Bill Zortman: Dr. Denis Miller, Dr. Lou George, Siouxland Oral Surgery. Gentlemen, good morning.
Dr. Lou George: Bill, it’s good to see you.
Dr. Denis Miller: Good morning, and welcome to getting over flu season.
Bill Zortman: You know, that makes us think a little bit about concerns for surgery, and today, maybe the cardiac concerns. How would we touch on that?
Dr. Denis Miller: Well, as you know, you know, we’ve got some great hospital systems here in the area, and one of the big dynamos for them is the cardiac care that people receive in the area, and it’s excellent, excellent care. People are alive today because of that care that 30 years ago wouldn’t be alive and here with us today. But, there’s a lot of cardiac issues that we see nowadays that we didn’t see 30 years ago, and I think what we wanted to do today was kind of talk about when people come to our office, as an oral surgery office, we tend to have a really detailed history and physical on people that a lot of dental offices just don’t have because we’re dealing with harder surgeries, we’re dealing with older people, and we’re doing sedation, so we have to be a lot more thorough in what we do, and one of the big things is the cardiac history.
Bill Zortman: The categorization system that you have, everybody has a different system. Explain what yours is and why the patient should feel very comfortable.
Dr. Denis Miller: For us, we go by an anesthesia categorization called the ASA class, and that was designed by the anesthesiologists to kind of categorize how healthy people are in general terms. I mean, there’s other cardiac indexes and other things that we look at, but just as a general statement, we like to know what ASA class people are. So, in its simplest terms, ASA class 1 is a, let’s say a teenager, no meds, no allergies, no medical problems, no surgeries, no social history, just a nice kid. ASA class 2 is someone like me; high blood pressure, on a pill, I like to think of myself as a nice kid, but generally healthy other than that. ASA 3 is now somebody where their high blood pressure needs, you know, two, three, four kinds of medications, maybe it’s not quite under control as it is, as we’d like it to be, maybe they have multiple other organ system problems. And then ASA class 4 is a lot of things are just uncontrolled. So, if we want to do surgery on people in the office setting, we want to do our surgeries on people who are ASA class 1 and 2. So their body, even if you’re on one medication, can regulate itself. So, it can regulate its own temperature, it can regulate its own blood pressure and heart rate and respirations and kidneys and all of that. You start getting into ASA class 3, well, those people are going to tend to have to need more help. You know, their blood pressure might get too high, so you might have to give them blood pressure meds to lower it, and the reverse, or their rates might get too high or too low. And all of a sudden, you’re trying to do your surgery and you’re trying to manage this other thing on the side, and ASA class 4’s are just right out—we just go to the hospital with them. So when we’re seeing patients, we see the ASA class 3’s and 4’s and a lot of people from the nursing home in a consult to try and figure out where they are, and then get a history and physical from their medical doctor and a cardiac workup, and then we can see if they’re stable enough to do surgery in our office. And it also depends what we’re doing. You know, if we’re just doing one tiny little tooth that’s kind of wiggling, OK, we’ll probably do an ASA class 3. But on the other hand, if we’re going to be taking all of someone’s teeth out and maybe they’ve got bone spurs and now we want to put in implants and this is going to be an hour-long surgery, and maybe the airway’s not the greatest, well, maybe that ASA class 3 person is not in the right spot because your risk factors for bad things happening start going up.
Bill Zortman: There’s a big difference between 10 minutes and an hour surgery.
Dr. Lou George: Oh, absolutely. You know, it has to do with the amount of stress, physiological stress, that a patient can withstand. So, a lot of peoples’ bodies can go along very nicely, particularly our healthy patients. You know, if you’re going to do a 30 or a 45-minute or even a 60-minute surgery, a healthy individual, the stress of surgery—which one of my attendings told me a long time ago, is surgery is controlled trauma if you think about it, OK—so you know, it’s not so much a big deal. But you have folks that are having some concurrent cardiac issues, respiratory issues, so forth. Well now, the difference between 10 minutes having a procedure and 45 minutes is huge, and they just don’t cope well with that stress. And just touching a little bit on what my partner Dr. Miller said with the ASA classifications, that’s important to realize that that’s for adults and teenagers. When you’re talking about pediatric surgeries, folks under 12 and so forth, you could have an ASA 1 or 2 patient, but still may be necessitated to go to the hospital based on behavior, for example, or airway issues, which is arguably one of the most important things we deal with as oral and maxillofacial surgeons and the ones who are administering that anesthesia.
Bill Zortman: 10 to 20 minutes, not a long time, but if you know what you’re doing, you don’t want an untrained person dealing with your wisdom teeth or taking your teeth out. You guys have the experience.
Dr. Lou George: Well, that’s why it’s so important, as we’ve said time and time again, to define training to competence. You know, we usually take 10 to 20 minutes to take out a set of wisdom teeth, where most untrained practitioners can easily take well over an hour to two hours. Again, in healthy folks, sometimes that stress isn’t a big deal. It’s a miserable experience to sit there for that long undergoing that procedure, but it doesn’t come with the baggage of physiological stress that is harmful to someone. Now, you start introducing a lot of these health issues, OK, particularly cardiac ones, and now you could have a very big problem on your hand besides just having trouble with the surgery.
Bill Zortman: The stress, as you talked about, people don’t want to go into surgery, it’s not their choice, but they need to do it.
Dr. Denis Miller: Well, yeah, for certain situations you have to go through surgery, and we try and make things as pleasant as we can, and one of the big benefits as oral surgeons is that we’ve been trained in residency to provide light, moderate, and deep sedation. And we function in a hospital setting during our training as the first-year anesthesia resident. So, we do all of the cases just like everybody else. So, we’ve got a really good grounding. We know what cases are acceptable for the office setting, which ones we should probably be doing in Same Day Surgery, and which ones we just have to keep an eye on. But as Dr. George was saying, the time—how long are you going to subject that person to that kind of stress? And what are you going to do to mitigate that stress? So, we can mitigate it with the sedation, but how long do you want to do that? You know, if we can get a surgery done in 10, 20 minutes, that’s certainly going to be a lot better for that patient versus sitting, you know, under the knife, if you were, for an hour or two. And so, this is what we’re talking about, the training to competence.
Bill Zortman: Well, you want to be in the right mindset as you go in. You want to make sure you’ve got professionals that are taking care of them. My guess is you guys do a pretty good follow-up with them as well to make sure they’re comfortable and everything worked.
Dr. Denis Miller: Right. We do that two different ways. We give everybody a phone call the next day, post-op phone call, and just make sure they’re doing OK, and if we know they’re having problems, we give them another call a day or two later. And of course, they’re always welcome to call our office and, you know, talk to us or come on in and have us take a look. And then we have a third-party evaluator call everyone about 2 weeks later and just see what their experience was, and of course we would like to hear that everyone had a good experience, but a lot of people say, “Yeah we had a great experience, but—” You know, a little bit of positive reinforcement or a little positive feedback, you know, “If you guys would maybe do this little thing over here, maybe that would make it a little bit better.”
Dr. Lou George: And we do listen to that. That’s not just brushed to the side or, you know, tossed away. We do pay attention to that and address it at every monthly meeting and see what we can do. You know, obviously to be better for our referring doctors and our patients. Part of what Dr. Miller said, checking in on the patients afterward, obviously post-operative is huge. I do want to definitely ring our office’s bell a little bit and also say that we try to be extraordinarily thorough pre-operatively. Picking out some of these issues that Dr. Miller and you discussed a little earlier, Bill. OK, for example, cardiac issues—if we have any questions, concerns or even doubts that, even if there’s nothing, you know, written extensively on the patient, we can tell after examining the patient and spending about 10 or 15 minutes with them in a consultation. You know, we will give a shout-out to their cardiologist and basically, if cardiology says, “Don’t do it.” We don’t do it, you know? I mean, we’re going to follow their guidelines. If they recommend something, you can be sure that we are going to take that to gospel. And that’s just what we try to do to get everyone involved. So, it’s a team approach to this, not just in the dental aspect, but also in the medical aspect where we have one of our boots as well.
Bill Zortman: For those listening today, how do they get started if they need the procedure?
Dr. Denis Miller: Well, they first give us a call at 335-1080, Siouxland Oral Surgery, or look us up on the web, siouxlandoralsurgery.com, or the short version is somsa.net.
Bill Zortman: If you’re needing surgery in your mouth, your teeth, you want to make sure that the people that are doing the work in there have done it before. They’re trained. They know what they’re doing, and these are two guys that make a big difference. Siouxland Oral Surgery, Dr. Denis Miller, Dr. Lou George, thanks for the visit.
Dr. Lou George: Thanks a lot, Bill.
Dr. Denis Miller: Thanks, Bill.