Dental sedation

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"

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

Quote:

Originally Posted by Eagle5US

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

RF 1

Sigaba · 12-13-2009, 20:02

Quote:

Originally Posted by Boomer-61

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

Quote:

Originally Posted by Sigaba

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

Quote:

Originally Posted by Gypsy

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

Quote:

Originally Posted by Sigaba

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.

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

Quote:

Originally Posted by caveman

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

Quote:

Originally Posted by caveman

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.