- Email: [email protected]
Techniques in Anesthesia
L E T T E R S
T O
T H E
E D I T O R
THE JOURNAL devotes this section to comment by readers on topics of current interest to dentistry. The editor reserves the right to edit all communications to fit available space and requires that all letters be signed. Printed communications do not necessarily re flect the opinion or official policy of the Association. Your participation in this section is invited.
P atien t education Jason M . T a n z e r’s letter to the ed i tor (p. 5 9 5 , Sept j a d a ) o verlo o ks an all too co m m o n area o f neglect— that is, th e failu re o f the dentist to e ffe ctiv e ly instruct and m otivate p a tients in oral hygien e. I have develop ed a patient educa tion program , in cludin g necessary equ ipm en t fo r patients to readily see all areas o f the oral ca vity . T h is has been used fo r n early four years and has been h ig h ly e ffe ctiv e as seen w h en exam in in g p atients’ m ouths years later. T o o m a n y dentists h ave the ap p ro ach used by a period on tist w ho treated m y brother-in-law . T h e den tist had him p u rch ase all the neces sary p arap h ern alia fo r m aintaining oral hygien e. I assum ed the dentist also h a d tau ght h im oral h yg ien e m ethods. T h in k in g I co u ld learn fro m his exp erien ce, I to o k m y brother-in-law to the clin ic and show ed h im the p h ysical la yo u t for the in struction classes and sprayed his teeth w ith the disclosing spray w h ich I use. A fte r rinsing, he looked into the illum in ated m irro r and c o m plim en ted h im se lf on the fine jo b he had been doing. W hen I p o in ted o u t that there was stained p laq u e on the gin gival third o f nearly all teeth, he said: “ N o w I see w hat I should be doing. A ll that the other dentist did w as fuss at m e fo r not d o in g it rig h t.” 1280
A ll dentists w ou ld do w ell to a t ten tive ly read th e booklet, R esearch
E xplores Plaque, C o m b a t Z o n e in D ental D isease. O n p age 5 it states: “ E v e n i f bacteria w h ich cause caries and p eriod on tal disease are present in the m outh, these bacteria can n o t initiate either disease p ro cess until they are able to attach them selves to the teeth as bacterial p la q u e ....B o th prevention o f initial in fectio n and co n tro l o f existing in fectio n s require only that one fo llo w a sim ple program o f ju d icio u s eating habits regardin g sugar-containing foods, and regu lar effective rem oval o f bacterial deposits from all sur faces o f the teeth. . . . O n ce a dentist or dental hygien ist has rem oved all p laqu e and calculus, m ost in d ivid u als ca n m aintain teeth essentially free fro m p laqu e through regular oral self-care.” It seem s that D o cto r T a n zer failed to read the co n clu sio n o f one o f his referen ces (K eyes, June 1968, j a d a ) w h ere h e w rote: “ T reatm ents o f d en tal caries that do not in clude c o n trol o f m icro b ic deposits represent the abatem ent o f sym ptom s rather than the co n tro l o f disease, nam ely, bacterial p laque infections. “ I f m odern dentistry is to m ake sign ifican t progress tow ard p reven t ing the p ro gressive loss o f teeth and dental tissue that presently occurs, it m ust develop m ore e ffe ctiv e ther apeutic p rogram s to control the fo r m ation o f odontop athic plaques o r
keep such deposits below the level at w h ich to x ic reactions o c c u r .” M a n y years ago , the A D A C o u n cil on D en tal H ealth stated that “ to d a y the dental profession has the kn o w led ge and skill to p reven t loss o f teeth as a result o f dental disease, p ro vid ed there is w holehearted c o o p eration by the in dividual p atien t.” P atien ts are v e ry receptive to oral h yg ien e instructions i f p ro p erly p re sented and i f adequate equipm ent is a va ilab le so they can read ily see w h at is needed. I f the results o f a p atien t education p rogram leave som ethin g to be desired, exam in e the p resentation and be sure it’s suited to fit th e patient. I w o u ld w elco m e anyon e w h o is interested in seeing o u r p atient edu ca tio n program and the equipm ent w h ich any dentist can con struct. E d u ca tio n in oral h ygien e is the m ost im p ortan t service w h ich w e can render o u r patients, and it ca n be don e e ffe ctiv ely and e fficie n tly in p riv ate p ra ctice as w ell as in clinics. L T C O L T H O M A S P. F R E E M A N , DC US A R M Y D E N T A L C L IN IC ED G EW O O D A R S E N A L , M D
T echniques in anesthesia T h is letter con cerns an article in the O cto b e r j a d a b y E verett and A lle n , “ Sim ultaneous evaluation o f ca rd io respiratory and analgesic effects o f intravenous analgesia in com bin ation w ith lo cal anesthesia.” T h e battlefield (Battle o f Britain) tactics in vo lved in the endless am m un ition o f p h ysiolo g ic param eters in graph and ch art form are w ell docum en ted in the case o f the B rit ish M ed ica l Journal (1969)— D o c tors W ise, R obin son , et al, against the A m e rica n S o ciety fo r A n a lg e sia and A n esth esia in D entistry— D o c tors D rum m ond-Jackson. A cco rd in g to th e latest in form ation quoted in the J u ly-A u gu st, 1970 issue o f A n es thesia Progress, their m eth o do lo gy has been discredited— resulting in p en din g legal action in the British courts. Is this the open ing salvo in the B a ttle o f A m e r ic a w ith the advocates
(Shane, Jorgensen, F orem an , Berns, K u rlan d , et al) fo r intravenous pain co n tro l lined up against the critical o nlookers w h o are loaded with statistical bullets to shoot dow n this p rogressive m o vem en t in the U S A ? T h e argum ents are as illo g ica l as those in the tim e o f D o cto rs M orton and W ells. S y lva n Shane has a w o n derful, safe tech n ique w ith universal app lication in the health field. T o d a y m illions o f m edical surgical p ro ce dures in the field o f E N T , eye, gy n e c o lo g y , geriatrics, and p lastic and m in o r surgery are done e ve ry year using m o d ified Shane techniques by personnel in exp erien ced in anesthesi o lo g y services. W h y is the oral surgeon “ lo ck e d in to ” anesthesiology techniques taught during his internship and residency trainin g periods— eg, m ethohexital and halothane-nitrous o x id e-o xygen ? O n a d a ily routine intravenous dental p ractice basis, I h a ve had no m o rtality or m o rbid ity experiences. T h is includes no loss o f lim bs due to th e ven ipu n cture tech n ique. T h is is the best tech nique w ith m o d ificatio n s fo r w artim e crash p ro gram s to train inexp erien ced person nel fo r anesth esiology services. U sin g endotracheal intubation techniques, abou t 9 0 % o f cases have acco m p an yin g arrhythm ias o r dysarrhythm ias— 7 0 % during in duction by m ask (“ F acto rs in arrh yth m ia dur ing dental outp atien t gen eral anes thesia,” D o cto rs M iller, R edish, et al Septem ber-O ctober, 1970, A n al gesia and A nesthesia, p ag e 706, W il liam L lo yd , Santa M o n ica, C a lif). H o w com e all the m ed ical surgi cal specialty procedures don e under intravenous analgesia-am nesic tech niques are not put on a sound re p ortable p h y sio lo g ic basis through con trolled studies o f p h ysiolo g ic param eters? W h y chan ge drugs o r dosages i f yo u are rep orting on the Shane technique? T h is is not fair co n cern ing the reality o f everyday practical clin ical adm inistration. D ru gs and dosages are in dividualized, depend ing on patient, p rocedure, length o f tim e, and so forth. T hus, it is d iffi cu lt to standardize a 25 m g V istaril dose for every adult p atien t (25 to
50 mg). O n ly after doin g hundreds o f cases can one gain insight into the advantages o f this technique. It is n ot statistically valid to m ake judgm en t on the entire scope o f in travenous techniques by reporting on nine m a le volu nteers (no w om en or
con sisted o f a refresher co u rse in go ld f o i l . . . ” (gold foil?). E vid en tly the dental colleges o f the co u n try, acco rd in g to his o b servations, can n o t p roduce better than 6 5 % co m p eten cy. E ith er that, or th e state o f F lo rid a has w ith in
children). I feel that the insertion o f catheters into the subclavian artery and superior ven a ca v a o f hum an sub jects is far m ore dangerous than any intravenous technique. T h e A m erican S o ciety fo r A n a l gesia and A n esth esia in D entistry (A S A A D ) is p ra ctically form ulating an intravenous p ain con trol program fo r general dentists and dental spe cialists fo r sim ple, safe, practical, clin ical, and com p rehensive pain control m ethods. It is h op ed that in terested hospitals, schools, and clin ics w ill assist and cooperate. T h e Sydney (A ustralia) D ental H ospital offers a tw o-w eek program in intravenous techniques. W h y not a clerkship-externship program co n sisting o f one day p er w eek for one year? A n education al process o f p ublic debate w ill dispel som e o f the lack o f kn o w led ge and m isconception con cernin g this im portant area o f pain-free and stress-free dentistry. L et’s think p o sitiv ely and co n struc tively fo r th e benefit o f o u r w elldeserving dental patients w ho are de m anding better pain con trol and pa tient m anagem en t services in the gray area betw een local and true general anesthesia.
its borders no incom petents. It is evident that R o bert E. W est m an is o v e rly co n cern ed w h en he states that “ it is n ot hard to v isu a l ize the m a n y retired and sem ire tired dentists open ing part-tim e p ractices w ith m arginal equipm ent and facilities . . . . ” T h is sounds m uch lik e a m an w ho fears co m p e tition. A t m y stage o f the gam e, I am defin itely n ot interested in o p en in g a n ew o ffic e there or co m p et in g w ith an yon e there. I am in ter ested, h o w ever, in con tin uin g m y life ’s w o rk — the one and o n ly p ro fession I kn o w — and, since this is a free co u n try, n ot bein g restricted o r segregated to any one state. I f a tru ck driver o r a tie salesm an ca n p ly his trade anyw here in the U n ited States, then I w an t the sam e p rivilege.
P H IL IP GARSON, DDS P R E S ID E N T , A M E R IC A N S O C IE T Y FO R A N A L G E S IA AN D A N E S TH E S IA IN D E N T IS T R Y
Licensure in Florida I hasten to rep ly to com m ents by R obert E. W estm an con cern in g den tal licensure in F lo rid a (O ctober j a d a , p ag e 807). H e states that “ as nearly as I was able to observe, the 3 5 % w h o failed were dentists w h o had m ade little or no p reparation fo r the exam in a tions, w ith perhaps a few w ho were not com petent. M y preparations
N E W M A N D . W IN K L E R , DDS N E W Y O R K C IT Y
M edica l liaison I w ish to co n gratu late the s ta ff on establishing liaison w ith the m e d i ca l profession and prin tin g J. V . W o o d w o rth ’s article on m edical em ergencies (O ctober j a d a ) . W ith each p assing day, the fields o f p h a rm a co lo g y and therapeutics b ecom e m ore im portant to th e den tal p rofession. D o c to r W o o d w o rth p resented the pertin ent in fo rm a tion in a p recise and co n cise m a n ner. T h e re should be m o re articles o f this sort review in g vario u s areas o f p h ysio lo g y as related to dentistry but presented by the m edical p ro fession. A lso , in case it does n ot a l ready exist, there should be articles in the m edical jo u rn als w h ich are w ritten by dentists. H A R O LD A . L E V IN , DDS HEM PSTEAD, NY
1281
T O
T H E
E D I T O R
THE JOURNAL devotes this section to comment by readers on topics of current interest to dentistry. The editor reserves the right to edit all communications to fit available space and requires that all letters be signed. Printed communications do not necessarily re flect the opinion or official policy of the Association. Your participation in this section is invited.
P atien t education Jason M . T a n z e r’s letter to the ed i tor (p. 5 9 5 , Sept j a d a ) o verlo o ks an all too co m m o n area o f neglect— that is, th e failu re o f the dentist to e ffe ctiv e ly instruct and m otivate p a tients in oral hygien e. I have develop ed a patient educa tion program , in cludin g necessary equ ipm en t fo r patients to readily see all areas o f the oral ca vity . T h is has been used fo r n early four years and has been h ig h ly e ffe ctiv e as seen w h en exam in in g p atients’ m ouths years later. T o o m a n y dentists h ave the ap p ro ach used by a period on tist w ho treated m y brother-in-law . T h e den tist had him p u rch ase all the neces sary p arap h ern alia fo r m aintaining oral hygien e. I assum ed the dentist also h a d tau ght h im oral h yg ien e m ethods. T h in k in g I co u ld learn fro m his exp erien ce, I to o k m y brother-in-law to the clin ic and show ed h im the p h ysical la yo u t for the in struction classes and sprayed his teeth w ith the disclosing spray w h ich I use. A fte r rinsing, he looked into the illum in ated m irro r and c o m plim en ted h im se lf on the fine jo b he had been doing. W hen I p o in ted o u t that there was stained p laq u e on the gin gival third o f nearly all teeth, he said: “ N o w I see w hat I should be doing. A ll that the other dentist did w as fuss at m e fo r not d o in g it rig h t.” 1280
A ll dentists w ou ld do w ell to a t ten tive ly read th e booklet, R esearch
E xplores Plaque, C o m b a t Z o n e in D ental D isease. O n p age 5 it states: “ E v e n i f bacteria w h ich cause caries and p eriod on tal disease are present in the m outh, these bacteria can n o t initiate either disease p ro cess until they are able to attach them selves to the teeth as bacterial p la q u e ....B o th prevention o f initial in fectio n and co n tro l o f existing in fectio n s require only that one fo llo w a sim ple program o f ju d icio u s eating habits regardin g sugar-containing foods, and regu lar effective rem oval o f bacterial deposits from all sur faces o f the teeth. . . . O n ce a dentist or dental hygien ist has rem oved all p laqu e and calculus, m ost in d ivid u als ca n m aintain teeth essentially free fro m p laqu e through regular oral self-care.” It seem s that D o cto r T a n zer failed to read the co n clu sio n o f one o f his referen ces (K eyes, June 1968, j a d a ) w h ere h e w rote: “ T reatm ents o f d en tal caries that do not in clude c o n trol o f m icro b ic deposits represent the abatem ent o f sym ptom s rather than the co n tro l o f disease, nam ely, bacterial p laque infections. “ I f m odern dentistry is to m ake sign ifican t progress tow ard p reven t ing the p ro gressive loss o f teeth and dental tissue that presently occurs, it m ust develop m ore e ffe ctiv e ther apeutic p rogram s to control the fo r m ation o f odontop athic plaques o r
keep such deposits below the level at w h ich to x ic reactions o c c u r .” M a n y years ago , the A D A C o u n cil on D en tal H ealth stated that “ to d a y the dental profession has the kn o w led ge and skill to p reven t loss o f teeth as a result o f dental disease, p ro vid ed there is w holehearted c o o p eration by the in dividual p atien t.” P atien ts are v e ry receptive to oral h yg ien e instructions i f p ro p erly p re sented and i f adequate equipm ent is a va ilab le so they can read ily see w h at is needed. I f the results o f a p atien t education p rogram leave som ethin g to be desired, exam in e the p resentation and be sure it’s suited to fit th e patient. I w o u ld w elco m e anyon e w h o is interested in seeing o u r p atient edu ca tio n program and the equipm ent w h ich any dentist can con struct. E d u ca tio n in oral h ygien e is the m ost im p ortan t service w h ich w e can render o u r patients, and it ca n be don e e ffe ctiv ely and e fficie n tly in p riv ate p ra ctice as w ell as in clinics. L T C O L T H O M A S P. F R E E M A N , DC US A R M Y D E N T A L C L IN IC ED G EW O O D A R S E N A L , M D
T echniques in anesthesia T h is letter con cerns an article in the O cto b e r j a d a b y E verett and A lle n , “ Sim ultaneous evaluation o f ca rd io respiratory and analgesic effects o f intravenous analgesia in com bin ation w ith lo cal anesthesia.” T h e battlefield (Battle o f Britain) tactics in vo lved in the endless am m un ition o f p h ysiolo g ic param eters in graph and ch art form are w ell docum en ted in the case o f the B rit ish M ed ica l Journal (1969)— D o c tors W ise, R obin son , et al, against the A m e rica n S o ciety fo r A n a lg e sia and A n esth esia in D entistry— D o c tors D rum m ond-Jackson. A cco rd in g to th e latest in form ation quoted in the J u ly-A u gu st, 1970 issue o f A n es thesia Progress, their m eth o do lo gy has been discredited— resulting in p en din g legal action in the British courts. Is this the open ing salvo in the B a ttle o f A m e r ic a w ith the advocates
(Shane, Jorgensen, F orem an , Berns, K u rlan d , et al) fo r intravenous pain co n tro l lined up against the critical o nlookers w h o are loaded with statistical bullets to shoot dow n this p rogressive m o vem en t in the U S A ? T h e argum ents are as illo g ica l as those in the tim e o f D o cto rs M orton and W ells. S y lva n Shane has a w o n derful, safe tech n ique w ith universal app lication in the health field. T o d a y m illions o f m edical surgical p ro ce dures in the field o f E N T , eye, gy n e c o lo g y , geriatrics, and p lastic and m in o r surgery are done e ve ry year using m o d ified Shane techniques by personnel in exp erien ced in anesthesi o lo g y services. W h y is the oral surgeon “ lo ck e d in to ” anesthesiology techniques taught during his internship and residency trainin g periods— eg, m ethohexital and halothane-nitrous o x id e-o xygen ? O n a d a ily routine intravenous dental p ractice basis, I h a ve had no m o rtality or m o rbid ity experiences. T h is includes no loss o f lim bs due to th e ven ipu n cture tech n ique. T h is is the best tech nique w ith m o d ificatio n s fo r w artim e crash p ro gram s to train inexp erien ced person nel fo r anesth esiology services. U sin g endotracheal intubation techniques, abou t 9 0 % o f cases have acco m p an yin g arrhythm ias o r dysarrhythm ias— 7 0 % during in duction by m ask (“ F acto rs in arrh yth m ia dur ing dental outp atien t gen eral anes thesia,” D o cto rs M iller, R edish, et al Septem ber-O ctober, 1970, A n al gesia and A nesthesia, p ag e 706, W il liam L lo yd , Santa M o n ica, C a lif). H o w com e all the m ed ical surgi cal specialty procedures don e under intravenous analgesia-am nesic tech niques are not put on a sound re p ortable p h y sio lo g ic basis through con trolled studies o f p h ysiolo g ic param eters? W h y chan ge drugs o r dosages i f yo u are rep orting on the Shane technique? T h is is not fair co n cern ing the reality o f everyday practical clin ical adm inistration. D ru gs and dosages are in dividualized, depend ing on patient, p rocedure, length o f tim e, and so forth. T hus, it is d iffi cu lt to standardize a 25 m g V istaril dose for every adult p atien t (25 to
50 mg). O n ly after doin g hundreds o f cases can one gain insight into the advantages o f this technique. It is n ot statistically valid to m ake judgm en t on the entire scope o f in travenous techniques by reporting on nine m a le volu nteers (no w om en or
con sisted o f a refresher co u rse in go ld f o i l . . . ” (gold foil?). E vid en tly the dental colleges o f the co u n try, acco rd in g to his o b servations, can n o t p roduce better than 6 5 % co m p eten cy. E ith er that, or th e state o f F lo rid a has w ith in
children). I feel that the insertion o f catheters into the subclavian artery and superior ven a ca v a o f hum an sub jects is far m ore dangerous than any intravenous technique. T h e A m erican S o ciety fo r A n a l gesia and A n esth esia in D entistry (A S A A D ) is p ra ctically form ulating an intravenous p ain con trol program fo r general dentists and dental spe cialists fo r sim ple, safe, practical, clin ical, and com p rehensive pain control m ethods. It is h op ed that in terested hospitals, schools, and clin ics w ill assist and cooperate. T h e Sydney (A ustralia) D ental H ospital offers a tw o-w eek program in intravenous techniques. W h y not a clerkship-externship program co n sisting o f one day p er w eek for one year? A n education al process o f p ublic debate w ill dispel som e o f the lack o f kn o w led ge and m isconception con cernin g this im portant area o f pain-free and stress-free dentistry. L et’s think p o sitiv ely and co n struc tively fo r th e benefit o f o u r w elldeserving dental patients w ho are de m anding better pain con trol and pa tient m anagem en t services in the gray area betw een local and true general anesthesia.
its borders no incom petents. It is evident that R o bert E. W est m an is o v e rly co n cern ed w h en he states that “ it is n ot hard to v isu a l ize the m a n y retired and sem ire tired dentists open ing part-tim e p ractices w ith m arginal equipm ent and facilities . . . . ” T h is sounds m uch lik e a m an w ho fears co m p e tition. A t m y stage o f the gam e, I am defin itely n ot interested in o p en in g a n ew o ffic e there or co m p et in g w ith an yon e there. I am in ter ested, h o w ever, in con tin uin g m y life ’s w o rk — the one and o n ly p ro fession I kn o w — and, since this is a free co u n try, n ot bein g restricted o r segregated to any one state. I f a tru ck driver o r a tie salesm an ca n p ly his trade anyw here in the U n ited States, then I w an t the sam e p rivilege.
P H IL IP GARSON, DDS P R E S ID E N T , A M E R IC A N S O C IE T Y FO R A N A L G E S IA AN D A N E S TH E S IA IN D E N T IS T R Y
Licensure in Florida I hasten to rep ly to com m ents by R obert E. W estm an con cern in g den tal licensure in F lo rid a (O ctober j a d a , p ag e 807). H e states that “ as nearly as I was able to observe, the 3 5 % w h o failed were dentists w h o had m ade little or no p reparation fo r the exam in a tions, w ith perhaps a few w ho were not com petent. M y preparations
N E W M A N D . W IN K L E R , DDS N E W Y O R K C IT Y
M edica l liaison I w ish to co n gratu late the s ta ff on establishing liaison w ith the m e d i ca l profession and prin tin g J. V . W o o d w o rth ’s article on m edical em ergencies (O ctober j a d a ) . W ith each p assing day, the fields o f p h a rm a co lo g y and therapeutics b ecom e m ore im portant to th e den tal p rofession. D o c to r W o o d w o rth p resented the pertin ent in fo rm a tion in a p recise and co n cise m a n ner. T h e re should be m o re articles o f this sort review in g vario u s areas o f p h ysio lo g y as related to dentistry but presented by the m edical p ro fession. A lso , in case it does n ot a l ready exist, there should be articles in the m edical jo u rn als w h ich are w ritten by dentists. H A R O LD A . L E V IN , DDS HEM PSTEAD, NY
1281