(CONT.)
out. About 20 minutes into the
procedure, the tooth disappeared.
When the patient arrived at my office,
he was in pain and had difficulty
opening his mouth. A cone beam CT
scan (Fig. 2) showed the location of the
tooth to be near the infratemporal fossa,
against the lateral pterygoid plate. The
reason this occurred may be due to
inadequate exposure and visibility, lack
of appropriate instruments, or lack of
surgical strategy. The decision was made
to wait a couple weeks for the tooth to
become encapsulated in fibrous tissue in
order to facilitate removal. It was then
easily removed under general anesthesia
(Fig. 3). The patient had an uneventful
recovery and was glad that he was asleep
for the second surgery.
So, I would like to discuss this
politically touchy subject from my
unique perspective as an educator and a
specialist, so that the patient’s best
interests always come first. In the new
Los Angeles Dental Society Explorer
economy, how does the general dental
practitioner decide which surgical
procedures to do in the office and which
ones should still be referred to the oral
surgeon? The answer to that question
will be different for every doctor. It
really comes down to what is your level
of training and experience in oral
surgery, and what is your resulting
comfort level. After all, it may be a slow
day in the office, it looks easy and your
favorite oral surgeon is on vacation.
What may sound like a great idea at the
moment may quickly progress to
something completely regrettable. As a
specialist, I want everything I do in my
office to be successful, all my patients to
have a great experience, and reflect
positively on my practice. As a general
practitioner, you should have the
same goals.
Preparation The first thing I would like
you to do is to assess your surgical
training and experience. Are you
prepared for the procedure you are
about to perform? How many times
have you done this, or a similar
operation? Are you able to mentally
walk through the steps, knowing which
instruments and supplies you will likely
need in order to successfully complete
the task? Can you perform the
procedure in a reasonable amount of
time? A single tooth extraction should
take 15 minutes or less. Most patients
can tolerate about 30 minutes worth of
surgery under local anesthesia. After
that, the experience becomes traumatic.
If the patient needs four third molars
removed and it will take you an hour, is
this a good idea? You may be fine after a
60-minute procedure, but what about
your patient? What will you do if a root
breaks or you encounter sudden
bleeding? Are you comfortable handling
those common surgical complications?
Do you want to handle them? If you
answered no, then the patient is better
off being referred to the specialist. If the
answer is yes, then go ahead and take
care of the patient in your office. Always
keep in mind that you will be held to
the same standard of care as the
specialist if things go wrong. Always
have a specialist who will back you up, if
necessary. If you have a problem, don’t
make things worse. Get help.
As I mentioned earlier, you want
everything you do in your office to be a
practice builder. A happy patient will
tell two friends. An unhappy one will
tell 10. Just because you have the time
in your schedule, you may not want to
take on a surgical procedure that you
are not prepared to complete in an
efficient and atraumatic fashion. Even if
you are comfortable and experienced
with the procedure, you still need to
consider other factors. Does this patient
have medical issues that may complicate
things? Is the patient very anxious, and
would they be better treated under