Dentistry Uncensored with Howard Farran
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323 Nitrous Oxide and Silver Fluoride with Fred Quarnstrom : Dentistry Uncensored with Howard Farran

323 Nitrous Oxide and Silver Fluoride with Fred Quarnstrom : Dentistry Uncensored with Howard Farran

2/25/2016 5:12:51 PM   |   Comments: 1   |   Views: 855

#323



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#323




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AUDIO - DuwHF #323 - Fred Quarnstrom
 

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VIDEO - DUwHF #323 - Fred Quarnstrom



This Episodes Discussion:

  • How can you get into trouble with nitrous oxide sedation?
  • When should you remove the nose mask?
  • How to be safe doing oral sedation?
  • What drug should not be in your emergency kit?
  • What can you do to help your insurance submissions?
  • And much, much more!


Fred Quarnstrom:

I am semi retired. I practice 2 days a week for the lady dentist who worked for me for 12 years and purchased my practice. I have now worked for her 8 years. This gives me a chance to stay in touch with my long time patients, their children and grandchildren. My practice was in a modest to low income, multiracial part of Seattle. It was successful beyond my fondest dreams.  


I graduated from dental school 51 years ago. I spend 2 years attached to the Marine Corps and Seabees as a dentist including the first across the beach amphibious assault in Vietnam at Chu Lai. I did dentistry on our troop, on Vietnam villagers and medical air evacuations of the wounded. In all, I had 8 years in the Naval Reserves and 2 years in the Army ROTC.  I next did a one year MD residency in an anesthesiology residency at the Washington Hospital Center in Washington DC.  


I have taught fear and pain control courses for 6 dental schools, in 35 states and 15 countries; in all 252 nitrous oxide oxygen sedation and 116 oral conscious sedation, 125 medical emergency and130 electronic dental anesthesia programs: 738 total CE presentations. I have had 56 papers published and wrote chapters in 3 books. I am a flight instructor and have 1000 hours of pilot in command and am a Docent at the Seattle Museum of Flight. I am active in Boy Scouts as and Eagle Scout Board member and am a Silver Beaver. 


in addition to sedation and pain control courses I have taught Age Relevant Dentistry programs, I spend 20 years doing quality reviews for union welfare dental programs. I served on our Dental Board for 4 years and have served as an expert witness in 45 legal cases. One had a $34,000,000 award. I have worked for dentists and for patients. I will not take a case I do not 100% believe in.  


You can reach Dr. Quarnstrom at fredq@comcast.net


www.faculty.washington.edu/quarn 


Howard:

It is a huge, huge honor for me today to be interviewing a legend in dentistry, Dr. Fred Quarnstrom. You are a legend when I got out of school, Fred. I got out of school in '87, I'm not going to give away your age, I'm 53 but you're ...

 

Fred:

I'm on the back side of 75.

 

Howard:

You're on the back side of 75, so you're three quarters done, and man, I got to read your bio. Fred says I am semi-retired, I practice two days a week for the lady dentist who worked for me for 12 years and purchased my practice. I have now work for her eight years, this gives me a chance to stay in touch with my long time patients, their children and grandchildren.

 

 

My practice was in a modest to low income multi-racial part of Seattle, it was successful beyond my fondest dreams. I graduated from dental school 51 years ago. I spent two years attached to the marine corps and CBs as a dentist including the first to cross the beach amphibious assault in Vietnam at Chu Lai.

 

 

I did dentistry on our troop in Vietnam villagers and medical air evacuations of the wounded, in all, I had eight years in the naval reserves and two years in the army ROTC. I next did a one year MD residency in an anesthesiology residency at the Washington Hospital Center of Washington DC. I have taught fear and pain control courses for six dental schools in 35 states and 15 countries and all 252 nitrous oxide oxygen sedation and 116 oral conscious sedation and 125 medical emergencies and 130 electronic dental anesthesia programs for a total of 738 total CE presentations.

 

 

I listen to your presentations in dental school, Fred. I have had 56 papers published and wrote chapters in three books. I'm a flight instructor and have 1000 hours of pilot in command and have a docent at the Seattle Museum of Flight. I'm a active boy scout, eagle scout member and I'm a silver beaver. In addition to sedation and pain management courses, I taught [inaudible 00:02:18] at dentistry programs. I spent 20 years doing quality reviews for union welfare dental programs. I served on a dental board for four years, and I've served as expert witness in 45 legal cases. One with a $34 million award, is that the right number?

 

Fred:

That is correct.

 

Howard:

I've worked for [inaudible 00:02:38]. I will not take a case I did not 100% believe it. Fred, you seriously, you are a legend and it is such an honor that you spent the day with my son, Ryan and I today. Thank you for being here today.

 

Fred:

Well, thank you for having me. The trick will be if I can make the computer work.

 

Howard:

Well, that's why we have Ryan here. You and I are both too old to see now, to figure this stuff out. My son was a senior in college and they told him in senior year that you could do it all online, so he moved back from school to live with that, to help his senile old man out with the podcast, Ryan. Is Fred and I are going to pull this off today?

 

 

He says we got it. We got it, Fred. Fred, what did you want to do? Did you want to give a lecture, or how did you want to do this?

 

Fred:

Well, I've got a PowerPoint setup and fair to start there and you interrupt me, whenever you wish to interrupt, then leave me astray.

 

Howard:

Well, I'll tell you what. I do these podcast, because they're so damn fun, it's like going to lunch with a friend and you don't even have to leave your house. It can be a, you're out there probably a thousand miles away. The number one complain I get on my podcast is shut up Howard, let you guest speak, so I have a post-it note on my screen that says shut the blank up. You got a presentation, Fred. Just let it rip.

 

Fred:

Well, let's see if I can get my computer run.

 

Howard:

Ryan, do you have any duct tape that I can put over my mouth to eliminate more of my ... By the way, if you do have complaints or suggestions or anything, just always email me, howard@dentaltown.com. I answer all my emails. Everyone thinks I have someone else doing it. I actually don't. Probably because I'm not smart enough to have someone do it.

 

Fred:

Okay. I thought we'd start talking about nitrous oxide, and then we'll go into some other sedation information and we will wonder on from there. The biggest concern lately that we've seen is concern from staff about trace contaminants. The words out that if you're pregnant, the dental office may not be a safe place to work.

 

 

The first evidence of problems came from Dr. Bruce who was in Salt Lake city in 1974, and he showed with some very sophisticated neurologic examination techniques that there was a bit of a problem with motor skills, if you are exposed to 50 parts per million nitrous oxide and one part per million halothane.

 

 

Halothane is a very potent general anesthetic gas. He did in that same study show that up to 500 parts per million nitrous oxide was not a problem. NIOSH and OSHA came to him before the paper was published and because of the problem of 50 parts per million, they forgot there was also one part per million halothane. They set the maximum time weighted average that dentist should be exposed to at 50 parts per million.

 

 

They even suggested at one time, we should be wearing a space suit, fresh air being pumped in from the outside. Well, Bruce move from Salt Lake and tried to repeat his study. A number of people have tried to repeat it with no success. In 1983, he retracted the paper and stated there's no longer any need to refer to our conclusions as controversial. They were wrong, derived from data, subject to inadvertent sampling bias and not application to the general population. However, NIOSH standards still stand.

 

 

Well, the good news is there's a fellow named Sweeney who did a study on dentist that were using nitrous oxide and he looked at the deoxyuridine suppression test which has to do with DNA synthesis and if you're pregnant, that feed is having a lot of cell division so it needs to be able to create DNA.

 

 

What Sweeney found with his role on tears is that test begin to show some abnormalities some place around 1700 to 2000 parts per million. Being conservative he said "okay, let's say you should stay below 450." This line is 450 parts per million, in Sweden there's 100 part per million rule. NIOSH and OSHA are saying 50 parts. In the state of Washington for about five years, we had a 35 part limit.

 

 

The good news here is so long as you stay below 50 parts per million. There's no hazard to your staff, but you do need scavenging. What scavenging works, a brown mask, and we'll see some examples. This is some research done by a friend of mine on UBC, Dr. David Donaldson, worked very well. They got below 43 parts per million. Porter was 48.

 

 

These next three masks don't exist anymore, the McKesson mask doesn't exist anymore, it was particularly good. I use a CO2 absorber in my office but that's a whole different story. It cuts down the amount of gas we used, and it turned out it worked as a scavenger. There are devices to test and see how much nitrous is going in your operatory. Here's one I found just the other day online, it's a handheld device.

 

 

It will tell you instantaneously how much nitrous oxide is in the breathing area and we now know if we're below 350 we're safe, on stage regulate at 50 parts per million. We can tell that. There are other devices like this one that you can clip on your gown and you take the cap off, leave it open all day, seal it up at night, record the number of hours that it was absorbing gas. You send it off and they will send you back a report.

 

 

Earlier, we had a device look like a thick pen. This device here, not to pick on the Porter company, because they weren't doing this was very similar and people love the reports they got, they were always very very low. Then at one of the dental schools exposed the devices to low levels of nitrous oxide and they got really low settings also.

 

 

It turned out the guys that were providing the service said it was a lot less costly to dummy up the results than it was to actually do the analysis. This is one that's been around for 10 years, it's really costly, about $2,000 but again it will tell you and instantaneous reading. It'll tell you time weighted average. You could move it around the office and see just how much gas is there that your staff is being exposed to.

 

 

The brown mask is the classic. It's a mask within the mask. There's suction applied to this gas. This area, the nose fits in when you inhale, you draw the gas out of the large tubes. When you exhale, there's a pop up valve that puts the gas into this space where suction lines take it out of the office. Very easy to stay 50 parts per million or below with the brown mask, so that really solves the problem for our staff.

 

 

I like, these are flavored masks, there's mint, orange, cherry, tutti fruity and the plane Jane grey mask down here. These have been shown to work very well. Cannulas I've used off and on, and there are some issues with them. They're nice to work around because they're very small but these are pretty small tubes. You can only get right around eight liters per minute of gas through the cannula.

 

 

When you inhale, that means two-thirds of the breath is room air, so you have to run very high levels of nitrous, probably 70% to get somebody relaxed, and when they're exhaling between breaths. This gas is being blown into the room. There is a company that's come up with something that looks very much like that. These small tubes fit up into nares and there's some other holes there we'll see in a second.

 

 

They did some research that I've been pretty critical off. Here's the mask down here, it's got a number holes. This is a suction hose here. Here are the cannula tubes that fit up the nose and they show this picture with puffs of nitrous oxide leaking out here and on the side of the mask but then they show this picture of a conventional mask with a big cloud of nitrous and my guess is it didn't have the section turned on, because from Donaldson's research that we see down here, they would be around 43 parts per million if that were a brown mask.

 

 

I'm pretty negative on that mask. Another one and this looks great because it's very small, there's a little bit of adhesive up here that seals it up to the nose, but we've got these small tubes again. One is bringing gas into the mask and the other one is taking gas out of the mask, and those tubes are just too small to effectively remove that waste gas that's being exhaled by the patients.

 

 

I would like to see a study on this to see just how good it is. This is a modern version of the brown mask. They now have a transparent shield, which looks really good to me. You can be sure, the flutter valves working. Inside here, you've got plenty of gap for this section to work to get all this stuff out and in fact there's a bigger gap down below.

 

 

If the patient says ha ha ha, they blow off some gas into the room and this section will then pick that up. There is an area which just came to my attention about a year ago, you do not want to use nitrous with Treacher-Collins syndrome kids, and they're pretty easy to identify. The bottom half of their face remains underdeveloped. They have tremendous airway problems.

 

 

They may have breathing problems. Some of these kids end up with a tracheostomy for life just to keep their airway open. There was a case where a young lad, 10 years old, use nitrous at a dental office and they lost his airway, and they were unable to take over and assist his respiration. Dr. Tom who's dental anesthesiologist at USC said he would only treat a child like this in a hospital with a good amount of back up because of the problems with their airways.

 

 

This is one no-no. You don't want to treat Treacher-Collins syndrome kids. The other one is brand new. I saw this about two weeks ago, or a report of it, and that's a facial fire. Both nitrous oxide and oxygen are able to support combustion. Normal room air has 21% oxygen. The gases that we're giving our patients are normally maybe 60, 70% oxygen, 40% nitrous, they both support combustion.

 

 

The patient was using nitrous oxide biomask, her lips were dry and so the staff moistened her lips with Vaseline, I don't know how many time we've done that in my office. We don't want their lips to crack. The dentist was grinding on an implant fixture and there was a very small spark that ignited the Vaseline.

 

 

Now we have an extra oral fire on the lips, the mask burst into flames, they were able to get the mask off and put out the fire quickly, but the patient's hair was singed as was her face. The point of all this is use a water-based lubricant for their lips, do not use Vaseline or a petroleum-based.

 

 

Here you see the nitrous and the oxygen escaping around that mask, so that would really make this Vaseline burn very very violently. The next question comes up, when can you remove a mask, and we suggest that you leave the mask on for five minutes. We do that because as the patient is coming off nitrous, their exhale, there has trace amounts of nitrous oxide in it. We don't want this blowing off into the office, so you got your scavenging hooked up, you got them on a 100% oxygen for five minutes.

 

 

By the end of the five minutes, the nitrous is gone. However, if the patient should stop responding or if anything seems strange, take the mask off, if you take nothing away from the talk today, it's okay to take the mask off ... Does oxygen reverse nitrous oxide? Absolutely not. Oxygen doesn't have the sedative effects of nitrous, so when they're on 100% oxygen, they will get rid of the nitrous that's in their body.

 

 

For years, we were taught that if you took the mask off and I learned this in my anesthesia residency, the patient could suffer diffusion Hypoxia. The nitrous moves in and out of the lungs much faster than oxygen or nitrogen, and so if you took the mask off, the nitrous would fill the lungs and the next breath the patient got would be 100% nitrous oxide and it would put him to sleep.

 

 

A little study that was done here at the UW hospital, they show that people were cyanotic, they had a slightly blue tinge when they got to the recovery room after surgery. Of course that patient had been on all sorts of drugs under general anesthesia that depress respiration and some surgeon had been rummaging around in their belly and in their chest, and it hurt like mad to take a deep breath.

 

 

I did a silly little study, looking for diffusion Hypoxia. Here we have our patients on this side is a percentage in hemoglobin saturation. We think it should always be above 90%. The average patients sitting down in my office was 97% saturated. We put them on nitrous oxide for varying lengths of time, whatever we were doing, from five minutes to an hour and a half, and we found their saturation got up to 99%.

 

 

The purple bars are one standard deviation for any statisticians in the crowd. Then at the end of the procedure, we took the mask off and let them breath room air. We saw the saturation slowly draw up and it ended up at about 96.5% right here. Started 97 ended at 96 but if you just sit in a chair and don't do any activity, your saturation will drop some. Out of this study with the help of the statisticians at the UWL school we showed with the statistical probability about 1 in 100,000 chance that you would ever see Diffusion Hypoxia doing what we did.

 

 

The folks at Harvard didn't believe our study so they repeated it about five years later and found exactly the same thing. The folks at the University of Texas took a look at this about five years ago, and they too published a study showing they didn't find Diffusion Hypoxia. The thing to remember about this if anything seems weird when you're using nitrous, take the mask off, get them back breathing room air.

 

 

I know about 75 times where systems have been plumbed backwards or gases have been switched and if you insist on oxygenating somebody, if you have switch gases, you're going to be giving them 100% nitrous oxide and you need oxygen to live, and we'll talk about a case in a little while about that. What sort of complications do you see with nitrous?

 

 

It's pretty good drug. You don't see much. Very rarely while you see somebody get nauseated and there was a study of 500 consecutive uses where if they stayed below 50% nitrous oxide, they didn't see any of this. Hallucinations did happen every so often, my practice was probably a third severely phobic patients. I ended up using a higher, I had a hygienist one day, a champ, I went in to check her patient, the lady broke down crying, she tried to kill me.

 

 

I've never had so much pain in my whole life. I don't know if I'm ever going to get my teeth cleaned again and I got her calmed down and okay, don't ... Next time talk to me first and then I had a little discussion with the dental hygienist. We didn't try to kill people. We could use local anesthesia in the state of Washington and we certainly could use nitrous oxide.

 

 

About 20 minutes later, I hear a scream, Dr. Q get to room one now, I raced down the hall, I've go a lady sitting in the chair going [inaudible 00:19:28] and her arms are flailing and the hygienist over in the corner crying. I took the mask off, what do we do in this case? We tell them who they are, where they are, and they're going to be okay. Sally, take a big deep breath, you're in the dental office, that away, blow it out, you'll be back to normal in just a moment.

 

 

Take another deep big breath, you're in the dental office, blow it out, come on, Sally, take another deep breath, and within about a minute, they're back to normal. One of my friends called me one day and he said "Fred, I've got a patient that's asleep." I said it's a good friend of mine. I said "well stupid, take the mask off." He said "I did an hour ago." I said "well, they can't be asleep then."

 

 

He said "well you know it, and I know it, but she's asleep, if I pinch her, she comes around, I've tried to give her some coffee, we spilled more on her than in her." I didn't know what was going on. I called one of my friends at the University of Oregon, he didn't know what was going on. In the meantime, I've asked this guy, I said "what's her blood pressure?" He said "well she's got a strong pulse."

 

 

I said "well a strong pulse is really good but remember when you take blood pressures in dental school 120 over 70, 130 over 75, well, he fast up, he didn't have blood pressure." It's been a long time. We all should have blood pressure cuffs in our office. As it turned out, she was in the state out of hypnosis. Nitrous reminded her of being hypnotized, she like being hypnotized and she put herself in a trans, and the solution there talk backwards from 10 to 1.

 

 

10, you're getting more and more alert, less and less relaxed, you'd be back to 1 or back to normal by the time we reach 1 or you'll never experience this again. Take another big deep breath, blow it out. 9, you're getting more and more normal, less and less relaxed, when you get to 1, you'll never experience this again if you're not back to normal. They want to experience it again. By the time you get to 1, they'll be there.

 

 

Everybody is set for years, you can't put anybody under general anesthesia with nitrous. In my 51 years I've had two people with relatively low amounts of nitrous 30% that were under general anesthesia. How did I know? I touched her eye latch, I pinched them in the back of their arm and there was no response, so what do you do as we stated several times you take the mask off.

 

 

Within about 30 seconds, they're back to normal. There are some sexual phenomenon that had been reported in the literature about half of the population can have what appears to be a sexual orgasm on nitrous. I was ask which half, I said it's a female half and then the question was, how can you tell? I said well, if it looks like a duck and walks like a duck and quacks like a duck, there's a pretty good chance you're looking at a duck.

 

 

The important of this is male dentist, male hygienist, they never use nitrous oxide, they can never be in a treatment room and operatory alone with a female patient. You always have to be escorted by a dental assistant. We've had a few people that came in really really uptight about dentistry, they got relaxed on nitrous, they loved it. When we're all done, they were just floating on cloud nine, they were just so happy. Why we keep them around, we're sure they're back to normal.

 

 

I was doing a course in a town a little north of Seattle here, Bellingham, and we tried to use the nitrous late in the day, that on the first day of a two day course. A lady used some nitrous and just broke down sobbing. I quickly went over to her, got the mask off, got her back to normal. I said ma'am, can you tell me what's going on? She said well I work for Dr. Smith for 30 years, he was the most nice caring dentist you've ever met, and he died about a month ago.

 

 

She just was sobbing. While it was near the end of the day, we finished the lectures, she was dressed very plain, straight hair, no make up, the next morning, she comes into the room, a flowery dress, big smile on her face, comes over, gives me a hug. That does never happen. I say I worried about you last night, how are you doing? She said fine, you thought I cried here, you should have been at my house, it came in buckets.

 

 

She said I'd never really mourn. Well I got it out of my system last night. This young man I'm working for now, it's not anywhere as near as good a dentist, but he's going to get a lot better. We wondered how that relationship went. Once in a while, you'd get somebody giggling and you just can't treat them. Obviously, you have to turn the gas down.

 

 

You want to watch out for recovering alcoholics and unfortunately they usually won't tell us or anyone who's been in any sort of a drug treatment program because the euphoria of the nitrous can remind them of all the fun that they used to have, and I had one guy who fell off the wagon, the next time he came in. He said don't ever use that gas again.

 

 

I lost it. I went straight from here to a bar. He said I'd been dry in over three months now, but don't use it again. There are some forms of Ophthalmologic surgery where they will inject the gas into your eyeball. They do this to plaster the retina back down if you're having a retinal detachment, then they tack it in place with a laser. Nitrous will diffuse into closed spaces. You wouldn't want to use nitrous on someone who's had a recent Ophthalmologic surgery.

 

 

They'll typically be wearing a wrist band. The one gas is gone, I think in about eight days, the other one takes about two weeks. Those are the no-nos, and we've already talked about this but I want to emphasize it one more time. Can you remove the nitrous mask? Do it, if anything appears weird. If the patient stops responding to you, remove the mask, get them back on room air.

 

 

They were fine breathing room air, get them back where they started, you don't have to worry about diffusion Hypoxia. Let's go on and talk a little bit about safe oral conscious sedation. I've done, I don't know, 500 or 600 cases over the years. Out of the first 400 I had, 4 failures, I couldn't treat them, I didn't get them relaxed. I sent them out to the dental school for general anesthesia.

 

 

Those are pretty good odds, I wish everything I did in my office was 99% successful. Nobody was ever asleep in the office. We're talking about oral conscious with heavy emphasis on conscious. As long as they're conscious, everything is fine. Nobody needed for me to use reversal agents to reverse an over-sedation.

 

 

I mentioned I had 4 failures that needed general anesthesia. Here in Washington, I can give a supplemental dose if I end up low on my dosing and we'll talk about that. About 10% of the time, I needed a supplemental dose. I'd much rather give a little less than I think they're going to need and be able to supplement it than to give them the big dose and then discover their totally worked out.

 

 

About 10% of the patients needed some nitrous to completely take care of their level of apprehension but again they were all awake. Can I mix two different sedative drugs? One pharmacist that I talked with said "that's a wonderful idea because if you get effect two from one drug or you get effect two from a second drug. If you combine them, you may get six, but we may not want to go to a six and it's illegal in many if not most states. You have to stick to a single drug."

 

 

On top of that, there's just no research to show what the effect is by combining those two different drugs. Equally and maybe more important is many states don't allow you to do two different sedative drugs. If they do, the requirements for training are just over the top. Somewhat allow you to try Valium the night before so the patient gets a good night sleep.

 

 

I have no problem with that. Remember that Valium has a 20 to 50 hour half-life, so the next morning, they shouldn't be driving themselves to your office. Gatorade is commonly believed by many dentist to reverse the Benzodiazepines. It absolutely will not. It's not a reversal agent. The only reversal agent for your Benzodiazepines is a drug called Romazicon or flumazenol. You should have that in your emergency kit. If you're using any of the Benzodiazepines, you need the reversal agent.

 

 

Here's our apprehended. This is our level of apprehension. Here we put them on nitrous oxide, they're just happy as a clam. Everything is wonderful. That's all we need. What if we have this situation where the apprehension level is here and the best we can do with a healthy dose of nitrous, maybe 50% is to get here. We're not going to be able to treat that patient. That's where the sedation comes in.

 

 

Where I would like to start with a lower dose, because at about a half an hour 40 minutes if I'm seeing no effect, I will give them a supplemental or second dose which is half as big as a first dose. What if I end up here, I still don't have them relaxed enough to treat. Well, I can always add some nitrous oxide and the advantage of doing it that way is when I take the mask off, they get rid of the nitrous very quickly.

 

 

The Halcion has about a two hour half-life. That's good news because four hours after they were at peak, they're down to about a quarter, they're still not ready to drive a car or cook or use sharp implements or power tools, but they're getting pretty close to normal. We normally figure it takes four half-lives to have the drug completely out of the system.

 

 

This is what we don't want to see and some people have been taught this. They give them a half a milligram to start with and then they give a quarter an hour later another quarter an hour later another quarter an hour later another quarter an hour later. You get something that slowly climbs like this. They can get into the danger where you start to obstruct airways.

 

 

The absolute no-no is a person to get a half a milligram, a half a milligram, an hour later a half milligram, an hour after that another one. They're getting way up here in to the danger area playing footsie with general anesthesia. I had a patient who went to a dentist north of Seattle here. He'd been coming to me. He moved 60 miles north. It was inconvenient to come back to meet.

 

 

This guy gave him a whole milligram. This was a big boy. He's about 260 pounds and about 55 years old, fortunately, the person who came along to drag him home. The responsible adult was his sister and one who's a registered nurse. She said during the night, his breathing would slow down to 3 or 4 breaths a minute, she nearly called the paramedics several times.

 

 

She said I'd pinch him, I'd slap him around a little bit. He'd come to, he'd get a good breath and then he'd go back to obstructing. The only good news about this is that the person is smart enough to reverse it when they see they're getting somewhat too relax. The reversal takes place almost instantaneously but the reversal agent has a half-life of an hour where the half-life of Halcion is two hours.

 

 

You're going to get a rebound with a maximum effect 3 or 4 hours after the drug was reversed, so you have to keep these patients around the office. What do I suggest for a dosing regimen. This is data that I kept in my office. All these patients I did. Up to 110 pounds, you get quarter of a milligram. At 111 pounds, you go to 0.375 milligrams. A quarter of milligram tablet plus a half of a quarter milligram tablet.

 

 

At 180 pounds, you go to a half a milligram and then some maximum recommended dose for Halcion being used as a sleep aid. There is no data to show what the maximum dose should be in a dental office, that research hasn't been done and it probably won't be done because it would cost millions of dollars.

 

 

What I found in my office was some of the bigger folks I had to give a supplemental dose, so I've gone as high as 0.75 milligram. I see reports on dental town and in the various other dental blogs of people giving a milligram or more and there's just no science to indicate that's an appropriate thing to do.

 

 

Now with your reversal agent, if you discover at this point, the patient's too relax, you give them flumazenil and it will drop the effect to 0 in about 10 or 15 seconds. Now the problem is this flumazenil half-life is an hour. Here we are an hour after we gave it. It's half as much the, the Halcion half-life is two hours. It hasn't lost as much and that's where we get the rebound.

 

 

There was a study done at the University of Washington by Milgram and Jackson and they took about a dozen healthy volunteers fairly ... 10 pounds or so. They injected the reversal agent in the tongue in the floor of the mouth, intramuscularly in the deltoid of the shoulder and intravenously.

 

 

This is what they found after five minutes, this reading over here which is a description of how [inaudible 00:33:45]. This person here was probably getting close to general anesthesia and they did this large doses of Halcion. When they reverse with the flumazenil within 5 minutes, she was up at a level of about 80 which is sedated but conscious.

 

 

Look at what happen when they inject it in the floor of the mouth. Now admittedly, wasn't as deep to start with but they got better results injecting in the floor of the mouth than they did IV. Why do I think that's true? Well, Jackson said "well, Fred, if you ever have to reverse this, inject it in the side of the mouth that's not numb." The pain of that injection helps reverse the effect also.

 

 

What they showed here is using the floor of the mouth works just as well as IV or IM and we are dentist, of course are accustomed doing injecting in the mouth so that maybe the ideal place. Now this is a very small pilot study, no one's done a really big study to show that it works, but if you find somebody's overdose, that would be a good place to start.

 

 

Because realistically, most dentist probably haven't started [inaudible 00:35:00] dental school. Let's talk a little bit about emergency kits. That's one of my pet peeves. What drugs do you need? What drugs do you want? How do I use the drugs? Always have in your emergency kit, every drug that you might want and know how to use, but do not have any drugs you do not know how to use, because in the heat of battle, you may do the wrong thing.

 

 

Why is this preparedness so important? Well, my IQ or my cognitive ability is inversely related to the severity of the problem. I want to have some pretty good guidelines as to what I'm going to do if something happens, how it's going to get done because it becomes exceedingly difficult to really get into exact mechanisms, et cetera.

 

 

What is an emergency, it's any condition if left untreated may lead to patient's morbidity or mortality or any condition of a patient that raises my blood pressure or my pulse rate. If I'm getting nervous, that's an emergency. Why do we have to take CPR every two years? I'm going to tell you a story.

 

 

I went and played Racquetball with a good friend of mine, and he was 38 year old, he had just beat the pants off me. I'd lost 17 to 2, he wasn't breathing hard, I was panting like an elephant, and decided I needed a new can of ball. I went to the pro shop to get a can of balls, so I come back and [Hal's 00:36:37] lying on the floor. His brother is there, I said 'what's going on?"

 

 

He says "I don't know. Hal just went to his knees and fell on his back." I go over to Hal and I said "Hal, open your eyes." Nothing happens. I grabbed his arm to get a radio pulse which was dumb, I should have gone for the carotid but I can find the bones, I can find the tendons, but I can't find any beat, beat, beat. Now my IQ is probably at about 90 and dropping like a brick.

 

 

My reflexes kick in, I go for a sporadic artery, there is no pulse. I still can't believe it. I'd like to just leave the Racquetball court and go home, I don't want to be part of this, but Hal is a good friend. I start CPR. This all took about maybe 10 to 15 seconds to get to that point. My IQ is now down about 60, I guess, I'm pumping on his chest, I'm breathing for him. There's an MD in the Racquetball court next door, he comes over.

 

 

He says here I'll do the chest [inaudible 00:37:37] you do the breathing. Very very smart [Van 00:37:40] because the next thing Hal does is he vomits. Now we have a decision point, how good a friend is he, well, he is a good friend, so I sweep his mouth out, I keep doing mouth to mouth, shortly thereafter, we had two piles of vomit, his and mine, paramedics arrived, and that's one of the delightful things about living in Seattle. They're only about three minutes from any place in the city.

 

 

They get him on their EKG machine, he's flat lined, they keep doing CPR. They try every trick in the book. They take him to our major trauma center. They worked on him for an hour because 38 year olds don't die. He didn't make it. That's why we do CPR every year, because if we ever need it, it needs to be pretty much automatic. They are not going to be very cognitive.

 

 

I've got six patients who are EMTs with the fire department here in Seattle. When they found out I was teaching medical emergency courses, they asked me, please tell your students to call 911 early. If we get there while the patient is still alive, our save ratio goes way up. Don't be bashful about calling 911, you don't get points against you. Someone asked have I ever called, I've called twice.

 

 

I got to call one morning at 7:00, a guy says I'm not a patient of yours and I thought, well, why are you calling me at this time. I was sleeping but I didn't say that. He says my sister is, he said I've been awake all night with a terrible toothache, she was sure you'd get me in. I said okay, meet at the office at 8:30, we'll get a chart and I'll get you out of pain.

 

 

About a quarter to 9, I get a scream, Dr. Q get out at the reception room right now. I raced out into the reception room and there's a guy lying on the floor, his eyes are open. I said well sir what are you doing? He said well I got dizzy, I thought I was going to fall down so I decided to lie down. I said well that was a good plan. I'm glad you did that. I turned him on the receptionist and said give me the blood pressure cuff, and she hands it to me, she says you're way behind.

 

 

I said call 911. She says you are way behind, they're on the way. Blood pressure was a little low, 90 over maybe 50. Looked at him. He appeared to be 60 years old plus or minus a bit. That's when the firemen came through the door, they got their EKG machine on him. It was in a bundle branch block, he was having a heart attack, he didn't have a toothache. It was referring to his jaw, but it was [inaudible 00:40:14].

 

 

They took him off to the hospital for treatment and he survived. It's not great marketing to have the fire department parked out in front of your dental office, but it's a lot better marketing than having a hearse out there. I had another elderly gentleman, he was 93, said he wasn't feeling good, and we called the paramedics and they checked him out.

 

 

Said maybe he's coming down with a cold or a flu or something, but I wouldn't let him go home on the bus. Brought one of my assistants and say put the emergency kit at the backseat of the car and we drove him home, so they didn't have to go on a bus. It's happened to me twice, I have no qualms about calling them at all.

 

 

Let's take a look at some emergency kits. At one time, I thought it would be cool to own a bunch of practices, so I bought one. This was their emergency kit. Look at those drugs. I think these maybe past their prime. They picked up the color of the stopper. [inaudible 00:41:13]. I have no idea how old they were, but I would not inject that stuff.

 

 

About the second office, and they have an emergency kit that expired in September of '79, I bought the practice in 1999, so I think that one's probably past its prime also. I scheduled income tax every year to go through the emergency kit. It's a bad time of the year, might as well make it really miserable and be sure all the drugs are up to date.

 

 

This was what I use, I had 3 by 5 cards, this was a Romazicon, the reversal agent for Halcion, I take two vials here. I had a syringe and needle taped to it. You use 0.1 to 0.2 milligrams which is 1 to 2 CCs and you can repeat it. Everything I needed to know to use that drug. Here's the rest of my emergency kit which we will briefly get into.

 

 

I found this emergency protocol manual which is kind of nice because it's one page per condition that leads through the things you might have to do. I've got Benadryl, I would rather inject it than use tablets, I've got four bottles of Benadryl taped here. I also have a syringe in my current kit taped to it.

 

 

Nitroglycerin here, pump it once to prime the pump. You spray one to two doses into the floor of the mouth. Don't use it if the patient's been on viagra, levitra or cialis. Those are potent nasal dilators as is Nitroglycerin. There's been 60 some deaths of people who didn't tell their physicians that they'd been on these drugs and the bottom just fill out of their blood pressure and reminded here to call 911.

 

 

Here's my albuterol to take care of bronchial spasm. My bottle of aspirin for angina or heart attack, they're the chew one tablet, call 911. My reversal agent for Halcion. Epinephrine here, we'll talk a bit about this. I like the ampoules. Well, what's a can of Pepsi doing here? The best way to raise the blood pressure, or the blood sugar of somebody's who's hypoglycemic which seems to happen right before lunch or about 5:00 when you're ready to go home before dinner is to have them drink a can of non-diet soda.

 

 

The carbonation gets in the stomach, that gets the Pepsi or the Coca-Cola into their small intestine, where the dextrose is absorbed. It's much better than cake decoration which is what we've learned in dental school. If you ever have a seizure call 911, don't screw around. You could have some Valium or some [medaseline 00:43:58] to help break it.

 

 

Seizures you need help. We just don't see this. Now, I have a much better organized set, they're printed out. If everybody wants these, if they email me, I'll be happy to send you the program, you just spit them out, in this case, it's Benadryl, I've got two bottles of Benadryl here. My syringe and needle. It tells me how much to use for kids, how much to use for adults.

 

 

Here's my albuterol, shake the dispenser, pump it a couple of times to be sure there's something coming out. Call 911 if no relief within a minute and you're in business. Here's my nitroglycerin spray, again it tells me how to use it. I've got a tennis ball with 911 marked on it in the emergency kit. What's with the tennis ball? Well, number one it reminds me to call 911.

 

 

Everyone in my staff knows that they will never be criticized if they call 911, that's their call. The worst that happens is the firemen say they don't need to be here. We don't get a lot of practice handling emergencies. Something is going on, I don't know what's going on. What did that guy say I should have given, I should be giving a drug, but which ones I should be giving. I just don't know, but I don't want this patient to die on me. I don't want to have to call 911.

 

 

What am I going to do? Well, I'm going to drop a drug and I'm going to inject it in the tennis ball, you're not going to hurt the patient if you inject the drug in the tennis ball, in the meantime, you call 911 and the paramedics will be there in short order. This is what my emergency kit look like when I came out of my anesthesia residency. I was really brilliant, I could use all those drugs.

 

 

As the years go by, I threw them away, and this is the collection I ended up with and now they come in this nice arrangement that I stick in a zip lock bag so that we know where they are. Epinephrine. The Epipen, we've all had in our kits, they're expensive, $140, $150. The new ones are $180 and we never use them, yeah, if we're lucky.

 

 

I had one that was passed its prime, so I thought I'd like to see how this works. One of the problems with the Epipen, the needles only three-eighths of an inch long. I looked at one and there's a whole, that must where the needles comes out, and we got a black plunge around the other end. I pushed the black plunger and injected myself in the thumb, the needle comes out of the back black plunger.

 

 

My thumb turned snow white, it hurt like heck. Now I'm a little embarrassed, do I have to go to the emergency room for this? I don't know, I hate to have that thumb fall off, I use them a lot in the office. I went to the Internet that never ending source of information and discovered that 30% of nurses who use Epipens have injected themselves in the thumb.

 

 

My thumb did remain sore for a couple of weeks but it survived. Here's the much less costly way, you get an ampoule of epinephrine and you snap the top off with a 2 by 2, be careful because you're going to have some sharp edges. They can be pretty sharp, but we work around sharp implements pretty well.

 

 

You stick a needle down in and aspirate the liquid. This is a special needle that has a filter, be good idea to get those and then you inject it into their thigh. The Epipen, you should have six of them if you're treating kids, three adults and three children. You can do the math, that's about $800 and now with $180 version it's getting pretty close to $1,000. The carpule of epinephrine and a 5CC syringe about $5.

 

 

You need a 25 gauge needle, you want it to be an inch and a half long because you inject this into the thigh and you want to inject it deeply enough that it gets right down to the bone, does that mean we're taking people's pants off to use it. No, you inject, you just drive the needle right through their trousers as close to the bone as you can get and inject the epinephrine there.

 

 

You can re-inject every three minutes, firemen should be there shortly and you do call 911 immediately, anaphylactic shock is a very dangerous situation. The new Epipens look like this, you pull the red plunger off and it talks to you. It tells you to put it up, tie it against the thigh, push it and hold firmly for five seconds. The problem again is the needles are only three-eighths of an inch long so you really don't get it as deeply into the muscle as you want. Typically if you're a fat guy like me.

 

 

Does the site matter, if we have to give epinephrine for Anaphylaxis, you follow every epinephrine injection with at least 50 milligrams of Benadryl, the half-life of epinephrine is about two minutes so it doesn't work very long. In the mean time, you've injected 50 of Benadryl, I learned this from my paramedic patients.

 

 

This is what you don't need in your emergency kit, I bet you 90% of people listening to this have it, Ammonia inhalants. We were all taught in dental school, somebody faints you wave one of these under their nose and they will take a swing at you, try to punch you, because it smells terrible, it's very pungent.

 

 

Ammonia is not something you want to get in your lungs. Ammonia is a very caustic chemical, and it can dissolve delicate lung tissue. If you want to know if somebody's fainted, you grab the fatty part of the back of their arm here and pinch and twist, it's a very sensitive area, and if they're conscious, they'll take a swing at you or ask you what you're doing.

 

 

I get rid of this ammonia, there's just no place for it in our emergency kits. That's what my emergency kit morphed into and we've talked about the Pepsi being used for hypoglycemia. The other thing I see and I go to the consumer electronics show every year in Las Vegas, is I'm going to hold up my phone. You see the connections on the back of the phone.

 

 

I can do an EKG with my phone. I simply wet my fingers and touch them here on one hand and here on the other hand and the EKG scrolls across the screen and I can print that out and email to their doctor. If I've got somebody with a weird rhythm, this is a pretty normal rhythm. You see a lot of artifact here because the muscles in your hands holding it will do that, but here's a beat that came a little prematurely.

 

 

At this area here, I was demonstrating this. I flexed my biceps and so you also see the action, the electrical action of the muscles, but I can then email this to their physician, by the time the patient got to their doctor, the arrhythmia maybe gone and they'll not have any idea what was happening. Cost about, I think they're $70 now, that's pretty inexpensive to be able to get a rough idea of what's going on with the electrical activity of the heart.

 

 

I've used it a couple of times in the office, I used it twice at the museum of flight when people started to get faint. Almost all cardiac arrest victim shocked within six minutes lived, whereas those shocked after six minutes almost all died. You can't get the emergency response team there fast enough.

 

 

Now if you're in a rural area, you're going to have to be better prepared than if you're in a city like Seattle. Here we were in the Edmonton airport and there's external automatic defibrillator right on the post. Here's the sample one that I use in the courses that I give so people can play with it. It watch you right through it. They're very easy to use.

 

 

Where do you want to have your cardiac arrest, well, it turns out Seattle and King County here in the state of Washington is a good place as is Rochester Minnesota, probably because that's where one of the Mayo Clinics are. In my office, I bought a refurbished automatic external defibrillator, that gave me a screen. I could put these small pads on a person's shoulder and see what their EKG looks like and I can then print that out and send it with them to their physician if I see something abnormal.

 

 

I'm old. I'm happy in the office because I know we've got an external defibrillator. I got to thinking about it, we had a lot of old friends too, so I bought one, we got one in our home. I spent a thousand dollars far more foolishly than that, I think I'm worth it. A couple of insurance hints, I did reviews for 20 years, if you want to get the highest possible acceptance rate. Always send an x-ray that shows why you're crowning the tooth.

 

 

You can't see in the x-ray send it anyway to prove that there's bone around the tooth, but send a photo showing the missing structure. If there isn't missing structure but if the patients having pain. Copy your chart notes and send a copy of the chart notes, showing what you've done to take care of the patients pain coming out of that tooth.

 

 

Whatever you do, don't play it fast and loose with the truth. I have seven fellows working for me. We did about 50 reviews a day when we're there, we were there three days a week. The rules were you never look to see what dentist did submitted the insurance form. You look at the data that was submitted. Can you see some evidence of the necessity for that crown and mostly we review crowns.

 

 

By the time we were done looking at the data, the x-rays, the explanation on the insurance form. 9 times out of 10 we knew who the dentist was. We quickly identify the players. It was just amazing. There were those offices, we had one office in Bellflower, California. 95% of what they submitted to crown, there was no evidence in x-rays, photos or chart notes that the patient was having any pain or there was any missing structure. Many of them were virgin teeth. We got a little cynical after a while. We're going to talk about, how are we doing on time, Howard?

 

Howard:

You can go as long as you want, as far as the actual time, I think we're at 55 minutes, but you're a legend and take all the time you wanted. You've done this half a century, you're 75 years old, and most evidence I have in my podcast years are all under 30, so pretend you're just talking [crosstalk 00:54:50] that walked out of dental school.

 

Fred:

Yeah. Mere children. Well, we're going to talk about some of our bad actors, they walk among us, I think they graduated. With sedation, general anesthesia, things can happen. Here's one of 47 year old police officer had four third molars to remove the brace symptomatic which makes me wonder if they needed to come out. They did it with IV sedation, general anesthesia in an oral surgery office.

 

 

Guys, been in practice about 15 years, the next day the patient can't swallow. He's in extreme pain in the left side of his tongue. He's having a hard time talking. His wife says sit down and let me look in your mouth. She looks at his mouth and she says no wonder your tongue is sutured to your palate, now I just don't know how that happens when you're taking out third molars or that you could recognize that it's sutured the tongue to the palate.

 

 

Unfortunately, the suture passed very close to his lingual nerve, and the guy's tongue varies between being numb as a post and feeling like its own fire. It's been going on three years so it's probably not going to change. Here's a guy, gave 20 milligram of Valium the night before, he's going to do an immediate denture, that's quite a lot of Valium. Then he gives three teaspoons of codeine cough syrup.

 

 

I called him, I said "what's with the codeine? The guy's got a cold, why not you wait till he's over the cold. No he didn't have a cold." I said "well, what's with the codeine?" He said "Well, I've given him Valium. I could only give one drugs, so I gave him cough syrup for the added effect of the codeine." I said "guess what, you just gave him a second drug."

 

 

Then all of this guy's patients got penicillin for four days prior to their extractions and metronidazole and then he gave them 30 carpules of Bupivicaine or marcaine. He should have had everything north of the knees numb with that sort of dose. This case came to me when I was on our dental board. We got three cases within the first two use 30 carpules of Bupivicaine.

 

 

I can't imagine where you'd put all that, even if you were doing upper and lower immediates. The second guy, the first guy if you weighed 300 pounds, that was 150% of the toxic dose. If he was 200 pounds, it was over twice the toxic dose. If anyone wants these spreadsheets to calculate these doses, again email me. Second guy.

 

Howard:

Actually, Fred. Why don't you start a thread called our podcast notes. You've posted over a thousand times, you may just start a thread that says I just did a podcast with Howard and here are my notes on the podcast.

 

Fred:

Okay. I can do that.

 

Howard:

They can email you too, what's your email, do you want to give that out or not really?

 

Fred:

FredQ@comcast.net.

 

Howard:

Right on.

 

Fred:

This is the guy's third phase, case, ASA is American Society of Anesthesia categorization of the person's health. One is a normal healthy person, but in his chart notes, he says the patient's in heart failure, angina, high blood pressure, cardiomyopathy, he has arrhythmias, and he's fat. That is not ASA 1. That's ASA 3, sliding into ASA 4. He gives him the Valium, he gives him the cough syrup.

 

 

He stops his warfarin, that's absolutely the worst thing you can do is to take people off their warfarin so long as their international normalized ratio, their INR is under four, leave them on the warfarin. If you take them off, they got a 1% chance they're having a heart attack or a stroke. You got a 1% chance that you might have to come back and put another stitch in later, and then they start bleeding.

 

 

He gave this guy 17 carpules of Bupivicaine which again is more than the toxic dose, but at least he took a little lower because of the guy's medical history. On DQAC was a case, DQAC is a dental quality assurance commission. Our board here in the state of Washington. Five year old, no monitoring, no blood pressure, we can't always get a blood pressure on kids, but you certainly got to put a pulse oximeter on one of their fingers.

 

 

No mention of how long they were under sedation. They gave him 40 milligrams of Demerol which is a very healthy dose. They gave him Vistaril 25 milligrams, which has a long half-life and is a big dose and then he gave this kid a quarter of milligram of Halcion for a five year old that's a gigantic dose.

 

 

Then he gave him this cocktail of meperidine, which is a narcotic demerol, hydroxyzine and scopolamine. There was no evidence of what sort of dose of that. There were no sedation records. Had all these drugs in a box with no lock which is a DEA violation. Fortunately, the child's father was an MD. As he took him home, he noticed his airway was obstructing and he got help for him and kept him breathing.

 

 

Here's an insulin dependent diabetic who's under poor control. She doesn't monitor her blood sugar, she's got a bad liver because she's never monitored or taken very good care of herself. She was told take your medication but no food after 11PM, so she takes her morning insulin but doesn't have breakfast. 35 year old, very fearful 120 pounds.

 

 

Given at 10 milligrams of Valium the night before. Remember that's got a 20 to 50 hour half-life, comes to the office, they gave him a quarter milligram of triazolam, 1 to 2 hour half-life, Lorazepam which is 8 to 12 hour half-life. I just don't know why you'd want to use something that long of half-life. Hydroxyzine which is, this is the common technique which I'm pretty critical of.

 

 

If you want to sedate, use a sedative. Use triazolam, don't mix these other drugs. Puts her on nitrous at 10:25 to start work, 10:30 gives her another quarter, at 11:00 another quarter of Halcion or triazolam. 12:00, another quarter. 2:00 another quarter. Is the guy treating the patient or is he treating the clock? 4:00, he gives her Gatorade to reverse the triazolam which is wishful thinking.

 

 

She went home, had a light dinner, he prescribed narcotics because he don't some surgery, she took her oxycontin and went to bed. Her mother tried to wake her in the morning and she was dead. Bad, bad case. This lady had bad liver, insulin-dependent diabetic, she didn't have any breakfast or blood sugar to bounce it off the floor during the day when she didn't get anything to eat. This just really get to me.

 

 

17 year old star athlete, A student, he needs four third molars removed. He's the first patient in a new office of this oral surgeon, the surgeon has about 20 years experience. Starts him on 50% nitrous oxide to start up intravenous line. That's good. Gave him some midazolam. Put him on a 100% oxygen. The oxygen saturation is measured by the pulse oximeter started dropping, 95, 90, 85.

 

 

He starts assisting his respiration or the push button respirator. The saturation's go to 80, 75, 70, the staff said should we call 911, he says no, no, it must be an allergic reaction. He intubates the child, keeps assisting the respiration with this push button respirator. Stats go to 65, go to 60, the staff again said should we call 911, the arms are going off.

 

 

No, he's got allergic reaction. He gave him some epinephrine to help with the allergies, Stats go to 55, 50, 45%. He's using this push button respirator, at this point he thinks he's got bronchospasm and he just keeps pushing the button on this respirator. Stats go to 55, 50, 45, again he's asked if he should call 911. No, no, I've got it under control. He keeps insisting the respiration.

 

 

Stats go to 40, at 35 they call 911. The firemen get there, they put him on their small tank of oxygen. The stats go immediately to 97%. The child wakes up, he's nearly blind, has a seizure disorder and has a marginal IQ. Had he been using the standard bag valve and mask, he could have told that he wasn't having a bronchospasm. When you squeeze this, you can feel the compliance of the lungs.

 

 

The system was put in by a non-certified plumber, never done it before. The surgeon didn't check his system, nor was it certified. The lines were switched by the plumber. Rather than giving 100% oxygen. He was given 100% nitrous oxide. Any time, anyone goes to sleep. Now in this case, they expected him to be asleep, because they were doing general anesthesia. Take the mask off, but use a bag valve and mask.

 

 

You should practice every one of your staff once a year, be sure you can breathe for them, they should practice on you because you're probably the oldest guy in the office and the one who's mostly going to need to be resuscitated. 47 year old male for implants. They used the DOCS protocol, the patient kept moving.

 

 

They brought staff in to hold his extremities so they could keep doing the implants. He suffered a cardiac arrest. The doctor was sued, insurance company settled for non-disclosed amount. The dentist had two patients under oral conscious sedation but only had one monitor. The monitor was in the room that they were not in monitoring that patient, so they didn't know the saturation was dropping.

 

 

Why do I bring this case up, because when I do cases in sedation, this is not what I'm suggesting you do because I might get sued also. DOCS was and there was an undisclosed settlement. This came from Dolan Media Newswire 2012. We got time to talk about local anesthesia.

 

Howard:

Of course. Keep going. This is like listening to Beethoven.

 

Fred:

Well, I doubt that.

 

Howard:

No. It is. You're a dental maniac. This is just an orchestra of information.

 

Fred:

Okay. This is a chart made by Rose Jaeger. She's a dental hygienist in Wyoming. Across the top here, she list all the local anesthetics. Lidocaine, Bupivacaine, mepivacain, 2%, 3% Bupivacaine, 0.5% prilocaine and articaine and then she list the weight down the side. It tells you what the maximum recommended doses are. What more could you want to know, she did the same thing for epinephrine. I think you probably ought to have this chart in every operatory.

 

Howard:

Can you post this chart on that thread on dental town too?

 

Fred:

We could put this one.

 

Howard:

What is your thread going to be posted on, Fred? [crosstalk 01:06:09]. Okay. Anesthesiology.

 

Fred:

Yeah.

 

Howard:

That's the first category.

 

Fred:

You can just find this right on the top. We've all, and we've had some pretty heated discussions on the anesthesiology section at dental town. If we look at the Paresthesia, xylocaine, lidocaine right here. About one chance in 4.4 million. If you go to the 4% solutions, 1.220,000, one chance in 294,000.

 

 

There's been one study to show the 4% solutions work a little better for infiltrations. I don't have the nerve to try blocking with a 4% solution, when I know there's a 20 time greater chance of permanent Paresthesia. This is a big study done by Dan Haas. I'd really be careful using the 4% solutions for blocks.

 

 

Now this is one of my pet hobby, should we shock them before we block them? I use a TENS machine, I'll get this started and get to the meat of the stuff. There we are here. [video 01:07:22] Let's go [crosstalk 01:07:48]. We clip our [crosstalk 01:07:51] syringe. Now with that, I have much greater success in topical anesthesia and it takes about 10 seconds to start injecting.

 

 

I did a little study where I ask people on this 100 millimeter line put a mark as to how much discomfort you have. One end was I strongly prefer electronic, the other end I strongly prefer topical anesthetic. Three quarters of the people preferred using the TENS machine in lieu of topical. I ask these guys over here, did you find the topical cause less pain? No, it hurt a little more, I just didn't like that sensation of that electronic device.

 

 

They tend to prefer it and your injection. You don't have to sit with the topical for five minutes before you're ready to go. Stabident. I suspect a lot of people have used. It comes with a thin 31 gauge needle, and a perforator. The perforator goes on your low speed, the needle goes into your syringe. Here's my TENS machine, providing topical anesthesia. I put a drop of anesthetic in the attached tissue, because it would hurt to penetrate that without it.

 

 

Then our drill perforates into the bone and the hardest part about it is to find that hole to thread the needle down, realized you're now injecting into the marrow space so it's essentially an intravenous injection to local. You want to inject very slowly. Here's the needle in the hole. Then I did another silly little study to see how well it worked.

 

 

Well, with the block, I think I had 20 blocks here. The average time for anesthesia was about seven and a half minutes. That's one of the things we do in dentistry. We try to start [inaudible 01:10:18]. Within filtration it was about three or three and a half, although I had one patient that took 10 minutes to get numb.

 

 

With the intraosseous device, I had one patient that still had some sensation at 30 seconds, everybody else was totally numb, so it's really quick and really profound, and you don't end up without the lower jaw numb, you just get a [inaudible 01:10:41]. Here's a Vibraject that you saw in action, I like those. This is a company that's come out with something, I think it's Accupal.

 

 

It's a vibrating device that has a little hole down here. You see here and you're to threat the needle through that and little topical. This guy has a flash light built into his into tips here that vibrate, you inject between them. Now, I called him and said if you'd put electrodes on those tips, that'd be the ultimate, I'd even buy one if you did that but he hasn't done that.

 

 

Silver fluoride, the next topic has now become available in the US about six months ago. One of the researchers out at the UW managed to get passed the FDA. What do you use it for? Well, you can take kids with beginning decay and just apply it on the areas of decay, use a very small brush, you got to be very careful you don't get this on the lip or skin because it stains black.

 

 

It does stain the decay black but it stops it. It doesn't progress and the incidents of decay elsewhere in the mouth drops dramatically if you're using this on the areas of decay. I got a mature practice. I've got a lot of elderly folks. I have six or seven people who are into dementia who do the best they can, clearly they don't get their teeth cleaned once a week.

 

 

It's ideal for these folks that they get rang around the root. It looks like little beavers have been on their way on these roots. If you get in with your silver fluoride and paint those areas, it'll stop the decay. These patients have a terrible time sitting through dentistry, they don't understand what you're doing and this is just a measure to stop the decay and keep them comfortable.

 

 

How do you use it? Well you dry the teeth, I use air and a cotton gauze square. Apply it to the open lesion with a small brush but keep it off the gingiva, they can eat or drink an hour later. If you get it on your fingers or on your clothes or on their lips, or their gums, it stains it black and it takes about two weeks for that black stain to wear off lips and gum tissue.

 

 

Here's a guy that I saw doing insurance reviews. We're getting close to the end. Three teeth maybe a little decay here. This is the treatment this patient receive. Three porcelain crowns and two root canals. I think that's obscene. Here's a guy, he writes in, he saw Mrs. S. She's a healthy 54 year old female. Her chief complaint is buzzing emulating from her allow fillings. Using the word emulating.

 

 

I know this phenomena has been proven to scientifically exist. The cure is to replace the fillings with porcelain onlays to the tune of about $8,000. I wrote back whatever you do, don't remove the fillings. Have you evaluated the buzzing for frequency shift or pulsation? With proper cryptographic analysis, we could find an embedded message. If you remove the fillings, mankind will, for all time, loose this channel of communication with the great beyond.

 

 

Now the secretary wouldn't send the ladder so instead we suggest that they send the lady to an ENT doctor to see about her [inaudible 01:14:09] to a psychiatrist. Let's take a look at some of my beautiful work. I did these crowns in '72. I repaired them with alloy in 95. The patient is now 74 years old. I got another little repair down here.

 

 

I think that's good dentistry. I could have told them they had to replace these crowns but to what end? With the simple repair, that's a lousy looking alloy. It's working. This allow here, ugliest sin, but there's no decay. Here's a lady, broke off one part of the [inaudible 01:14:44] of a four tooth bridge. It's going to cost her $4,000 to replace that. I cut off the porcelain.

 

 

I created a little onlay, this is ridge lap here. This is incisal edge. It slips over this part. She did this when she was 70. I kept seeing here until she was in her 80s and she passed away. It worked. She ended up with one. Had some more gold crowns. I did a long time ago, that we've repaired. I think that's [inaudible 01:15:16] dentistry. They don't have to sit through so much.

 

 

Now, let's take a look at some work here. Here's a pretty nice looking gold inlay, but look at the wear on that cusp. Another one, even more rare and I see some darkness there. There may be some leakage there on this gold inlay. Would you replace them? What if you knew they were done by Dr. Gordon Christensen. Most of us would be a bit hesitant and what if they're 48 years old?

 

 

Well here's a gold crown in this guy's mouth. There is a hole here, endo was done through it. The endodontist says it's leaking. The crown is 48 years old. The endo was completed five years ago. It remains asymptomatic. Let's look at this. Now this has got to be the ugliest silver filling you've ever seen. We've got halo here. We've got cracks running there and there, we've got cracks running here. Up here, the incisal edge is worn off.

 

 

I think everybody agree that tooth needed to be crowned. What if that alloy was done 65 years ago, do you still think it needs to be done? It might outlast this person. Well, a couple of things I didn't tell you is this patient is 75 years old and is in pretty good health and it's me, and I'm not going to let any of you touch any of those until something breaks because it could very well outlast me all over this.

 

 

Why do I do these things? Sometimes I'm critical of some of my colleagues and some of the things I've reviewed. The challenger blew off in 1986. If you were alive, you remember that day very well. Christa McAuliffe was a school teacher on that and a total loss of the crew. Well, I went to a test pilot symposium and a guy named Allan McDonald was there, gave this presentation and I bought his book and read it, pretty heavy engineering, I missed a lot of that.

 

 

He was in charge of Thiokol as to whether the challenger should go up that day. It was very cold. It was about 15 degrees on the cape. He had evidence that their o-rings had failed before and I think it was on the range of 25 degrees, so it was colder and were failures he said occur. He said I won't sign off on this launch. I won't do it. It's dangerous. His boss said either you will or I will, and he said well I won't.

 

 

The boss signed the papers and passed it to NASA. McDonald is standing there next to the NASA guy, he says don't accept that. This is a dangerous launch. The NASA guy is under a lot of pressure. The president was supposed to interview this teacher later that day and so the rest is history. McDonald said you're the only person that can stop this launch. The NASA guy didn't stop it. The rest is history. It blew off.

 

 

When McDonald got back to Thiokol in Salt Lake City. They moved his desk into a small closet. He no longer had a job. He wasn't chief engineer. Fortunately, the New York Times picked up on this and it ended up in a congressional investigation. This guy is a real hero. Most dentist are honest, good people that do what's best for their patient but we've got some bad actors out of there and I think it's all of our job to blow the whistle when necessary, take them to lunch, explain what they're doing isn't working. We got to get involved.

 

 

This is my last slide. I'd like to thank all of you for attending today and listening. I really think this thing is going to be the future of CE. It's really a shame to have to travel across country to go here, of course you wanted here. I want to thank Howard for providing me the opportunity and mostly I want to thank his son, Ryan who [inaudible 01:19:23] from someone, who didn't know my tale from a hole on a ground and assisted me so that this work this morning. Thank dental town for the opportunity and here's my other email address, anyone that has questions, Quarn Q-U-A-R-N @UW.edu. I thank you, Howard. I've just about run out of things to say.

 

Howard:

Hey, can I ask you a few questions?

 

Fred:

Absolutely.

 

Howard:

Hey, how does someone, why isn't that TENS unit a commercially popular device?

 

Fred:

Well, you can go online and buy them, they're $40 to $50. If you search YouTube for TENS. T-E-N-S dentistry, you'll see that whole video. I published a couple of papers, but that really didn't catch on.

 

Howard:

I'm embarrassed to say this, but it is dentistry uncensored, but when I got out of school, one of my friends told me that he was using an actual vibrator, a sex vibrator and he would put that on the mandible, the assistant will hold it, while he gave an injection and he's been doing that for 30 years. This looks like, he was capitalizing on that vibration to extract and you're saying the TENS unit works a lot better.

 

Fred:

It did work better but why not use a combination. One of my patients was the director of the emergency room at our trauma center and he came in and I used this to inject [inaudible 01:20:56]. He says that was great. I wonder if that had helped to start IVs. I said well, I have never tried it. What he said you got a big needle, and I said yeah, I do. Get a 25 gauge needle and he says well here, you hold that on either side of the vein at the back of my hand. Let me see if I can stick the needle in. He says wow it works, I didn't feel the needle. Yeah. It has more applications than just dentistry.

 

Howard:

Well, maybe somebody listening to this podcast will start to comment to that. Do you care if I ask you a few more questions?

 

Fred:

No. My time is yours.

 

Howard:

Okay. Today is the 71st birthday of Water Fluoridation today. We're podcasting January 25th. You podcast. Usually we book these ... We take these a month in advance and usually our guest are booked out half a year in advance, six months advance, but Fred, I worked with my first water fluoridation campaign for Phoenix in 1989.

 

 

It seems to be more controversial in 2016. You're 75, you've been on the block. What is the deal with water fluoridation? Do you think it's good? Do you think ... because the argument always comes back to get the government out of my life. They have no right to shove this mass medication down my throat by putting it on the water.

 

 

Then of course my response back but we live in a community and you don't want me to shove fluoride down your mouth but you're more than willing to shove all my tax dollars out of my wallet to pay for expensive pediatric dentist to [inaudible 01:22:30]. I'd rather pay $0.15 a year per person to prevent decay than hundreds and thousands of dollars of doing pediatric dental cases. What's your view on water fluoridation that it's the 71st birthday today?

 

Fred:

Well, we didn't have it here in Seattle until about '63. I graduated in '64. I was back in '67 and easily half of what I did was to treat kids. Partially because I'm in a low income area. Lots of immigrants and within 10 years the number of children that I treat dropped to about 5%. It is rare today for me to find a child with decay.

 

 

What's the difference? Seattle has fluoride in the water and it was just, I don't know, last year I believe that Bellingham, the little, not such a little town, a town about 100 miles north of Seattle right on the Canadian border voted it out of their water system. That's unconscionable. I had a good friend who is a physician. He said Fred, you put fluoride in the water today, you're going to have birth control on the water next year and the year after that, everybody will be on the anti-depressants. Howard, that hasn't happen. Fluoride works. It's the most important thing we can do for our kids, I think.

 

Howard:

I've had the same story here. I got involved because I couldn't believe the difference in the higher decay rate when I opened up my practice in Phoenix in '87 versus where I'd gone dental school four years in Kansas City, and I couldn't figure it out. I finally called the centers for disease control.

 

 

They said dude, Kansas City's got fluoridated water and Phoenix doesn't. Then we fluoridated Phoenix and then I practice 28 years since, the same thing I watched pediatric decay literally melt away in five years. I'm a border town Phoenix. 25% of my patients don't even speak English. It's common with the rich kids as it was the poorest of the poor.

 

 

I want to keep going on. A lot of people are looking for unique selling proposition to build their practice and you started off this podcast saying that a third of your practices were phobics, is that because you were focusing on phobia and is that a practice builder. Because you're talking to a lot of young kids coming out of school. Do you think of these young kids got into nitrous oxide and oral sedation, it would be a game changer and a practice builder for them to build their practice?

 

Fred:

Well, absolutely was for me. Starting out, and I remember this is 50 years ago, you couldn't advertise. There was no way to tell people you were in town. It was word of mouth. I happen to end up practicing on Beacon Hill, Seattle. There'd been an elder German dentist who didn't believe in local. Everybody was paranoid schizophrenic and the word got out that this guy was using this gas that helped you relax and he could use these tablets.

 

 

Fearful people are hard to treat, you got to treat them a lot more carefully. You got to spend a lot of time explaining. If you've got a vacant share. A bad patient is a whole lot better than no patient, and when you treat a phobic patient right and they're able to get their work done and be comfortable. They literally rent sound trucks and go around the neighborhood telling people how wonderful you are.

 

 

Yeah. I think it's a phenomenal practice builder. It's easy to do. You want to be safe. I've got a real problem with people that use stack doses of Halcion, one after another after another after another. If you just use it conservatively, you can treat 90, 95% of even the most fearful people with nitrous oxide, you can treat at least 80% of fearful patients, and they love it, and they refer other people to you, it's a big practice builder.

 

Howard:

Another thing that I always really respected about you is it seems like whenever you're within any tribe, most whatever that tribe may mean to you. People are very tribal that it just not politically correct to challenge any of the tribal leaders. My God, Fred, you've always had guts. You flippantly made a comment about you even wondered if there's third molars have to come out.

 

 

I noticed in Germany, they remove half the number of wisdom teeth as they did just 20 years ago. If anybody ever says there's no reason to remove asymptomatic wisdom teeth. You'll be thrown under the bus because there's a lot of money to be made to be removing four wisdom teeth. Most people diagnosed to remove four wisdom teeth because they exist. What is your view? When do you think four wisdom teeth should be removed? Fred, what do you think? Do you think too many wisdom teeth are removed for economic purposes?

 

Fred:

Absolutely, Howard. There's a guy, Jay Friedman. Are you familiar with him?

 

Howard:

I'm not. Is he an oral surgeon?

 

Fred:

No, he's a general dentist. Received an award from the public health organization for a paper he wrote on wisdom teeth removal. He came and talk to us at the American Association of Dental Consultant meeting. They refused to put his paper in our journal. It took four years until they had a white paper from oral surgery community. Only in America do you turn 16, get your driver's license and have your four third molars removed.

 

 

You're not walking around with a cast on your leg on the off chance you're going to break it this afternoon and so why take out all these wisdom teeth unless they're a problem. Some of them are going to have to come out, there's no question about it.

 

Howard:

When was this paper published?

 

Fred:

It was published four or five years ago.

 

Howard:

Are you friends with him?

 

Fred:

Yeah. I talk to him on a regular basis. He being older than me, I like to hang around with old people, it makes me feel young.

 

Howard:

You got [inaudible 01:28:56]. Can you get Friedman to podcast and we talk about that paper?

 

Fred:

Well, I'll tell you what, I'll send you his contact information in these paper. You never know. He might.

 

Howard:

Yeah. Yeah. I'd love to. Also, Fred, a lot of these young dentists don't realize, they'll realize it when they're in our age. A lot of patients pre-medicate. I don't know a lot, I don't know why I'm getting this number. A lot of patients pre-medicate with alcohol.

 

Fred:

Yeah.

 

Howard:

They've confessed it to me. Because sometimes I remember when I was young, I was confused is that [inaudible 01:29:35] as you get older, you realize that's liquor. Fred, what percent of patients do you think are taking a few belts of whiskey before they come in, what's your thought be when we actually know a patient as a non-drinker but loaded up at the bar before they came to the dentist?

 

Fred:

Well, if you smell a liquor on their breath, you certainly want to go very slow with any sedation. Nitrous oxide probably not such an issue because you can get rid of it quickly. Talk to them. Obviously you're pretty apprehensive about being here, it smells like you got a little liquid courage on the way to the office. [crosstalk 01:30:17].

 

Howard:

I love that. Liquid courage, I've never heard of that.

 

Fred:

Yeah. I'd much rather by the one that gave it to you so I knew how much of what you got because when we start adding a little of A, and some B, and heaven forbid today the heroine addiction is totally off the charts, and that's a very potent respiratory depressant. They come in having some oxycontins or heroines cheaper than the pills. You start adding some Halcion, you're going to have a very balance general anesthesia.

 

 

You just got to realize that that's a big part of our population problem at the moment. If I have any doubt, I used to have a receptionist who'd come back and say this next one has been smoking weed, and I said how can you tell, she said you can tell by looking in their eyes. Well, I ain't ever developed the skill of telling but Ruth Anne would let me know, and I suspect that's pretty common here in Washington because pot is legal.

 

Howard:

I think the next thing that's going to come along is you can eat pot now, they have marijuana brownies, do you think that will ever be a pre-medication at a dental ... do you think patients will ever go to the dentist and eat a marijuana cookie or a brownie?

 

Fred:

I don't know, Howard. I, like many of the nutraceuticals, the production of this is getting better control but you never know exactly what you got when you bought it. It could be very very potent or it could not be so potent. There's no controls. At least if I give you a quarter of a milligram of a Halcion. I know you're getting a quarter of a milligram of Halcion.

 

 

I know there's been some really good research to indicate what's an appropriate dose and what isn't an appropriate dose. There's a drags on the marijuana that's necessary to be able to face me as a dentist or do you need a brownie that's one inch by one inch or two inches by one inch. That data just isn't known. I'm a little bit hesitant to suggest people how to use that for their courage in the dental office. I'd much rather give them something that I know is pure and clean and I know what the effect is going to be.

 

Howard:

Fred, my last question and I'm going to ask this last because if you don't like the question, my son can edit out. One of the things I was very proud of you about was you wrote a book in 2008 called Open Wider: Your Wallet Not Your Mouth. That had to be one of the most controversial threads on dental town. You have over 1,100 post on dental town. That thread was so crazy, we actually had to close it down. I just reopened that thread because I saw that it'd been close in 2008 and now everybody had a chance to breath for eight years. Tell me what your thoughts are looking back at that book.

 

Fred:

Well, the book came out as ...

 

Howard:

Hold the book up to the screen again.

 

Fred:

I knew the question was coming so I brought it out.

 

Howard:

Read the title, Open Wider: Your Wallet Not Your Mouth, everything you need to know when you visit the dentist. Consumer's guide to dentistry. Fred, there was a couple people. Fred Quarnstrom, DDS. Marzena Makuta, PhD. Anne Woodley, MA. Who are the other two?

 

Fred:

Well, they were two patients and they came to me because they got these just absolutely outlandish treatments plans and we looked in their mouth and show and tell this is what I see. This one, you may need to have something done in the future, maybe not. They both became patients. In fact, Anne had been a friend on the East Coast when she got this similar thing.

 

 

I said, well, we should write a book about this. People should be forewarn that there are some folks out there whose ethics are just a bit lasting. We spent a couple of years writing it. It never got to the New York Time's best-seller list, the last count, I'm getting pretty close to having sold 100 copies on Amazon.

 

Howard:

You're going to sell 100 more today, I guarantee you that.

 

Fred:

I don't know about that.

 

Howard:

I bet you will. I bet you will.

 

Fred:

I left until I sold the practice, there was always one in the reception room. I encourage people to read it. If you're a straight shooting dentist that are really looking out for your patients. This book will do you no harm at all, in fact, it can do you a lot of good if they read it. It tells that the way I saw it, I started out at our peer review, then I was on our dental board for four years.

 

 

Then I did insurance reviews with seven other dentists all of whom had at least 20 years experience, two are more dental school professors. All of a sudden I'm not up to 65 legal cases. I've seen the bad side. We aren't very good reigning in the outliers in our profession. The joke here in the state of Washington, if you're not having sex with the governor's wife, the dental board is not going to give you any trouble.

 

 

You got to be way out left field to get into any sort of problems here. It's not a very effective system to reign in bad dentists. You got to really screw up badly. I don't know if the books had any effect or not, if there's maybe a few people that read it, and thought a bit about it, made their dentist explain a little more.

 

Howard:

Well, I have a weird. I have to make weird judgment calls on this. Because I'm a publisher. I have a dental magazine and a website. What I don't understand about my [homies 01:36:33] is that on dental town, if you're a dentist from America, it's probably about a 80% chance you're a republican. They're anti-government and all that stuff. They don't like any governments. That leaves that we should please our own profession.

 

 

If I publish a case of a dentist that was putting hidden cameras in the staff's bathroom or taking drugs and or whatever, then they get mad at me for saying, hey that tarnishes our profession. Your book, they just couldn't believe that one of their own homies, Dr. Fred Quarnstrom would how dare you say that there is a dentist out there that did anything wrong and that's just total bullshit. You got 150,000 dentist, what percent of them do you think are just completely batshit crazy with elastic as settings.

 

Fred:

I don't think that many.

 

Howard:

What percent would you say?

 

Fred:

I'd like to think it's less than 1 or 2%.

 

Howard:

Okay. If it's 1%. What's 1% of 150,000?

 

Fred:

A lot.

 

Howard:

It's been a while since I've had geometry so I can't quite figure that one out.

 

Fred:

Right about 1,500.

 

Howard:

I've lived out here in Arizona for 28 years. We've had some cases for the board where you just say you've got to be shitting me and then but everyone else thinks the board should be, they're republican, they should be shut down. No government regulation. Same thing with interns coming. I never understood because when I realized so much of my revenue was coming from delta. I called up the delta CEO and said man I want to buy you a lunch, thank you.

 

 

He thought it was a joke. He's like is this a joke? Why you want to buy me a lunch? I'm like well dude you send me insurance checks every day. I want to know my supply chain, my value chain up and down the line. We have a great friendship. He'd always call me up because he wasn't understanding something or I wasn't understanding something.

 

 

I don't know why dentist, I just think it's Neanderthal [inaudible 01:38:30] not to police our own industry and not to work with our manufacturers, our dental insurance companies, our public health people. We're all in this together. Aren't we all firemen fighting a fire?

 

Fred:

Yeah. I think so. On the insurance thing, know what they need. If given the right data, unfortunately what happens a lot if somebody comes in and they want to have the smile of J LO, and that's going to take 18 porcelain crowns realistically. Well, I have insurance that's going to cover everything. Yeah, that'll be wonderful.

 

 

For crying out, just submit it before you start cutting teeth down because they're welcome to do that, it's like plastic surgery but the insurance company isn't necessarily going to pay for it. Now I worked for one multi-state company that we review cases in Washington, Oregon, Utah and Idaho. I looked at the data they showed me, and I went to my boss who happen to be a physician and said if you start reviewing every single crowns.

 

 

At that point, I was only reviewing TMJ surgery, I can save you $5 million next year, you could lower your premiums, you could increase what you cover, or you could just make a lot more profit if you being self-serving. He said no, we don't want to do that. We don't want to review that. We'll just go ahead and pay for it up their yearly maximum.

 

 

I think in some ways, that company's responsible for a lot of very healthy tooth structure being flushed down on the drain. I didn't last long as a reviewer for that company. It was a two year stint. [crosstalk 01:40:20] I'm pretty negative to it. I just don't see many good outcomes.

 

Howard:

Last but not least, I just want to say that my goal for 2016 for the website, not my dental office, today's dental, but for dental town was on the app, we're going to add the classified ad section on the app, but we're introducing our new audio books. The audio books, well, you're up there in Seattle home of Amazon, and Boeing, and Starbucks, and Amazon. When they told me that over 50% of their books are now audio books.

 

 

I just got done yesterday reading my book, and so what I'm saying is we're going to release the audio book section, so you've done a podcast, you could log back on some time, at your own speed and read that book, that you wrote. If you want to just get readers. Because there's 210,000 dentist on dental town, 40,000 of them have downloaded that app.

 

 

If you read Open Wider: Your Wallet Not Your Mouth, which you can buy on Amazon.com by Dr. Fred Quarnstrom. If you didn't want to put on dental town, you could do that audio book and put it on iTunes. You could put it on barnesandnoble.com. If you put it on dental town, if you just want a lot of people to read it, you can put it up for free.

 

 

If you want to sell it for the same price you sell it on Amazon and Barnes and Noble, you can do that too, we're going to have it. Because some dentist, it's their magnum opus and they just want everyone to read or hear what they have to say. Some people are that's their living. If that's your living.

 

Fred:

Cost is more to have it formatted for Amazon than we got out of it. I found dental town was fun. We eventually ended up with 1,800 hate emails on the book.

 

Howard:

What percent of those were from dentist on dental town?

 

Fred:

All on dentist, and none of them bought the book.

 

Howard:

They were complaining they hadn't read it.

 

Fred:

No, they hadn't read it, well you can go online and you could read a few pages of them.

 

Howard:

You wouldn't believe how many emails and things I've seen for me over the years. Where they're saying well, Howard said this and they're in outrage and I'm bringing the quote and I'm me and I'm just like whatever. I love the deals. I don't care what you say about me, just get my name right. Because that's what they learn with Howard Stern and Rush Limbaugh that they actually a bigger part of their audience hates them, and listens to them to see what outrageous things they're going to say so they can tell all your friends.

 

 

If you absolutely hate my guts, just please tell everyone to download the Howard, dentistry uncensored with Howard Farran podcast. Just tell them, just say man you got to listen to this guy, he's horrible, he's an asshole and you just got to hear all those stupid things he says. Hey, based on that, Fred. Last question, I swear this is the last question.

 

 

You're 75. Most of these podcasts are being listened to juniors and seniors of dental school, they're been out five years, and Fred, they're a little scared. They don't know what's ahead of them, all they know is they got $350,000 student loan. I want to ask you this very tight question. Do you still think it was a good idea to go to dental school and graduate in the year 2016 as a dentist, $350,000 in debt or you looking back and say maybe it was a good idea when Howard and Fred did it, but it's not so much a good idea anymore?

 

Fred:

I don't know what else I would have done, Howard. The dentistry I saw in the Navy particularly on the beachhead in Vietnam was pretty grim. I had a foot pedal powered drill, I had no x-ray, I came home from there, and I wasn't sure I hadn't made a mistake that I should have gone to medical school. I did get involved in a couple medical evacuations of wounded.

 

 

I was in way over my head. One kind of funny story, we were on the C-130 bouncing through the air, really turbulent and this kid that's on the stretcher turns to me and he says, sir I'm getting air sick. I thought, holy cow, if he rouse, it's going to trickle down through the five guys below him and this whole airplane is going to be air sick.

 

 

I went to find a waste basket, there were none, there were no [inaudible 01:44:38]. I finally handed him my hat, I said here barf in this. Sir, I couldn't barf on our hat. I said you always wanted to barf on an officer, this is as close as you're ever going to get. He filled my hat, there was a toilet I was able to wash it down at.

 

 

I came home and I really thought maybe I should have gone to medical school which is what got me to this anesthesia residency, and after a year in the hospital doing anesthesia and attending all the cardiac arrest that occurred on the hospital when I was on a call. I knew I didn't want to be in medicine. I didn't handle people dying very well. I feel really bad when I lose a tooth, but I would not have been happy as an MD where you work in with people's lives.

 

 

I've been a dentist for 51 years. It's phenomenal. Now when I went to dental school, I worked three jobs so I came out without any death. In fact, I took a cut in pay my first year in the Navy. That's not possible today. Be careful about your student loans, it's easy to get that money, but man, it's hard to pay back.

 

 

I think there's still a great future in dentistry. You're doing good for people. They appreciate it. You're just going to have a wonderful life. You're all like [inaudible 01:46:00], it's very uncommon. Almost never anymore. It's a great life. If you're a woman, you can raise a family, you can take some time off the office to have children and go back to work. I still think it's a great profession.

 

Howard:

Fred, you graduate in '64, then you went to Vietnam. Were you drafted?

 

Fred:

No. I was dumb. I joined the Navy while I was in school, they didn't pay us anything. They didn't pay tuition or books or anything but you could use the officer's club which was an impressive place to take a date and the drinks are only a quarter. I get orders to the marines which caught me off guard. I knew as a Navy dentist, the worst that could happen to me was to be on a large ship.

 

 

I didn't know about the marine corp. I'm down at Camp Pendleton and it's pretty much the end of the world as far as a bachelor is, and another married officer got orders to a Seabee battalion and he was crying the blues because they were going to [inaudible 01:47:04]. He was going to have to leave his new wife.

 

 

She was going to have to live with her parents for a year, so I said maybe we can switch, I don't think they care who they send where. I was right. I turned in my marine greens and my marine combat boots, and I go pickup my Seabee greens and may Seabee combat boots. The very next week I'm back at Camp Pendleton but I'm now with a battalion, so I'm not in a dental clinic. I'm out in the field throwing hand grenades and shooting machine guns and a bazooka.

 

 

I'm thinking, how did this happen? I go, gunny [King's X 01:47:37] here I'm medical, I'm a non-combatant, I shouldn't be doing this. He says son, all marines are riflemen first, sir. Shut up and run, sir. We went to Okinawa, it was a delightful place. We were there five weeks. They loaded me up in an LST. I've made the first to cross the beach amphibious assault into Vietnam.

 

 

A year earlier, I couldn't place Vietnam on a map. There was no war. I stood on that beachhead and I'd shake my head and say God what did I do wrong? How did I get here? I've got a ... We did add a little electric motor to the drill. I'm doing impacted wisdom teeth because they get infected, I've never done one in school. I've never even assisted an an infection in school.

 

 

I'm the man. There's no other dentist for about 600 miles to get you to an oral surgeon, I've got to get you transportation to the Philippines and that could take three or four weeks. I learned a lot often times with a book opened behind the patient's head so I could see what to do next.

 

Howard:

That was my favorite instructor in dental school is [Mathias Horgen 01:48:51] who is an oral surgeon and he learned oral surgery because they sent him to Korea, and all they sent him with was a 150, a 151, a small and large elevator and a Periosteal. He said I pulled a thousand sets, a gazillion sets with those four things.

 

 

An oral surgery residency, if Mat Horgen was up there and you ask for any forcep other than a 150 or a 151, he jumped you with that marine story again. Fred, was that ... Did you come back with PTSD? Was that a brutal experience or did you survive that? What was that like?

 

Fred:

Well, the war hadn't gotten bad yet, we were attacked a few times. I actually put together a presentation I'm doing at high school about Vietnam and history, and how we got there. I wrote an article for ADA news, about a guy that came in one day. He's a crane operator. He's up on one of these cranes 500 feet in the air or awfully high, I don't know how high.

 

 

He chipped a tooth and I said well we can just dis that down, it'll be good as new. You go back to work. He says no, I really didn't need to have anything done to this tooth. I needed to get out of the tower. He says I'm only getting a couple hour of sleep a night. I said really, what's going on? Well, he'd been in the jungles and the rice patties for a year.

 

 

Young kid at that time, 19, 20 years old and he said I go to sleep and the next thing I know I hear the bugles and I hear the screams and he said it's very uncommon for me to get more than two hours of sleep uninterrupted. He says I think I'm going crazy. I said I don't think you're going crazy. I think you'd be crazy if you weren't having those problems.

 

 

I know the VA is doing some work with PTSD and they're only a few blocks down the street to VA hospital. Let's call and get you an appointment. They got him on some medication and he did much better and he recently retired and we're best buddies now. I've had a guy come in from Afghanistan with same story, came to get his teeth cleaned.

 

 

He comes back the second time, he said had I known you were a veteran, I never would have come here. I did, why would you say that? He said because I just know you couldn't understand. I said no absolutely I can understand and as I told you last time, you're in control here. If I do anything you're uncomfortable, stop me. If I do anything that hurts, for crying out loud, stop me.

 

 

It took us a couple of appointments to get his teeth cleaned. He became another really good patient, they require some special understanding. I was lucky, I was there before the war got bad. I only spent nine months there, I was a bit older so I probably had a little more maturity than the kids who were 18, 19 years old. Our Seabees work 7 days a week, 12 hour days, and then they'd be in a foxhole all night and they were expected to stay awake at least 4 hours while their buddy slept.

 

 

No, I don't think I brought home much baggage until I saw the movie with Robin Williams, Good Morning, America, and they got into a traffic jam and I just almost had to get up and leave because traffic jams were bad. Traffic jams never happen unless things were about to explode and hit the fan. Maybe I brought back a little bit but not like the guys that were in the rice patties and jungles all day.

 

Howard:

Well, Fred. Thank you so much for serving. That is amazing. I know war is hell. I'm a lucky man I never had to do any of that stuff. I'll never forget when I pulled up of my uncle's house with a Japanese car. It was my first, my car was a Subaru. He served in World War II and he was in the Navy and he was in Seattle where you live, my uncle [Chuck 01:53:08].

 

 

He was on supply ships so they'd run flat boats from the ship to the shore in Okinawa and about every single day about 1 in 10 of those ships got blown up and he'd come back, deaf, hearing aids. When I pulled up in a Japanese car, he just absolutely could not. He lost it all. He completely lost it. I know that war is hell. Thanks for serving.

 

 

Fred, thank you seriously for all that you've done for dentistry for half the century. 730 total CE presentations. Seriously, Fred. I think you're an amazing man. You are an amazing man when I was in dental school in '87, my instructors were quoting you and talking about you. When I was earning my FAGD and MAGD. I think I heard you speak about three different times. Again, Fred, seriously, I'm your biggest fan. Thank you for all that you've done for dentistry, and thank you for spending one hour and 55 minutes with me today.

 

Fred:

Thank you. I put my pants on one leg at a time. Nothing special. It keeps me out of taverns. I get bored if I didn't do this.

 

Howard:

Well, if I ever go to Seattle, you have to show me one of them taverns.

 

Fred:

Yeah. I will.

 

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