higher risk. You give smaller doses of drugs, that bell shaped curve thing again; under six and over sixty-five are patients who tend to hyper respond to medications. But again, when you go back to the sedation techniques and you are titrating, it doesn’t matter. If you titrate, then you wind up using less medication. If you’re giving that .25mg of Traisolam to an eighty-year old, they’re more likely to over respond and be over sedated, but I think the numbers you gave me; eighteen and sixty-five is too constricting, but I understand from their perspective the risk perspective. Insurance companies or big companies, they don’t want to have any risk, so I understand that. I don’t agree with it, but I understand it.
Howard: When I was getting my FAGD, my MAGD, I’ve sat through your lectures so many times in the last thirty years, when I told my friend just today, and my alcoholic dentist drinking buddies at the bar that today it was you, they were like, “Are you serious?” Thank you so much for all that you've done for dentistry, you’re a legend, you’re the modern-day Horace Wells, I hope you don’t end up in Vegas throwing acid on some girl walking down the strip. But seriously, thank you for all that you’ve done for dentistry, it was just a complete honour to be able to podcast here with you. Thank you so much for coming on the show.
Stan: Howard, thanks a lot, my pleasure.
Howard: And don’t lose all your money in Vegas!
Stan: It may be too late, but thank you.