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shr7
12-11-2009, 23:21
Good evening everyone. I have a question for the dentists/anesthesiologists on the board. Of course, anyone with personal experience is more than welcome to comment.

It is approaching that time when I need to have my third molars removed. I only need two removed on the same side of the mouth. I am chewing on the two on the other side and am able to brush and floss them without issue.

Currently, my dentist is a friend from school who is in his final months of dental school, and the only contact I have to the oral surgeon is through him. Both teeth are impacted into the gum, but I believe they are not "bone impacted". (Forgive my lack of knowledge about dentistry.)

My question is, the oral surgeon suggested Halcion (triazolam) PO and NO. Now, I have had NO only once before in my lifetime (for another tooth extraction) and I STILL remember that event. In fact that is the ONLY memory I can CLEARLY recall from when I was 12.

I'm fairly certain that the procedure will not be traumatic enough to require general anesthesia (unless it is done by a student or resident...) but is wisdom tooth removal usually performed using PO benzos and NO?

I was more leaning towards the IV midazolam route. I would just feel safer with the more predictable and titratable response of IV sedation. However, I have absolutely no experience in outpatient sedation, so I am hoping for input from those with much more experience than I.

Or, I could just man up and chew on some Motrin...

Thank you for the help.

SR

Dusty
12-11-2009, 23:40
Is this a joke?

Eagle5US
12-12-2009, 23:45
As a PhamD you should know better than to come onto an internet BBS and expect any kind of credible response. Your oral surgeon is going to give two flips what "some guy on PS.Com said":rolleyes:

Procedural sedation can be accomplished with any number of drugs and drug combinations. The most effective and most important one is going to be one that your SGN is both qualified to accomplish and comfortable doing.

You may like Versed, he may not. This is a conversation you should have with your SGN - not us.

Eagle

shr7
12-12-2009, 23:57
As a PhamD you should know better than to come onto an internet BBS and expect any kind of credible response.
Eagle

You're right. I wouldn't do it for a patient, I shouldn't do it for myself. I'm sorry.

Moving out.
SR

Boomer-61
12-13-2009, 19:30
I hate it when my patients come into my office loaded with pages of crap they've down loaded off the internet and start dictating to me what they think their diagnosis is and what I should do about it and what approach to use and what prosthesis they think I need to implant. I have to spend the first 15 minutes after my H&P dispelling all the marketing hype and myth. Then I politely ask them if they treat their auto mechanic the same way. The answer is usually no. Then I politely tell them that they've come to our institution with a certain amount of confidence and that they should continue with that level of confidence and trust our judgement in the selection of components, the surgical approach, the post op protocol, etc.. Just let your surgeon do his/her job.

Red Flag 1
12-13-2009, 19:56
Sedation choices are really up to the sedater. As a provider of care, I really avoided direct involvement with family and friends. The closer you are to someone, the less objective one is. It really places undue pressure on patient and provider. So.........

Before addressing the sedation, I would humbly suggest hooking up with an Oral Surgeon who has taken out tons of molars, that is part their specialty. Oral Surgeons also, in general, have a better handle on sedation for dentistry. In my Air Force residency, oral surgery residents spent 4-6 months rotation through our anesthesia department. These residents had a pretty good handle on sedation and airway management.

To address the sedation, find a good Oral Surgeon. Do what your Oral Surgeon suggests. Be the patient. PM if you like.

Best of luck!

RF 1

Sigaba
12-13-2009, 20:02
I hate it when my patients come into my office loaded with pages of crap they've down loaded off the internet and start dictating to me what they think their diagnosis is and what I should do about it and what approach to use and what prosthesis they think I need to implant. I have to spend the first 15 minutes after my H&P dispelling all the marketing hype and myth. Then I politely ask them if they treat their auto mechanic the same way. The answer is usually no. Then I politely tell them that they've come to our institution with a certain amount of confidence and that they should continue with that level of confidence and trust our judgment in the selection of components, the surgical approach, the post op protocol, etc.. Just let your surgeon do his/her job.Boomer-61--

What guidance would you give a layperson seeking to educate himself (or herself) so that they could talk to their doctor intelligently when it comes to the process of making a diagnosis?

For example, an elderly woman I know was mis-diagnosed by a doctor. The misdiagnosis was only corrected because the woman's daughter kept asking questions. The correct diagnosis was reached but then the wrong medication was almost given. Again, that situation was cleared up only by the daughter's additional research and questions.

If this woman had let the doctors "just do it," she might have end up with a much more complicated situation.

Gypsy
12-13-2009, 20:26
Boomer-61--

What guidance would you give a layperson seeking to educate himself (or herself) so that they could talk to their doctor intelligently when it comes to the process of making a diagnosis?

For example, an elderly woman I know was mis-diagnosed by a doctor. The misdiagnosis was only corrected because the woman's daughter kept asking questions. The correct diagnosis was reached but then the wrong medication was almost given. Again, that situation was cleared up only by the daughter's additional research and questions.

If this woman had let the doctors "just do it," she might have end up with a much more complicated situation.

Good questions, and it's a concern of mine as well because I feel I have a responsibility to myself to be educated as much as possible about my own health and well being.

I had a difference of opinion with a doctor about a course of treatment last year and after trying to converse intelligently with her to no avail I told her to pound sand and went elsewhere. I was, in this instance, correct. Doctors are great...but they are only human and can't know everything. Especially about what's going on in a person's body.

However I believe Boomer61 is referring to people who come in "dictating" vice asking questions and mentioning they've been reading up etc...

Sigaba
12-13-2009, 20:33
However I believe Boomer61 is referring to people who come in "dictating" vice asking questions and mentioning they've been reading up etc...I took Boomer-61's post the same way.

I am hoping for guidance on finding a 'happy medium' in which one can respect the medical professional but still speak up.

Gypsy
12-13-2009, 20:38
I took Boomer-61's post the same way.

I am hoping for guidance on finding a 'happy medium' in which one can respect the medical professional but still speak up.


Ah. I think you can speak respectfully while asking questions in an inquiring but direct manner.

If someone is offended and thinks you are questioning their knowledge whilst seeking information or discussion on what your reseach has yielded then maybe they're not the doctor for you. ;)

Remington Raidr
12-13-2009, 22:49
I tell my dentist I don't wanna feel nothin'. I get the gas then the novacaine. My DDS rocks.

caveman
12-13-2009, 23:40
I have a fuzzy memory of my impacted wisdom teeth being removed. I remember them giving me pills and numbing pretty much my entire face with stuff in syringes. Then they put a gas thing on my nose and I remember having a pretty pleasant, vaguely detached, conversation. I asked nonchalantly if the blood covered instrument in the Dentist's hand was, in fact, a scalpel. He looked hesitantly at his assistant before confirming my suspicion. I nodded, my curiosity sated, and continued a story from my freshman year of college which I doubt they could understand due to the thingy in my mouth holding my tongue halfway down my throat. I also seem to remember the Dentist, huffing and straining, standing astride me on the chair with both hands grasping the pliers he was using to pull out my wisdom teeth. I suspect at some point during the procedure the lines between reality and drug induced hallucination became blurred.

Good luck with your visit, try not to think about bloody scalpels and the force required to rip teeth from your head with pliers.

shr7
12-14-2009, 01:10
Just to clarify-

I asked the question here in addition to performing research on my own, so that I could be an informed patient when going back to discuss with the oral surgeon. I was wondering what the general guidelines or normal evidence based practices were for this kind of procedural sedation, or if there are any published guidelines. In addition to looking for anecdotal evidence from those who may have been through the procedure before. I am well aware of where any information learned here would fall on the hierarchy of evidence and only intended to use this as a starting point, and not a finishing point.

That said, I worded the question very poorly and my overall intentions were unacceptable. I was looking for medical advice on an internet BBS that is not designed to give that kind of advice. Instead of taking the time to talk to the oral surgeon and address my concerns, I tried to take a shortcut and receive medical advice on here. I was wrong, and I apologize.

It is my understanding through the responses here and through my own research that while guidelines exist, they do not specify drug/dose/route per procedure, and that choice of agent is practitioner specific with patient input. I will take this information into account when I go speak to the oral surgeon. Thank you to everyone for their input.



To address the other questions floating around about how best to speak up and ask questions of the medical professional. I would suggest you take a similar approach as you would for any other professional. Educate yourself as best you can before going in, and ask questions respectfully, but forcibly. Make sure your questions are being answered fully and that you understand exactly what is being done. Go in respecting the knowledge base of your physician, but understanding that medical issues are not always black and white, and sometimes you have to challenge your physician in order to fully understand the issue. Also, respect the experience your physician has. There is a reason why they do rotations before they can be licensed. Just reading about a condition or medication is not enough to know how to treat the condition or how to use the medication properly in all patients.

A quick reference on being a "smart" patient:
http://www.abms.org/who_we_help/consumers/educate.aspx

The "health resources" linked in the article links websites that can offer good information to the layperson. I usually refer to the Mayo Clinic source for good, simple medical information.

I know I may be young and idealistic, but every time a patient questions me, I see it as an opportunity to double or triple check myself. From asking myself "Are they referencing a study that I need to read?" to "Yeah, why does that pill look different than the one they were getting?" Having a patient catch an error is far superior than no one catching it. This doesn't just mean at the pharmacy, a study published earlier this year by AHRQ noted that 70% of the medication errors in the study were prescribing errors.

I will every now and then read an article on WebMD and learn something completely new. Or, a drug rep will come in and tell me something I have never heard before. I will then proceed to hit the textbooks and primary literature and work on understanding mechanisms and implications. I try not to treat the issue any differently if it is the patient who brings this information to my attention.

Questions I would like to know before taking any medication would be:

Are there any other names for this medication?
Do I need to take this medication?
Is this an on label use for this medication or an off label use?
Has this medication been proven to work for my condition?
Are there other medications that I can take?
What are the possible side effects?
When and how should I take this medication?
How soon will this medication start to work?
Will I need any lab tests while taking this medication?
Will this interact with any of my other medications?
Are there any food/drink/activities I need to avoid?
How long do I need to take this medication?
What do I do if I miss a dose?

If I can think of others, I'll add them.

Sorry for the length and wordiness. Trying to salvage my mistake. If it a misguided effort, let me know, I'll call it a day.

SR

Dozer523
12-14-2009, 07:34
I have a fuzzy memory of my impacted wisdom teeth being removed. I remember them giving me pills and numbing pretty much my entire face with stuff in syringes.
Good luck with your visit, try not to think about bloody scalpels and the force required to rip teeth from your head with pliers.
I hear that! My Reason For Living and I both had our wisdom teeth. We got semi-annual check-ups together.
Dentist sez: "You both should have those things removed."
MRFL goes first.
I pick her up after the procedure. She's a zombie. Her face is grossly swollen and her mouth is packed with gauze. For days meals are babyfood. I have to rinse out the holes in her gums which requires me to look at them. Lots of moaning and groaning.
Doc calls me up to confirm MY appointment. "F*ck that."
(Still got 'em.)

Masochist
12-14-2009, 07:59
I have a fuzzy memory of my impacted wisdom teeth being removed . I remember them giving me pills and numbing pretty much my entire face with stuff in syringes. Then they put a gas thing on my nose and I remember having a pretty pleasant, vaguely detached, conversation. I asked nonchalantly if the blood covered instrument in the Dentist's hand was, in fact, a scalpel. He looked hesitantly at his assistant before confirming my suspicion. I nodded, my curiosity sated, and continued a story from my freshman year of college which I doubt they could understand due to the thingy in my mouth holding my tongue halfway down my throat. I also seem to remember the Dentist, huffing and straining, standing astride me on the chair with both hands grasping the pliers he was using to pull out my wisdom teeth. I suspect at some point during the procedure the lines between reality and drug induced hallucination became blurred.

Good luck with your visit, try not to think about bloody scalpels and the force required to rip teeth from your head with pliers.

I wish I could say mine was equally as fuzzy. My first experience with DENTAC was having all four of my wisdom teeth removed. I had a full-bird working on me and he assured me that removing four teeth from my skull wouldn't be as unpleasant as it sounded. Having 10 removed already for orthodontics (I had LARGE teeth as a child), I wasn't all that worried.

After a short prep, I hear a large crunch and a shooting pain in the lower-right side of my mouth. Apparently he started to work on my impacted tooth with no Novocain (I asked for no sedation as I've been awake for all removals). A few unhappy grunts later he got the point and filled my face with needle pricks. I couldn't feel my face for almost a day after the procedure. :)

Boomer-61
12-14-2009, 08:00
Points taken. Doing your research is essential but carefully consider your sources and tactfully ask your questions and gther information. Most Dr.s and PA's will take the time to answer your questions. If they don't then move on if your healthcare plan allows. If your concerned about potentially conflicting information then respectfully move on. I think the number of successful surgeries and care plans greatly out weight the unsuccessful. I guess I'm a bit narrow in focus as I work at a tertiary care facility. By the time the pt gets to me they've seen one or two other physicians. In my mind if the refering physician has confidence in our institution then that should lend itself to the pt's confidence in our institution. Getting back to the original point of the thread; make sure your intentions are truly info seeking. Some of my most humble patients are physicians.
Boomer

PedOncoDoc
12-14-2009, 08:06
Ah. I think you can speak respectfully while asking questions in an inquiring but direct manner.

If someone is offended and thinks you are questioning their knowledge whilst seeking information or discussion on what your reseach has yielded then maybe they're not the doctor for you. ;)

I think this is the approach I appreciate most, but I've seen all sorts. I'm always happy to answer questions such as, "How do you know that x is what's going on?" or "Is there anything else that could be causing this?" It makes for a fun exercise in creating and prioritizing my differential diagnosis.

I also welcome "What are my options for treatment?" and "Why did you choose this particular treatment/medication?" Again - it makes me reconsider my current practice and consider at medications which I may not typically use but may be better for my patient. It also opens the door for further discussion os side effects, reason I use treatment "x" vs "y". Some times it reminds a patient to bring up an old medical condition or treatment reaction they had not disclosed previously.

If a doc can't justify his diagnosis and treatment decision he/she needs to take pause to figure out what was missed...

OTOH, there is a call to decrease the cost of health care - sometimes what we would feel is best for the patient medically is not what is best for them financially - I would not order a test that would cost a patient $5,000 out of pocket if it would compromise their financial stability. A physician should discuss this with the patient and let them participate in that decision. There are usually cheaper alternatives that are "good enough."

Thankfully, I have some good trump cards in my practice. I have yet to find an insurance company that will refuse a request for a diagnostic test that I consider "standard of care" for a child who has a chance to be cured from cancer. All I have to do is request the insurance company's name, the names of the people making the decisions about paying for testing or not, and let the person from the company that I'm talking with that I wil document all of those names in my chart as the reasons I am not able to provide appropriate care for the child. It seems they would rather pay for the $5,000 test than have the potential for a multi-million dollar lawsuit. :D

Whether or not the test should cost $5,000 is another discussion for another day...

Sacamuelas
12-14-2009, 08:24
Eagle and PedOncoDoc have given great advice. Without all the specifics, no advice can or should be given for your specific case. As you know, drug of choice is a preference for each provider based on their experience and the patient's risk profile/med history. I do not mind having a patient that is well informed and full of questions. If the provider can not answer and explain any reasonable question... find another doc.

The use of sedation is not always mandatory for soft tissue impacted thirds. Some patients require a little sedation to tolerate the procedure, and the surgeon giving the choice of PO meds/Nitrous will save the patient significant expense. However, most oral surgeons will have no problem using IV sedation if it is your preference.

If your buddy is a general dentist, then he may not have the legal ability to administer IV sedation . If he is taking out the thirds instead of an oral surgeon, that may be the reason PO meds are being used instead of IV.

If you want IV sedation, then talk to your oral surgeon. There is not a right or wrong answer on your question. Good luck

and don't let all these horror stories get your scared. I take thirds out ALL THE TIME under local only. They never feel a thing. :D

The Reaper
12-14-2009, 09:06
I take thirds out ALL THE TIME under local only. They never feel a thing. :D

As far as you know.:D

Seriously, thanks for your professional advice, as always.

Feel free to jump on one of the preparedness threads with some more post-Katrina lessons learned, if you have time.

TR

caveman
12-14-2009, 09:33
They never feel a thing. :D

True, till about three hours after the procedure ;)

Sacamuelas
12-14-2009, 12:44
True, till about three hours after the procedure ;)

I have ways to manage post-op pain too. :D For the patients that I like.......LOL

Back when my thirds were removed, I let a classmate do them at a local oral surgeon's office. IV sedation, two large sinus exposures, and four mutant teeth:eek: later (my upper molars had five diverging roots not the normal three converging to the tip)..... I woke up to a Rx for Tylox and lots of postoperative instructions to prevent sinus communication from opening.

Next day I was back at school... no pain. I never took a tylox after the first one on the day of surgery. You see....there could not have been more trouble or tougher extractions to have done and yet I had no postop pain.

Gypsy
12-14-2009, 18:16
I tell my dentist I don't wanna feel nothin'. I get the gas then the novacaine. My DDS rocks.

That's my approach...my DDS rocks as well. The gas is the bomb as far as I'm concerned. I had 3 really old fillings she wanted to replace all at once. :( A little gas and novacaine and I was good to go. The sound of the drill drives me over the edge otherwise.

I think this is the approach I appreciate most, but I've seen all sorts. I'm always happy to answer questions such as, "How do you know that x is what's going on?" or "Is there anything else that could be causing this?" It makes for a fun exercise in creating and prioritizing my differential diagnosis.



I'm sure! I ask out of curiosity and to learn more about whatever it is that's going on...

Roguish Lawyer
12-14-2009, 18:47
Dentists don't cause pain. People who don't take of their teeth do. Suck it up, people! ;)

PSM
12-14-2009, 18:54
Dentists don't cause pain. People who don't take of their teeth do. Suck it up, people! ;)


"Is it safe? (http://www.youtube.com/watch?v=TPQ7KMCrPLE&feature=related)

:eek:

Pat

The Reaper
12-14-2009, 19:26
Dentists don't cause pain. People who don't take of their teeth do. Suck it up, people! ;)

How do you "take care of" pre-emerging third molars, Counsel?

TR

Dozer523
12-14-2009, 20:16
"Is it safe? (http://www.youtube.com/watch?v=TPQ7KMCrPLE&feature=related)Pat Poor Dustin, just couldn't answer that one, could he?
But THIS dentist met his match!
http://www.youtube.com/watch?v=iAKYQjpDtpA&NR=1

Ambush Master
12-14-2009, 21:44
I had my wisdom teeth (3rd molars) taken out one side at a time. They were infected, so several trips to the Doc were reqired!! It was done with just a local and after it was done I climbed on my '71 Bonneville, kick started it....and rode home, some 45 miles!! This process was repeated!!!:munchin

Then again, some of us can simply ignore pain.

Later.
Martin

GratefulCitizen
12-14-2009, 22:03
Had wisdom teeth taken out under general at age 14 (hadn't come in yet).
Came to about 1300.

Told mom that I should attend basketball practice "just to watch".
She was skeptical. Wouldn't let me take my shoes.

Didn't notice the Chuck Taylors that were being worn.
Was practicing and having violent collisions with teamates at 1600. :D

(Bah...just call an ambulance if I start bleedin' too bad)

PSM
12-14-2009, 22:32
THIS dentist met his match!
http://www.youtube.com/watch?v=iAKYQjpDtpA&NR=1


No Doz! :D Denton enjoyed it! Not the same.

Pat

Smithdogs
12-22-2009, 13:43
SFC Macintire drank a bottle of Gin and dug his tooth out with one of then nut hooks.

Next.

Dogs

TF Kilo
12-23-2009, 01:26
My first third molar that presented issues, was #1 3rd molar. It was coming in at a 45% angle towards my cheek, and was rubbing a raw hole on the inside of my mouth. We had a medical team that was augmenting our standard level of assets for an upcoming med-cap mission in afghanistan. After the med-cap, the dentist held dental sick call for anyone having issues. I was the only one that showed up.

Novacane injected, and I slurred with my half numb face after he had already failed with 2 good attempts at prying, "here, use my leatherman"

Popped it right out without a hitch. Prescribed motrin at first, anything else we had on hand if necessary. Did not need a single pill.

I wish I could say the same for the surgical intervention for the other 2 that started causing issues around 4 years ago. I am lucky that I won't end up having the #16, my last panorex showed that there was no tooth growing, hidden, or otherwise conspiring against my well being.

Asking questions is something I did as a patient, and as a in-house crosstrained medic. It's just smart.

But remember, his profession is what it is, and when it comes down to it.. let him do what he's trained to do. Just talk with him about your previous experiences, perhaps that might raise his awareness about comfortable methods of ensuring you "don't remember a thing and wake up with a smile"

My first oral surgery I woke up with a smile at 11. That nurse was HOT..... :eek:

shr7
01-14-2010, 21:38
Had them both out today. Resident took it out with my buddy on suction. I took the pill about 45 minutes prior to the surgery. Got about the equivalent of "2 beers in". Numbed me up and the resident had them out and stitches in in under 1 hour. Easiest dental procedure I have ever had done. One was bone impacted and required a bit of drilling, but overall a pleasant experience. I learned something and the 3 dental students who were in the room learned something. Everybody wins. Of course, the resident had the look of boredom on his face for the entire procedure and was out the door before I could say "thank you".

Thanks for advice from the board. I'm even a little embarrassed for starting the thread after how easy the procedure went.

SR

Sacamuelas
01-18-2010, 09:56
another satisfied customer.....good for them. :lifter
Glad it worked out for you.