IV Sedation

Outpatient Intravenous Sedation.

No Hospitalisation. Sleep Through Your Surgery, Wake Up, Walk Home

S$600 per hour (includes cost of drugs and anaesthetist charges)

After 17 years in private practice, I have met numerous patients who tell me they have "dental phobia". In reality, most people do not have a genuine phobia for dental treatment. By "dental phobia", they usually mean that they just want to be pampered.

Well, whether it's true dental phobia or patients just want to be pampered, we can reduce anxiety with intravenous sedation. If you wish to be pampered and have no "budget problems", we recommend IV sedation for wisdom tooth surgery, implant surgery and even difficult extractions. "Intravenous" means that the drug is injected into a vein, usually in the back of the hand. After the needle is inserted, a plastic tubing is left in place for continuous infusion into the vein. The tube stays in place throughout the procedure.

The patient's pulse and oxygen levels are measured using a pulse oximeter. This gadget clips onto a finger and measures the pulse and oxygen saturation of the blood. It will warn the dentist and anaesthetist if your oxygen level is low. To be kiasu, we would give our patients supplemental oxygen through a nasal cannula throughout the procedure. The device also comes with a cuff around the arm to measure blood pressure at regular intervals.

What drugs are used?

The most commonly used drugs for IV sedation are benzodiazepines. These are sedative drugs sometimes prescribed as sleeping pills. Examples include Dormicum. Someone who has been consuming sleeping pills regularly for years may not react well to benzodiazepines. The patient may be "knocked out" when the drug is administered in a bolus but effects of sedation are gradually lost as the operation progresses.

Propofol is usually preferred for a deep and a consistent level of sedation throughout the operation. The advantage of Propofol is in its rapid recovery time of less than 5 minutes. Because of the short duration of its action, the drug must be continuously administered. We do this by pumping Propofol using an electric infusion pump. The dose rate is set by the anaesthetist.

What about safety?

IV sedation is very safe when carried out by an anaesthetist. Statistically speaking, the mortality rate is literally 1:1 million. In contrast, the mortality rate for general anaesthesia (GA) is 1:598,000.

However, contraindications include pregnancy, known allergy to the drugs used, alcohol intoxication, CNS depression and some instances of glaucoma. Cautions include psychosis, impaired lung or kidney or liver function, and advanced age (above 70). Heart disease is generally not a contraindication.

What are the advantages of IV sedation?

* IV sedation tends to be the method of choice if you don't want to be aware of the procedure - you "don't want to know". The alternative in the US is oral sedation using Halcion, but oral sedation is not as reliably effective as IV sedation.

* The onset of action is very rapid, and drug dosage and level of sedation can be tailored to meet the individual's needs. This is a huge advantage compared to oral sedation, where the effects can be very unreliable. IV sedation, on the other hand, is both highly effective and higly reliable.

* The maximum level of sedation which can be reached with IV is deeper than with oral or inhalation sedation.

* The drugs produce amnesia for the procedure. The patient forgets the trauma of the operation even though he/she may not be unconscious.

* The effects of intubation and nausea from GA are not found in sedation. No fasting and long preparations are required before the operation.

Are there any disadvantages?

* You need to bear with the initial discomfort of having a needle inserted into your hand.

* It is possible to experience complications at the site where the needle entered, for example haematoma (a localised swelling filled with blood).

* Patients may become dependent on IV sedation such that they want IV sedation even for non-invasive procedures like fillings.

* Recovery from IV administered drugs is not complete at the end of dental treatment. You may need to be escorted by someone who can take care of you.

After IV Sedation:

(1) Have a companion (sorry, we don't provide) take you home and rest for the remainder of the day.

(2) Have an adult stay with you until you're fully alert.

(3) Don't perform any strenuous or hazardous activities and don't drive a motor vehicle for the rest of the day.

(4) Don't eat a heavy meal immediately. If you're hungry, eat something light, e.g. porridge or bread.

(5) If you experience giddiness, lie down for a while or have a glass of isotonic drink.

(6) Don't drink alcohol for the rest of the day.

(7) Take medications as directed by your dentist.

(8) If you have any unusual problems, call your dentist.

What's should I do ? If my patient wants high quality, look nature, prefect BUT very cheap.

It happens often enough in any dental practice. A patient walks in to have a new denture done. He tells you all the horrible things the old denture is doing to him. He wants those things rectified. You faithfully design a different denture that addresses all his concerns.

Patient’s Denture Wish List
1. Teeth that look new
2. Teeth that look real
3. Whiter teeth
4. Teeth with more bite
5. Sexier teeth

When the new denture is ready, the patient, spits it out, can’t tolerate for one second and start comparing the “merits” of old denture with the demerits of what you’re just done. It doesn’t matter if you pull out that wish list written in the patient’s own handwriting and signed against “sexier teeth”. They think the new teeth you’re giving them just ain’t sexy.

Most dentists will reel from the shock of seeing a happy, enthusiastic patient walk in for the first visit, only to be entertaining a critical and uncooperative one at the end. Can these cases be spotted at the beginning and weeded out before taking the case? I find it difficult. During initial examination, the dentist may be able to establish how the patient felt and what the patient wanted at that point in time. They may feel that their old denture had teeth which were too short. They wanted longer teeth, bigger teeth, whiter teeth… Even if the dentist could read their minds at that point in time, he would have seen that they wanted longer teeth. But once the longer teeth are issued, they begin to sound funny, feel funny and chew funny, they may decide to take issue with their new dentures in the most unexpected ways, saying that it’s uncomfortable, unstable and just not right.

The vast majority of dentures do require some adjustment before issue. Nothing is perfect - especially a set of new dentures to which the patient is not accustomed. In the vast majority of cases, patients are satisfied after adjustments are made. If the new dentures are significantly longer, larger or thicker than the old ones, then a period of adaptation (with 100% patient participation and cooperation) is required. Only in rare cases are redoing the denture necessary. If the patient is agreeable to a redo of the denture, this time without such a great departure from their old set of dentures, then, an amicable conclusion is still possible. And it usually ends up amicably. Even if the patient is unwilling to bear the cost of the redo, the dentist would still be in the position to end off with a satisfied patient - something more important to the dentist than making a profit out of every single case.

Just for the sake of job satisfaction, many dentists are willing to redo dentures. But not all patients allow the willing dentist to redo. What if the patient declares that he has lost all confidence in the dentist even before wearing the denture for any reasonable length of time (less than an hour)? He is not asking for a redo. He is asking for a refund.

Reading their minds now, the dentist may see a totally different patient from the very nice and accommodating one on the initial visit. So mind reading doesn’t help. What might help, is a third eye that can look into the future and predict trouble and unpleasant responses from initially nice and friendly patients. How I wish I can do that.

Speeding Up Our Life Cycle

Are you one of those parents who always need to be around when your child is doing his/her homework? I may not remember much of my primary school curriculum, but I’m sure I didn’t do algebra at Primary 1!

Ali has 3 marbles more than Tom who has 1 marble more than Jerry. If Jerry has 2 marbles, how many marbles do Tom and Ali have?

Answer:

Let Jerry have j marbles
Tom has j+1 marbles
Ali has 3+j+1 marbles
Given that j=2
Therefore Tom has 2+1=3 marbles
Ali has 3+2+1=6 marblesWell, at least that was the way I was taught to do this sort of “problem sums”. I don’t know how smart other people and their kids are. But I certainly wouldn’t have a clue as to how many marbles Ali and Tom have when I was in Primary 1. And I don’t expect my 6-year-old son to be able to do that. To me, this is probably Primary 4 work. Why are they teaching it at Primary 1 now? A chill runs down my spine when I imagine what they might teach in Primary 2, 3, 4, 5, 6.

If you think that’s not bad enough, have you heard of the Primary 2 kids who had to write book reviews as homework? Almost every child would seem to have read a book that no child would find interesting. Almost every child would get an A for their insightful review copied from Amazon.com. My son would probably get an F because instead of a book review, I’d be the only parent who would write an essay on how stupid the whole exercise is.

We are a nation obsessed with upgrading, efficiency and bang for buck. That’s not a bad thing - provided we don’t let things get out of hand. Compared to my son and other kids in school today, I went through primary school at a very comfortable pace. It’s not just about enjoying childhood. It’s also about being true to yourself. So what if my homework was never flawless? At least I understood most of it and did it myself. So what if my projects were made out of cheap cardboard and coloured paper? At least my parents didn’t have to scrimp on the next meal to get materials that would make my project look as professional as the others.

If learning is forever, why rush into it? More importantly, how much does a Primary 1 kid really need to know at Primary 1? Are the schools really in such need to show that they are improving and reaching ever higher standards? What simpler way to show “improvement” than bringing Primary 2 work to Primary 1.

Wow. That’s an impressive improvement. What do we do next year? Let’s bring the Primary 3 work to Primary 1. Wow!

The end point? There is no end point in theory, but for practical reasons, most people would stop at an MBA or a PhD. And my friend who holds an MBA (and a very expensive one too) just got retrenched for the nth time. He has been switching careers, attending diploma courses to help him remain employable. After multiple humbling career switches with equally humbling salaries, he still ended up retrenched. It’s quite baffling that with so much more experience, he is worth much less than he was young. He’s finally considering becoming a tour guide - a job done very well by another friend of mine who only finished his O Levels.

Is it because this friend of mine didn’t learn about how many marbles Ali has when he was in Primary 1? Would our kids not fall into the same predicament when they hit 40 because the education system they are under is now an improved one that will make sure you won’t wash toilets or drive taxis if you have an MBA?

I’m glad that I can sometimes decide my own worth. My years of experience are tangible and worth something in the field of dentistry. While I can still hold handpieces and scalpel blades steady, I don’t have to retrain and acquire new skills in a food court or toilet to remain employable. Not so for many friends my age. Many of them have reached their “employ by …” age. Like the primary school system, everything is being sped up in Singapore. We can’t wait to graduate. We can’t wait for the IRs to be built. We can’t wait for the next rally at the stock market.

So why not attain O Level knowledge by Primary 6. Retire to wash toilets by 40 (already happening). Draw CPF at 90. No, this is one thing which will only be slowed down. Happy speeding on the other lanes.

~~~End~~~

Crown Lengthening Case

Smiles are not just affected by tooth positions. They are also affected by gum levels. Gum surgery can correct gum levels.

Her main concern is her crooked teeth. To fix that properly, it would be good to first correct her gum level. The gum level ought to be where it's indicated by the black dots.

The gums are peeled back to expose bone.

The gum level around the 2 "sunken" teeth has been brought up. The next step is to change the positions of the teeth.

It's a week after gum surgery, our patient is back for her crown preparations. Her canines have been root canal treated. We ground them down to gum level, then placed fibre posts inside the canals.

The crowns of the canines are rebuilt from scratch to conform with the crown positions we want.

The rest of the teeth are carefully prepared to conform with the final tooth positions we want.

The prepared teeth are protected with temporary plastic crowns. We will wait for the gum level (after surgery) to stabilise before we take impressions for the final e-max crowns. So far, we have already successfully realigned the patient's teeth.

Case completed.

Horsing Around

Oh no! I had a drop too much of Knock Out Beer and I’m dreaming again. I bought a horse in Australia (the girl is part of the package). I wanted to keep it as a pet. Then I found out that it was used for racing (the girl was the jockey). So I sold the horse …

Yao mo gao chor ah?

If I find out that a horse has been used for racing, then all the more I should keep it in my own stable, my own ranch (with a decent room for the girl) and not sell it. But then, this was just a dream and dreams don’t have to make cents … I mean sense.

And I also dreamt that I spent millions upon millions of other people’s money to build a titanium building. Then angry mob came to tear down the building, melted down the titanium and the expensive metal was turned into thousands of dental implants for edentulous patients who would otherwise not be able to afford it.

More Knock Out Beer. And another dream. This time, I dreamt I was CEO designate for some company running a sovereign wealth fund. I panicked. I didn’t know anything about managing SWFs. The job was killing me. I was losing billions and people were staring, pointing fingers at me. I had to find a replacement, a scapegoat if you will.

I found him. But the guy was too smart to be a scapegoat. He soon realised that like Obama, he’ll be inheriting a disaster in the making. He quits over “strategic differences”. Whatever that means. It’s just a dream. I’d better go back to work and stop horsing around.

Going for wisdom tooth surgery.

Pre-operative instructions for patients undergoing surgery.
1. Have a good meal a least 4 hours before surgery. Comsume only water after that.
2. Make sure all the medications you are taking are made known to the surgical team.
3. Avoid supplements like ginseng and gingko biloba for at least 4 days before surgery. Consult TCM practitioner if in doubt.
4. Do not smoke.
5. Maintain good oral hygiene.
6. Have an adult to accompany you home after the surgery if you are to be sedated.

Post - operative care for patients who have just undergone surgery.
1. Bite as hard as you can on the gauze provided when the surgical site is still numb.
2. Be careful not to bite your lip before anaesthesia wears out. Ulcers may occur due to stretching or accidental biting.
3. Swallow overflowing saliva. Do not keep rinsing your mouth. If you need to spit, do so very gently.
4. Avoid drinking through a straw.
5. Do not blow your nose. Sniff if there is mucus. Pinch your nose when sneezing.
6. Do not consume hot drinks, alcohol or coffee for the first 48 hours.
7. Do not smoke.
8. Apply cold compress on the cheek or lip over the surgical site during the first 24 to 48 hours.
9. Stop cold compress and rinse your mouth with warm salt water after 48 hours. Maintain good oral hygiene.
10. Avoid food that requires chewing for at least 3 days.
11. Avoid physical exertion for at least 5 days after surger.
12. Follow all instructions on medication.
13. Panax notoginseng promotes healing. Consult your TCM practitioner for a suitable formula.
14. Call the clinic immediately if "sand" leaks out from the would.

Teeth Whitening FAQs.

Q: Why bleach my teeth?
A: It's mainly for cosmetic reasons. Whiter teeth look cleaner, healthier and younger. In the reel and real world, cosmetic reasons can make a world of difference. The cast from the TV series Baywatch had their teeth bleached. The wannabes below obviously had no tooth whitening budget.


Q: Can all teeth be bleached?
A: Crowns and fillings do not bleach. Brown or grey teeth are much harder to bleach than yellowish teeth. Make sure that your teeth have a uniform colour and not a patchy appearance.


Q: Do you do laser whitening?
A: No, we do not do laser whitening. Our system is chemically activated and works just as well. Laser whitening will cost about $1200. This is because the dentist needs to rent the machine and buy the bleaching gel from the same company. The high advertising costs must also be paid for. For laser whitening, the total cost to the dentist can be as high as $900 per patient. The bulk of what you pay for goes to the supplier.

Q: How quickly can I see results with the take home kit?
A: Results are noticeable after an hour's application. It takes about 4 days of continuous wear (1 hour 2 times a day) to reach maximal results.

Q: What sort of results can I expect?
A: You will never get chalky white teeth. Going two shades whiter is a reasonable expectation. Results do vary and satisfaction cannot be guaranteed as some teeth may not bleach well in spite of our best efforts.

Q: Can everyone go for bleaching?
A: Bleaching is not recommended for pregnant women.

Q: What are the side effects?
A: Sore gums and sensitive teeth are common side effects. However, it's often temporary. See your dentist if it gets uncomfortable.

Q: How long does it last?
A: Re-treatment may be required every 1-2 years or so. It depends on your diet and how well you maintain your teeth. Coloured drinks and some herbs will cause staining very quickly.