Howard Farran, DDS, MAGD

For information on Dr. Farran's speaking schedule, his book, "The Business of Dentistry Volume 2: A Consumerist's Road Map", or his newsletter "The Farran Report", call 602-598-9757, fax 602-598-3450 or e-mail hfarrandds@worldnet.att.net

Is Anesthesiology Good for Your Practice?

Some progressive dental schools, like the University of Oregon Health Sciences and the University of Pittsburgh, have added a two-year post graduate anesthesiology rotation to provide graduates with full board-certified anesthesiology privileges within any hospital. Dental fear is probably the number one reason people avoid a dentist's office. It's a very real problem for a lot of people and if you're going to stay in business, it's best to give the people what they want, or feel they need. But, is IV sedation the way to go?

Ever notice when someone dies in a dental office they almost always have an IV in their arm? It is for that reason I really do not recommend being a one-man band when it comes to performing dental work and anesthesiology. I realize there are numerous dentists who started this type of procedure when they were young and didn't have much to lose. Then, after years of practice, continue performing solo because they have so much experience. I know several high quality dentists that do this very well.

Thanks to scientific research, drugs are now available that are much better and provide more reliable results than in previous decades of dentistry. There are even reversal antagonistic drugs available to reverse a sedative's action. Years ago, a dentist would just have to wait it out if a patient went too far under.

But even the dentist who personally does it all will have to admit that in American hospitals, a doctor doing both surgery and anesthesia is becoming an incredibly rare and risky business. Many of the large, metropolitan hospitals have banned one person from preforming both surgery and anesthesia with statistically good reasons. I strongly agree; doctors should not solely perform surgery and anesthesia simultaneously. However, I endorse the safe administration of anesthesia with a licensed professional when warranted.

This became very apparent to me when my wife "Flawless" and I were driving to the hospital in the middle of the night for the delivery of our third baby, Ryan. She had already given birth naturally to our two sons, Eric and Greg. The end of this pregnancy, however, had left her really tired and physically exhausted and mentally depleted. In short, she was not up to handling a "natural" birth. I suggested she get an epidural. She was convinced to have it "all natural." I got her laughing so hard she was crying by explaining to her that only a white male named Dr. Lamaze -- who by the way, never had a baby -- could have convinced women to have a 9 pound live ape come out of their bodies moving and kicking, and still want a natural birth.

I told her, let's get that idiot Dr. Lamaze in my dental office and I will pull all four of his wisdom teeth naturally without any anesthesia. "Come on, Dr. Lamaze! Just breathe! It's only pressure! Come on, these four teeth do not even weigh a pound and they're not kicking!" I told her if men had all the babies in the world they would be on an IV Demerol drip starting in the second trimester.

Dentistry has experienced a historically bad reputation in our culture, due to pharmaceutical anesthesiology being seldom used in our armamentarium. I really do not recommend learning how to "do it yourself," since that custom is dying out as the world realizes that if you only do "one thing" and "specialize" in it, you get more proficient and statistically speaking have a better chance of producing positive results.

Believe me, you can get an anesthesiologist to come to your dental office anywhere in the United States. There really isn't a more competitive field in medicine. They literally hang out in hospitals just waiting for a call. If your patients want to be asleep for a procedure, put them in touch with an anesthesiologist. I have the patients take charge of contacting the anesthesiologist themselves. The one I use in my office charges $200 an hour with a two hour minimum. He brings all his own stuff, including drugs, equipment, and a personal dental assistant. I don't have to worry about the paperwork that goes with their medications, the shelf life of the pharmaceuticals, which monitors to get, and all the bells and whistles. Actually that is not true now, but that is how I started out.

Eventually it was so successful that we set up our operatory room #5 as a surgical suite that still functions as a regular room for any dental procedure and is ready for IV sedation when the anesthesiologist shows up. This is also the room where all of our surgical dental implant armamentarium equipment is set up. I surgically place a half dozen or so dental implants a month. This way, all the equipment I bought when I went through the Carl Misch, DDS Institute of Oral Implantology doesn't have to be moved around and can be stored and left ready to go, in one dental operatory. It saved about 30 minutes setup time after I placed all my implant surgical equipment in one operatory. If you have the space, I firmly believe you should look into making these procedures as easy and efficient as possible.

Every time a patient requests IV sedation I tell them, "Yes, we can put you to sleep with no problem and it's only $200 an hour, with a two hour minimum. The sedation will be done in our own office with an anesthesiologist who, by the way, is also a dentist." I offer them exactly what they ask for, nothing more. Every time, I put the ball in their court! I'll get one of two responses, either, "Really! Are you serious? In that case, can you do everything I need done when I'm asleep so I could wake up and be finished? I have been putting this off for years!" Or, I get an occasional patient who is really just moaning and groaning who will say, "No, that's okay, I don't want to go through all of that!" But whatever their answer, my response clearly states to the patient I've done my homework in fulfilling their needs.

We simply do not make a habit of saying "NO" as a reflex without thoroughly exhausting the questions, needs, or desires of our patients. I tell my entire staff every day that our patients do not have to come here. You cannot say "No" to everything! It is a lot easier for us to say "Yes" to evening appointments, early morning at 7 am appointments, Saturday appointments, nitrous oxide, pre-operative sedatives, in-office anesthesiologist, electronic anesthesia, white fillings, all porcelain crowns with no dark root metal line, a play area with Nintendo 64, and an in-your-face location with an internally lighted sign, than to lower all our costs down to the bone and try to enjoy doing HMO, bare bones, clinic style, factory dentistry on an assembly line!

Dental anesthesiology is a great addition to our sovereign profession. It will elevate our image higher and be a great asset to the profession. The only requirement we as professionals have is to stay on top of research and learn everything we can about the subject and use it wisely. Anesthesiology is only facing opposition because oral surgeons feel threatened by its universal acceptance and in-office procedures. Yet, have they made any attempt to supply family practice general dentistry with help in utilizing this great patient asset? How many oral surgeons will come to your office and do sedation for a fee? Or conversely, would an oral surgeon equip one of their surgical operatories with everything you need so you could go to their office and perform dentistry? If you know of any, tell me about them!

I believe a lot more people would have their concept of ideal optimum oral health restored if the word on "the street" was how easy it is for dental phobics to just visit the doctor's office, go to sleep and wake up with their teeth and gums all fixed up. IV sedation is the most dramatic form of sedation but electronic anesthesia, oral sedatives, and great chairside manners have always been valuable adjuncts to add to your 21st century practice. I personally did not get off to a good start with electronic anesthesia because, like many of my friends and dental colleagues, I missed the boat. I relied on it entirely to complete the job even when it was apparent it wasn't doing the trick. I have since learned electronic anesthesia is very effective when used in conjunction with nitrous oxide, and/or with an oral sedative such as Halcion, Ativan, Valium, or Xanax.

Any successful dentist should have both eyes focused on comfort since this is still one of the top three reasons people either do not go to any dentist period, or why they slipped out the back door and left their last dental office. Believe me, the vast majority of dental phobics can be managed very easily.

It will probably be at least two more generations before the reputation and all the horror stories of yesterday's dental nightmares go the way of the buggy whip. Until then, keep up your continuing education, hire an anesthesiologist when requested, and master patient comfort. Take it as seriously as anything you do in life!