GDA Action October 2021

30 • October 2021 their support, not their resistance and discouragement. The staff will need to be credentialed, which is generally merely proving they have the dental assisting or dental hygiene degree, and are covered under your regular office liability insurance. They will work with you to determine what equipment and tools are available and what you need to obtain. Usually the only things I bring, besides my wonderful staff, is my laptop which includes the patient’s chart, treatment plan, and X-ray images. We also bring any appliances for this particular patient, such as immediate dentures, space maintainers, implant parts, crowns and bridges, or anything specific for only this case.  In the OR Pre-Op Procedures #1: Consult and Consent Every OR case begins with a meet and greet, obtain and review the necessary data, discuss the case with the patient and/or responsible party, then obtain proper informed consent. Discussion and agreement are required to determine which treatment plan to select, what procedures will be performed, who will pay for the services, which insurances will participate, what pre-op tests are needed, and what physicians need to sign off their medical approval. Many of these pre-op requirements are valid for only 30 days. Pre-Op Procedures #2: Clinical Considerations It is rare to have only one treatment plan on the table for the patient to accept or reject. The great majority ANXIETY OR SPECIAL NEEDS Continued from page 29 of the cases, just like in the office, are multiple treatment plans to select from. I urge the patient and responsible parties to reject, not select. Tell me what you don’t want. After they reject all but one, then we estimate their co-pay and arrange clinical details on what preparations are needed before the OR date. For example, if we prepare a crown in the OR, will we cement it later in office with OCS, or return to the OR at a later date to cement? If we are extracting primary teeth for a space maintainer, do we take impressions in the office, then extract and cement the appliances in the OR, or do we extract and take impressions in the OR then cement in the office with OCS or do we return to the OR for cementation? Should the space maintainer be unilateral or bilateral? Do we take X-rays pre-op in the office, or take them in OR then develop and modify the pre-op treatment plan based upon intra-op exam and X-rays? Pre-op diagnoses and post-op diagnoses are rarely identical when we walk into the OR without a good exam, X-rays, and a firm treatment plan. More often than not, we clinically prepare for the most likely, plus worst-case scenarios that we may encounter in the OR. That is part of what makes this so interesting, exciting, challenging, and rewarding for my dental assistants, hygienists, and me. This is the best medicine to prevent professional burnout. Intra-Operative Consideration #1: Anesthesia The anesthesia team is responsible for safely putting my patient to sleep, assuring no movement while we work, and safely waking them up when I remove the throat pack and declare the care completed. The only essential dialogue I have with the anesthesiologist or nurse anesthetist is to reiterate my request for nasal intubation (Photo 3). In the mouth are my two hands with mirror and drill, my assistant’s two hands with her suction and retractor, or the hygienist’s scaler (Photo 4). There is not much room for an anesthesia tube. We always prefer the tube be inserted from the nose to the lungs. This happens 85% of the time. The other 15% we have to accept an oral tube (Photo 5). The reasons could be physical anatomy of the throat, interference by adenoids in the very young, the patient has a bleeding disorder or is on blood thinners, a nasal respiratory infection that should not be pushed into the lungs, or simply they tried and failed several times and just ceased trying to force a nasal tube. More than once a novice anesthesiologist or nurse anesthetist called in a seasoned veteran who was able to accomplish the difficult task. When I have to work around an oral tube, we prop the side with the tube and do all our clinical dentistry on the other side. When that work is completed, we have the anesthesia team switch the tube to the other side, and we complete the work on the second side. This minor inconvenience generally adds a few minutes to the case, because working on only one side at a time is inefficient. The X-rays have to be taken twice, then the sequence of treatment of perio, then restorative, then endo, then surgery, etc. has to be repeated (Photo 5). All the work gets done, but takes a little longer. That is still far better than not getting the work done at all. Sometimes, this is the best available option, and is still a gratifying and clinically successful result. Intra-Operative Consideration #2: Keeping Records My practice partners and I always work 6-handed. One assistant is sterile gowned and hands me my instruments. My second assistant or dental hygienist is not sterile, and takes notes as I announce what surfaces and what procedures I am performing. She 4-6-handed OR dentistry