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The Tyranny of Oral Surgeons

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I wanted to give kudos to Jim Du Molin. He is the founder of Internet Dental Alliance, which is a direct competitor to my company, Infinity Dental Web. But I’m on the same side as he is in this dental political issue of oral sedation, which I believe is slated to be voted on at the annual meeting of the American Dental Association, November 5-10, in Washington, DC.

He sent me an email early this morning about this issue. I had heard about this issue through other sources, but he put it rather directly and I liked his style of not pulling any punches. He titled it “The Tyranny of Oral Surgeons.” I’d like to quote it here:

The rivalry between oral surgeons and general dentists has never been fiercer.

And it looks as if the oral surgeons have seized the upper hand.

Right now, a tiny group of oral surgeons in positions of influence at the ADA who are pushing forward a proposal – Resolution #77 – that will make it much harder and much more expensive for general dentists to continue serving their fearful and anxious patients using moderate enteral sedation.

In fact, if their proposal, Resolution #77, is approved at next month’s ADA annual meeting, it could well spell the beginning of the end of oral sedation.

The BIG problem is this: Most of the ADA House of Delegates members who will be asked to vote on Resolution #77 have no clue what’s behind the proposal or what a dramatic impact it will have on dentistry and patients. The oral surgeons are counting on their ignorance – and their blind trust that if the ADA is proposing changes, they must be for the better.

We know that millions of patients have been treated safely and effectively – without incident – by general dentists who adhere to the existing guidelines and their states’ associated regulations.

Yet, under the ruse of concern for public safety – and it is nothing more than a ruse! – oral surgeons are poised to rewrite the ADA’s oral sedation guidelines to conform to their selfish interests.

I am joining with concerned leaders in the general dentistry community in urging you to contact your ADA House of Delegates representatives immediately (there is no time to waste) to let them know you strongly oppose Resolution #77.

Calling or writing them will only take a few minutes of your time, but it could make the difference for sedation dentistry and the millions of our patients who rely on it.

Thank You,

Jim Du Molin

On mynewsmile.com I reference this issue as it played out in Iowa. (See my page on Iowa Sedation Regulations.) In Iowa, the oral surgeons were able to use their influence with the Iowa Board of Dental Examiners to put in place highly restrictive rules on the use of oral sedation, effectively outlawing it in the state. Many patients were hurt by this policy. Until they did this, I was able to treat hundreds of patients using oral sedation without a single adverse incident. But being able to use oral sedation meant that I could compete with oral surgeons in offering wisdom tooth extractions and other services that they wanted to perform. I had a lower rate of complications, including zero dry sockets, over a period of many years, than our local oral surgeons.

The links below, provided by Jim Du Molin, courtesy of TEAM1500.org, include contact details for any member dentists who wish to contact their ADA House of Delegates representatives, plus additional details on Resolution #77.

Three Simple Steps to Help
https://www.team1500.org/cta2.html

Calls to (ADA) Action: Briefing
https://www.team1500.org/briefing.html

State-by-State Directory of ADA House of Delegates https://www.team1500.org/delegate_directory.html

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Click here to ask Dr. Hall a question of your own.

About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

Why couldn’t my dentist get me numb?

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Dear Dr Hall,
I have a peculiar problem which my dentist could not solve even after 11 sittings. My front lower teeth (two of them, I think they are called central incisors) are partially dead (injury from football during college) now half of it is infected and half of the nerves are still alive. I have got 5 injections and a paste on the tooth to numb it, it simply does not numb enough for a root canal. My dentist returned my fee, I am virtually living on ultraset since last 2 weeks now. your view and guidance would be a blessing.
Best regards,
Ankur from India.

Dear Ankur,
I’m confident I know precisely the answer to your problem, because the same thing has happened to me, when I had a root canal treatment done.

There is always a certain amount of anxiety when you’re having dental work done. And especially after trying and failing to get a tooth numb for dental work (you said 11 times), the amount of anxiety is going to increase dramatically. A lot of dentists don’t understand the connection between this anxiety and the novocain that they depend on to get you numb, but the anxiety counteracts the novocain and can even make it impossible to get you completely numb.

This happens with me, and once I understood this, I saw this in many of my patients who were difficult to get numb. What you need is some type of anti-anxiety medication. Taking 10 or 20 milligrams of Valium could do the job. Or, if you can find a dentist who uses nitrous oxide gas, that could do it also. If it’s Valium, take that at least 30 or 40 minutes prior to your appointment. But be sure you have someone who can take you to the appointment and take you home, as you will not be fit to drive probably the rest of the day. There are other good anti-anxiety medications that are useful for dentistry also, such as Halcion.

Dr. Hall

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About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

Follow-up from Kenneth – Novocain doesn’t work for him.

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This is the a response to my posting of Sept. 16, “Novocain doesn’t work for me.”

Absolutely fascinating Doctor! You are the first who has actually made that connection even when I did not mention it in my email. It is an unfortunate fact that as a child I was a ward of the county and subject to the welfare medical care available at the time. My siblings and I were removed from our natural parents custody and sent to different homes. I was particularly fortunate in that the people who took me in were fine Christians who gave me an outstanding start in life. It is also true that the dentist I had as a child was (I truly believe) a sadist. As I have reviewed the experiences I had as a child in the dental chair, I now know that this sadly disturbed individual derived some sort of perverted pleasure from inflicting pain on helpless children. Of course, when I told my parents that “I don’t like the dentist!” they dismissed it as normal childhood anxiety and did not give it any weight. I do not blame them at all. I hold no bitterness toward anyone. Not even the dentist himself. My Christian heart still hopes he found a healing somehow. I do believe that it is a combination of anxiety and the conviction that failure is inevitable because of a long string of dentists who have promised painless procedures and failed, each in their turn to deliver. I will take the advice you gave and seek out an appropriate dentist who might help me end one of my life’s greatest embarrassments. Thank you for your thoughtful reply to my email. Are you at liberty to recommend such a dentist in the greater Cleveland Ohio area? I would be very interested in any thoughts you may have along this line. Thanks again for your help and understanding.
– Kenneth from Ohio

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About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

Novocain doesn’t work for me.

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I have an extreme sensitivity to “all” of the numbing drugs commonly used by dentists. This is not a biological reaction, I am not allergic to anything at all, the drugs simply do not work as they normally do with most other people. I have, through hideous experiences come to the realization that I cannot tolerate dental procedures unless I am unconscious. Have you had experience with persons with my situation? I must emphasize that this is not simply a case of inability to handle pain or discomfort. I was the victim of a pilanidal cyst of considerable dimensions and endured the surgical procedure necessary for its’ removal. That really stung a lot! That is nothing compared to what I experience when undergoing dental procedures. Please let me know if I have any hope of improving a less than dazzling smile. Thank you in advance for your time and help.
– Kenneth from Ohio
PS – by the way… well designed for visually impaired persons. Great job!

Kenneth,
Yes, I have had a lot of experience with patients like you, and I understand this problem particularly well because I have had times when I have had so much anxiety that the novocain hasn’t worked for me, either. For me, usually nitrous oxide will calm me enough that the novocain will work. But I have treated a number of patients that had to be deeply sedated in order to become numb.

Few dentists really understand this phenomenon, so I wrote about it a few years ago for a dental journal. There’s something in your body chemistry that if you are stressed or anxious enough, it prevents the complete action of the novocain or causes it to wear off exceptionally quickly. Here is a scenario that I often had in my office. A person comes in for treatment and doesn’t want to admit that they have had past traumatic dental experiences. I give the patient the injection of novocain. They begin to feel numb right away, so I know I have “hit the target.” I begin to work, and they feel pain. So I tell them I think they need nitrous oxide gas. Now here comes the interesting part. If I just give the nitrous oxide gas, they will still feel pain when I start working again. I learned that I had to wait until they were sufficiently relaxed and then RE-ADMINISTER the novocain, and then they were fine. Or if they needed stronger sedation, then I would give that and then I would need to do a new injection after they are fully sedated.

My experience is that this happens when people have had past traumatic experiences in the dental chair. In my case, it was a children’s dentist who didn’t use novocain, and then later painful experiences with other dentists.

I don’t know if you have a dentist, but my suggestion would be to look for a sedation dentist or a dentist who practices sleep dentistry. Conscious sedation rather than general anesthesia is much less expensive, safer, and more convenient than going with complete general anesthesia. And most people will not remember the appointment. But if that isn’t strong enough for you, then you will need to go to the general anesthesia.

Dr. Hall

Click here to read Kenneth’s follow-up e-mail, Novocain doesn’t work.

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click here to ask Dr. Hall a question.

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About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

Should I have an oral surgeon do this extraction?

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Dr. Hall,
A couple of years ago, a filling came out of my tooth, and the tooth later broke. When the pain finally became too much to bear, I went to a dentist and ended up having a root canal done, although I’m not sure it was successful. I’m ashamed to admit that my apprehension about dentists has kept me from proper routine check ups and maintenance. The dentist that did the root canal failed to follow up with me and I was in no rush to have more work done, as the pain was gone for the most part, so I did not follow up either and I did not have a cap put on. The temporary filling ultimately fell out, the tooth is about half gone as well and is now infected.

I’ve seen a new dentist that was recommended by a friend, he confirmed the infection, and has advised that the tooth needs to be extracted. He explained that it would be quite invasive due to the condition of the tooth, cutting gum and bone, and that I could have it done by an oral surgeon under anesthesia, or by him with a local. Because of cost considerations, I’ve elected to NOT use an oral surgeon/anesthesia.

I guess my question is this—Due to the invasive nature of the procedure, would it be advisable to use the oral surgeon, or is it safe to assume that a ‘regular’ dentist is qualified to handle to job safely and effectively?
– Amy in New Jersey

Amy,
Giving patients options like this can leave them in a quandary. You leave them with the impression that they might not be safe taking the cheaper route. I would suggest asking more questions to help get at the answer.

It’s possible that the extraction you’re dealing with is beyond the comfort level of your dentist and the dentist could end up in trouble during the appointment. And it’s possible that this appointment could be a traumatic experience for you. Those are the two issues.

Dental anxiety can be very expensive, as you are finding out. If you had the filling replaced when it first came out, you wouldn’t have needed a root canal treatment. If you had the crown done right after the root canal (which sounds like it was done properly), you wouldn’t need the tooth extracted and now a much more expensive tooth replacement to keep your bite from collapsing. So I wouldn’t dismiss the idea of having this appointment with the best anesthesia possible, to keep you from having a bad experience and the resulting lifetime of serious dental anxiety. The end result would be that your mouth would gradually fall apart.

So I would try to pin your dentist down with some specific questions about just how comfortable he feels with this appointment, if he has done extractions like this in the past, if there is nitrous oxide sedation available for you that would help it be more comfortable, and if it is likely to be traumatic for you. Are the roots straight and tapered, or are they twisted with knobs on the end?

Having answers to these questions would help. It sounds like your dentist is trying to be fair and honest with you, so I would give his expressed opinions considerable weight. My tendency would be to encourage you to see the oral surgeon if that option is being offered—it indicates a degree of discomfort on the part of your dentist.

– Dr. Hall

Related links:
Read about dental crowns and why they are needed. In particular, you may want to find out about porcelain fused to metal crowns.
Read more about sedation dentistry here.

We thank our advertisers who help fund this site.

About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

How much dental work can I have done in one sitting?

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Dr. Hall,
I need a lot of work on my teeth. I need over 7 root canals, I have a few cavities, one tooth needs to be shortened and my teeth need to be whitened. I would like to have most of this done at once, how much work can be done in one sitting?
– Lisa in New Jersey

Lisa,
There’s a lot of variation from dentist to dentist as far as how much work they’ll get done in one sitting. You have to ask the individual dentist.

The dentists who will do the most work in one sitting will be those who do sedation dentistry. You can find listings of sedation dentists if you do a Google search on sedation dentist.

If you want a New Jersey cosmetic dentist who can also do sedation dentistry, I’d recommend Dr. Joel Singer. He is up just outside Manhattan, which is at the other end of the state, but if the appearance is important to you, you’re going to have to go that far. If your tooth whitening is not complicated, and there isn’t other work on front teeth, you could have a general dentist do that.

If you don’t want to go with sedation dentistry, then it partly depends on your endurance ability. If dentistry doesn’t make you uncomfortable at all, then you could probably do a four-hour appointment in one sitting, and if your dentist can work fast, then you can get a lot done.

If your seven root canal treatments are on front teeth, then a general dentist or a cosmetic dentist who does root canals could get them done in one appointment. If they are on molars, and it’s important to you to get them done in as few appointments as possible, I’d go to an endodontist (a root canal specialist), as they work much more quickly than non-specialists. It can take a general dentist one and a half to two hours to do a molar root canal, where a specialist will get the whole thing done in an hour, easily.
– Dr. Hall

We thank our advertisers who help fund this site.

About David A. Hall

Dr. David A. Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does advanced internet marketing for dentists.

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