Episódios
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Today, I want to dive into a topic that affects us all: fatigue in our dental practices, particularly in oral surgery. We all experience tiredness from the daily grind of dentistry, and I want to share some insights on the different types of fatigue we face and how to manage them. Physical fatigue is often the most obvious. It can stem from poor sleep habits, lack of exercise, or simply working long hours. While I've improved in this area, it's still a challenge for many. Mental fatigue, or decision fatigue, is a big one for me. Our job requires intense mental engagement from start to finish, and it can be draining. Techniques like meditation can help, but I still struggle with this aspect. Emotional fatigue comes from dealing with charged situations - difficult patients, conflicts with colleagues, or frustrations with insurance companies. Compassion fatigue is another challenge, especially as we progress in our careers. It's when we start to lose our capacity for empathy and begin to objectify patients. This can be a sign of burnout and may require professional help to address. Other types of fatigue include creativity fatigue (though less applicable in dentistry) and sensory fatigue from constant exposure to things like handpiece noise. When these different types of fatigue stack up, it can lead to burnout. For me, the top three are mental fatigue, emotional fatigue, and compassion fatigue. It's crucial to find ways to counteract these, whether through hobbies, time off, or setting boundaries in your practice. It's okay to say no to cases or patients that aren't a good fit. Refer out what you're not comfortable with - I do this with certain complex procedures I no longer regularly perform. Ultimately, focus on what you enjoy and what you're good at. Set boundaries, refer when necessary, and don't be afraid to dismiss problematic patients. These strategies can help reduce overall fatigue and make your practice more enjoyable. Remember, it's okay to ask for help if you're struggling. If you have any questions or comments, feel free to reach out at [email protected]. Talk to you next time!
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Oral Surgery Is Hard
Hey everyone, it's Russell. Today, I want to talk about something a bit different – our profession itself and the challenges we face. The main thing I want to emphasize is that oral surgery is hard. We all struggle sometimes, and that's okay. As we progress in our careers, more experience leads to better outcomes and techniques. You'll find the instruments and approaches that work best for you, and case selection improves with time.
Early in our careers, we often face pitfalls like taking on cases beyond our skill level, and our ego can cloud our judgment. But even as we gain experience, we'll always have wins and losses. Referrals are sometimes necessary, even for experienced surgeons, and consulting colleagues for validation is valuable.
Having support is crucial in our field. We need people to bounce ideas off of, and it's important to keep going and improving. Our ultimate goal should be to have more wins than losses, but we must accept that some cases won't go as planned. It's also vital to recognize when we simply can't help certain patients.
We need to extend grace to ourselves. We're human and imperfect – it's called a "practice" for a reason. Over time, we should have more successes than failures. It's equally important to support our colleagues. Be kind when others share struggles online and avoid harsh criticism – we don't know the full context. Remember, everyone has complications, even the "experts."
Ultimately, what we do is valuable and unique. Be proud of your skills and the good you bring to the world. I hope this reflection helps you feel less alone in your challenges. We're all in this together. As always, feel free to reach out at [email protected] or follow me on X @RussellKirkDDS.
Talk to you next week!
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Estão a faltar episódios?
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I want to share a story that highlights the importance of comprehensive evaluation and patient education when it comes to third molar pain. Imagine this scenario
A 17-year-old female presents with bilateral jaw pain. Exam reveals
Impacted third molars, no obvious pathology
No intraoral signs of infection or pericoronitis
Teeth are removed without complicationBut at post-op visits, the patient reports
Pain persists or worsens
No response to anti-inflammatories
Headaches developWhat's going on? In this case, we may have missed an underlying diagnosis of TMD, specifically myofascial pain in the muscles of mastication.
Key signs of TMD to watch for
1. Headaches, often behind the eyes or at the temples
2. Tenderness at the temporalis insertion (near maxillary first molar)
3. Pain at the angle of the mandible (masseter attachment)
4. Pre-auricular pain (pterygoid involvement)
5. History of gum chewing, ice crunching, or other parafunctional habitsThe problem: When we assume third molars are the sole cause of pain and remove them, we set ourselves up for trouble if TMD is the true culprit. The patient's pain persists, and they may blame us for their worsened condition.
The solution: Thorough assessment and clear communication
Palpate the muscles of mastication for tenderness
Document pre-existing TMD in the patient's record
Discuss the distinction between third molar pain and myofascial pain
Set expectations for potentially prolonged recovery due to TMD
Consider the necessity of third molar removal if no obvious pathology is presentI learned this lesson the hard way when a patient reported me to the dental board, claiming I had caused her TMD by "dislocating her jaw" during surgery. Thankfully, my documentation of her pre-existing condition exonerated me, but it was a stressful experience.
By sharing this story, I hope to help others avoid similar pitfalls. Remember, a thorough exam and clear patient communication can make all the difference in achieving optimal outcomes and maintaining trust.
As always, I'd love to hear your thoughts and experiences. Feel free to reach out at [email protected], and follow me on X @RussellKirkDDS for daily posts on all things oral surgery.
Talk to you next week!
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Case Selection Versus Case Complexity
Hey ya'll. In a recent post on X (formerly Twitter), I proposed that case selection is one of the most critical factors in achieving good surgical outcomes. Today, I want to dive deeper into that idea and explore some common pitfalls that can lead us astray.
Why do we sometimes struggle with case selection?
1. Ego and overconfidence: We overestimate our abilities and take on cases that exceed our skills and experience.
2. Inability to admit limitations: We're reluctant to acknowledge when a case is beyond our current scope of expertise.
3. Lack of self-awareness: We have blind spots and don't recognize areas where we need improvement.
4. Ignoring feedback: We dismiss constructive criticism from patients, team members, or colleagues that could help us grow.
5. Financial incentives: The prospect of higher fees for complex cases can cloud our judgment.
6. Institutional pressures: Quotas or expectations from employers (academic, military, DSOs) may push us to take on more than we should.
7. Fear of losing referrals: As specialists, we worry that referring out challenging cases will diminish our referral base.
The dangers of poor case selection include: choosing case complexity that exceeds our skills and experience sets us up for suboptimal outcomes. Negative results can damage our reputation and lead to a loss of referrals.
8. Focusing on successes while downplaying failures gives us an inflated sense of capability. Dunning-Kruger effect: Early-career practitioners may not recognize their limitation.
9. Inadequate training in specific areas (e.g., an OMS skilled in craniofacial surgery but undertrained in implants)
10. Stress, rapid pace, decision fatigue, and burnout can skew our judgment
The key to success is aligning case complexity with skills and experience.
When skills/experience exceed the complexity of the case, success is likely.
When they're evenly matched, consider patient factors and personal readiness.
When case complexity exceeds skills/experience, refer out or pursue additional training.
This topic resonates with me, as I've personally experienced the consequences of misaligned case selection, including burnout.
By sharing these reflections, I hope to spark meaningful conversations and encourage thoughtful decision-making.
I'd love to hear your thoughts.
Follow me on X @RussellKirkDDS, where I post daily on oral surgery topics (I promise, no controversial tangents).
As always, feel free to reach out at [email protected].
Talk to you next week!
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TLDR. Course link: PRFBasics.com
Today we're diving into the world of platelet-rich fibrin (PRF). I learned about this technique from Dr. Anthony Sclar out of Miami, and I've found it to be a game-changer in my oral surgery practice.
Let's break it down into my "P3 Approach":
1. Phlebotomy (Drawing the Blood)-Check local regulations on who can perform phlebotomy; - Draw directly from IV (if sedating patient) or vein-Equipment: Tourniquet, alcohol swab, gauze, Vacutainer with glass tubes (no preservatives) - Typically draw 4 tubes - Free phlebotomy course available at PRFBasics.com
2. Preparation (Making the PRF)-Spin tubes in centrifuge (timing varies by patient; check at 3 minutes)A fibrin "slug" forms on top of blood layers-Remove the slug with cotton pliers, trim red cells if needed, place the slugs in PRF box, and compress into membranes. Reserve some plasma to mix with bone graft for "sticky bone."
3. Placement (Using the PRF)-Extraction sites: Fill with sticky bone and cover with PRF membrane. Cyst/tumor removals: Place PRF membranes to reduce pain and swelling and aid bone healing. Sinus lifts: Use PRF membrane to patch a torn Schneiderian membrane. Ridge augmentation: fill buccal defects with sticky bone, cover with PRF membrane.
Root coverage/recession: not predictable in my experience.
I've found PRF incredibly helpful for reducing post-op pain and swelling, especially in larger cases like third molar cysts. It's cost-effective and relatively easy to implement.
If you're doing oral surgery, I highly recommend exploring this technique! Feel free to check out my free PRF Basics course at PRFBasics.com; it's a quick watch and can get you up and running in no time.
As always, reach out with any questions at [email protected]. Talk to you next week!
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Here are the show notes for this episode, where I tackle a few more great listener questions related to previous topics. As always, I'm sharing my personal opinions and experiences, not definitive clinical advice.
Bone Wax, Bisphosphonates, and Type 1 Diabetes: Listener Q&A
Hey everyone, it's Russell again. I really appreciate you sending in these fantastic questions! This week, I'm diving deeper into a few topics we've covered before, based on your queries.
Question 1: How do you use bone wax for bleeding control? Place minimal amount (think ortho wax size) directly in bleeding void, apply pressure, remove excess, aim for wax to be flush with bone level - Leave in place to avoid re-bleeding - Caution: Excess wax can cause inflammation, foreign body reaction, and impaired bone healing - Hemostatic agents like Surgicel or Gelfoam are preferable when possible; diode laser is my go-to
Question 2: MRONJ risk with short-term Fosamax use? Case: Patient on Fosamax 1x/week for 4 months, needs extractions and implants. Key considerations: - Confirm no previous bisphosphonate use - Check for concurrent steroid use (increases MRONJ risk) - Controversial, but I prefer short drug holiday if MD agrees - Ensure complete healing before restarting medication; - Assess other risk factors: smoking, diabetes, overall health - Case-by-case decision based on comprehensive picture
Question 3: Managing type 1 diabetes on steroids for extractions? - Case: Type 1 diabetic with A1c 8.1, on steroids for arthritis, needs #31-32 out - Ideal A1c for surgery: 6-8 based on general surgery literature - Expect increased post-op infection risk, swelling, pain, delayed healing; discuss with patient - Blood sugar management: consult with physician - Minimal intraoperative variation in my experience - Post-op challenges with dietary changes; recommend sugar-free options - Not a contraindication, but high-risk case requiring diligent management - Prophylactic antibiotics - Close follow-up until complete healing - Urgency if teeth are infected; discuss risks/benefits with patient
Keep those great questions coming!
Email me at [email protected].
Remember, every case is unique, so always use your best clinical judgment.
Talk to you next week!
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Link to Youtube video
AI Differential Diagnosis Smackdown: ChatGPT vs. Claude vs. Meta AI
Hey everyone, it's Russell, your resident tech nerd and oral surgery geek. This week, I wanted to put some of the big AI language models to the test with a fun little experiment.
The contenders: OpenAI's ChatGPT. Anthropic's Claude3 Opus. Meta AI's LLaMA-3.
The challenge: Given the same photo of a lip lesion and identical prompts, how well can each AI generate a differential diagnosis list?
The lip lesion: Left lower lip, 0.75cm, irregular Pink, firm, mobile, non-tender, non-ulcerated Becoming bothersome due to size.
My initial DDx: Traumatic fibroma (most likely) Mucous cyst (common in this area) Lipoma (less likely based on appearance)
Results: ChatGPT: Impressive! Ranked fibroma/lipoma as most likely, generated a solid 9-item DDx list with descriptions. Even knew my specialty and suggested next steps.
Claude: Also very strong. 5-item DDx with great descriptions, emphasized biopsy for definitive diagnosis. Mentioned referral to OMS or ENT.
Meta AI: Interesting! Seemed to start generating a good list (benign and malignant possibilities) but then apologized and deleted its response. Possible guardrails around medical advice?
My take: While not a substitute for clinical judgment, I'm impressed by the AI's performance in this niche scenario. As capabilities expand and HIPAA/security concerns are addressed, I believe AI will become an increasingly valuable tool in our practices. Exciting (and a bit scary) to think about!
What do you think about AI's potential impact on dentistry and OMFS? I'd love to hear your perspective!
As always, feel free to reach out at [email protected]. Talk to you next week!
P.S. For those following along on YouTube, I've included a video of the AI interactions. Check it out and let me know what you think!
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Here are the podcast show notes for this episode, where I answer some common questions from referring dentists and online dental communities. As always, I'm sharing my personal approach and opinions.
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Hey everyone, Russell here. This week I'm switching things up and answering a few questions that have come my way recently. Remember, these are just my thoughts - if you do things differently and get good results, that's great too! Let's dive in.
Sinus Perforation Repair:
- 5mm perforation during #3 extraction
- My approach:
- PRF membrane over exposure
- Collagen plug on top for added soft tissue support
- Primary closure with 4-0 chromic gut, creating 4-corner flap and scoring periosteum
- If repair fails, next step:
- Titanium-reinforced non-resorbable membrane over PRF and collagen plug
- Wait months if needed before removing membrane to avoid re-exposureExpose & Bond for Impacted Canines:
- Surgical side: Expose tooth, remove bone, etch & bond button/chain (I use Smart Bond), secure to ortho wire with nylon sutures
- Ortho side: My colleague uses elastics and a spring (not twisted wire) to apply traction and prevent debonding
- Key tips: Luxate tooth for mobility, suture chain to a spring on arch wire, get patient to ortho within 7 daysBone Grafting Extracted Sites:
- I'm comfortable with immediate grafts if no frank pus present
- Clean out site well, use PRF sticky bone and membranes
- Controversial: Are grafts even needed for mandibular molars? Some evidence shows minimal difference vs. non-grafted sites
- Case-by-case basis with many variables to considerAs always, feel free to send me your questions at [email protected] and let me know if you enjoy this Q&A format. Talk to you next week!
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MRONJ Review: What You Need to Know
Today I want to dive into the important topic of medication-related osteonecrosis of the jaw, or MRONJ. We used to call this "BRONJ" for bisphosphonate-related osteonecrosis of the jaw, but now we know other medications can also cause this serious complication.
Common culprits I see in my practice:
- Bisphosphonates: Fosamax, Boniva, Actonel, Reclast, Zometa (IV forms like Reclast and Zometa carry higher risk than oral)
- RANKL inhibitors: Prolia, XgevaWhen patients on these meds need extractions or other oral surgery, we take extra precautions:
- Consult with prescribing physician
- For IV drugs, wait as long as feasible after last dose
- For oral, consider 3-month drug holiday (though this is controversial)
- Unfortunately, no reliable pre-op tests to predict individual riskMRONJ staging and management:
- At-risk: Not yet affected. Focus on prevention, education, and optimizing oral health before starting meds.
- Stage 0: Non-specific symptoms without exposed bone. Conservative care.
- Stage 1: Exposed/necrotic bone, no infection. Rinses, hygiene, avoid further surgery.
- Stage 2: Exposed bone with infection, pain, swelling, pus. Add antibiotics, limited surgical debridement.
- Stage 3: Extensive necrosis, severe pain, pathologic fracture, extraoral fistula. Aggressive resection may be needed.I have high-risk patients sign a special MRONJ consent so expectations are clear. Extra red flag if they also take steroids!
Feel free to reach out for a copy of our consent form or with any other questions at [email protected]. Talk to you next week!
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Risk Factors for Post-Op Infection in Third Molar Extractions
Hey everyone, it's your host, Russell, here. In this episode, I want to share with you an interesting article I came across in the Journal of Stomatology Oral Maxillofacial Surgery, published just a few days ago on March 21, 2024. The article is titled "Risk factors for post-extraction infection of mandibular third molar: a retrospective clinical study" by Muka Naka et al., out of Japan.
Key takeaways:
- This large-scale retrospective study looked at 2,513 third molar extraction cases over 8 years (2014-2022) at a single facility in Kobe, Japan
- The overall post-op infection rate was 5.73% (144 out of 2,513 cases)
- Risk factors for increased post-op infection included:
- Age over 36 (risk increased with each additional year of age)
- Pre-op infection/inflammation (patients given pre-op antibiotics had higher infection rates, likely because infection was already present)
- Post-op paresthesia (suggests more difficult surgery)
- Need for intraoperative hemostatic procedures
- More severe impaction (deeper impactions on Pell & Gregory scale, horizontal/inverted on Winter's classification)
- Delayed treatment in older patients allows more time for disease processes to occur around third molars
- Increased bone density with age makes extractions more difficultI believe this provides more rationale for preventively removing wisdom teeth in younger, healthier patients rather than waiting until issues arise later in life. While there is controversy over prophylactic third molar removal, avoiding the increased surgical risks and prolonged recovery in older patients is a compelling argument in favor of earlier intervention when indicated.
I hope you found this information interesting and useful. Feel free to reach out to me at [email protected] with any questions. Have a great week!
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Hey everyone, I recently had a viewer ask me a great follow-up question to my video about performing coronectomies on lower third molars. They wanted to know how often patients need to come back to have the retained roots removed after a coronectomy, and how long they should wait before doing so.
I initially misunderstood and thought they were asking about the timing of the post-op visit, which I'll quickly address. I like to see coronectomy patients back at one week post-op to check their healing and make sure there's no sign of infection. I also take a post-op x-ray at this visit for insurance purposes. Most insurers require this to reimburse for the procedure.
But back to the original question about removing roots - the key thing to understand is that after a coronectomy, there are two possible outcomes:
1. The roots remain in place and the site heals over them with no issues. This is the ideal scenario.
2. The roots start causing problems like pain, swelling, infection or migration, and need to be surgically removed.
In my practice, I did a retrospective analysis and found that about 94% of coronectomy patients don't require any further treatment. But in 6% of cases, the roots cause issues that require a second surgery.
So when do these problematic roots typically present? I've seen it happen as early as 2 months post-op, usually due to incomplete enamel removal on my part. But it's most common in the 12-24 month range. After 2 years, the risk decreases significantly but isn't zero.
Bonus information: retained roots can be surprisingly difficult to remove! Even when they've migrated to the surface, they often require a handpiece and bone removal to fully retrieve.
I hope this helps answer some common questions about coronectomy follow-up.
Keep those great questions coming, I'm always happy to address them.
Thanks for listening.
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In this episode, I want to discuss a very specific but important topic—how I use panorex X-rays to evaluate lower third molars and decide on the best treatment approach, whether that's deferral, coronectomy, or extraction.
While CBCTs provide 3D imaging, I still find panorex to be a valuable screening tool that I use all the time in my oral surgery practice.
When looking at a panorex in relation to lower third molars and the inferior alveolar nerve canal, there are several key things I assess to determine nerve injury risk:
1. Is the superior cortical border of the canal intact or disrupted where it crosses the tooth roots?
2. Are the third molar roots deflected?
3. Does the canal divert or change direction as it approaches the tooth?
4. Is there narrowing of the canal near the tooth roots?
5. Is there darkening of the tooth roots, indicating canal involvement?
6. Do the roots appear narrowed near the canal?
7. In rare cases, is there bifurcation or perforation of the roots by the canal?
Disruption of the cortical border, root darkening, and canal diversion are the findings I see most often that point to high nerve injury risk. When I note these signs, I'm likely to recommend either CBCT for further evaluation or coronectomy/deferral rather than proceeding with extraction.
I explain these panorex risk factors not just for my oral surgery colleagues, but to help referring dentists understand what I look for and why I may recommend a certain approach after they send a patient my way.
I'm always eager to discuss these topics further, so please leave a comment if you have any other thoughts or questions. Thanks for tuning in!
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In my practice, I frequently deal with challenging root tip retrievals when teeth fracture during extraction. It's inevitable if you're taking out teeth. I want to share my approach to managing these painful cases.
First, I recognize high risk extractions in advance based on the radiographs. Curved, dilacerated, or endodontically treated roots often break. Vertical fractures, decay to the bone level, missing PDL space, and apex shape can also foreshadow issues. Knowing the challenges ahead of time allows me to set proper patient expectations, assemble the right armamentarium upfront, and decide if I should refer the case out.
When issues do occur, I focus on creating space around the fragment by removing local bone or reducing the fragment size itself. Good initial tooth loosening helps. For big pieces, I first try straight elevators or use purchase points on the fragment to lift it out. Small tips often require round burs to create a slot I can spin against to retrieve it or endo files to snare it. If the piece is very small, I'm okay leaving it in place sometimes after ensuring it's disinfected and clearly documenting it for the patient.
Pushing fragments into nerves or the sinuses causes bigger issues, so it’s best to abort the procedure if complications ensue. The key is avoiding self-criticism, as we all deal with root tips. Learning creative solutions to remedy them is an important skill in our work removing teeth. I'm always interested in learning new techniques, so please email me if you have tips to share.
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In my oral surgery practice, I frequently use 10 things that help me on a daily basis. I'll share them rapidly, not in any particular order:
1. C sponges/throat screens: I use these constantly whenever I put instruments in a patient's mouth. They prevent dropped instruments from going down the throat.
2. Hemostatic gauze: I put this in most extraction sites. It helps stop bleeding and oozing, especially for patients who can't go off blood thinners pre-surgery.
3. Disposable #15 blade scalpels: safer for me, staff, and patients than reusing blade handles. The extra cost is negligible compared to the risk reduction.
4. Russian forceps: better than hemostats for retrieving fragments, teeth, etc. Wide tips and teeth grasp securely.
5. Diode laser: originally for soft tissue procedures but now invaluable for getting control of bleeding vessels that can't be managed otherwise.
6. Surgical time out: We cover patient details, planned procedure, location, allergies, etc. pre-surgery. Gives staff permission to stop me if anything seems off.
7. PRF (platelet-rich fibrin): I add this to bone grafts and use membranes for coverage. Speeds healing, reduces swelling and discomfort.
8. The CBCT scanner: changed my surgical decision-making. Let's me see the pathology I'd miss on panorex and avoid unnecessary extractions near nerves.
9. Surgical headlight: Augmented vision is non-negotiable for me, and overhead lights just don't cut it. I use this for every surgery.
10. Side cutting burs: Contrary to training, I often use these to remove root tips in lieu of elevators. You have to be careful with pressure, but it works well.
I'd love to hear your top 10 instruments, products, or techniques too; please email me! I'm always trying to improve.
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I revisit my belief that continual learning is key to better patient outcomes. I also maintain that having a coach accelerates growth.
I introduce a new belief: dentists should eliminate the phrase “simple extraction.” I see it as my mission to end the use of this term.
There is no such thing as a Simple Extraction
The ADA code D7140 does not say “simple.” It just describes erupting a tooth with an elevator or forceps.I feel insurance companies have popularized the term pay less. But there are risks even with seemingly straightforward extractions.Reviewers judge based only on the X-ray, not the full patient picture. But many complicating issues can make a “simple” case complex.Prefacing with “simple” also downplays the procedure's importance to patients. This can inhibit them from sharing critical health histories.Dentists aren't paid merely for procedure time, but for skill and expertise that make it look quick and seamless.Conclusion
I suggest coding appropriately per ADA descriptors, but dropping the word "simple"—call it extraction or forcep extraction.Scrub websites and training; catch yourself using the term and correct it.My mission is to get all dentists to quit saying “simple extraction” given the risks involved. -
In this episode, I explain the meaning behind the provocative title "Running Sutures are a Sign of Weakness." This mantra originates from my formative experience observing renowned plastic and reconstructive surgeons at Johns Hopkins Hospital during my anesthesia fellowship. I was intrigued to find the esteemed Dr. Paul Manson and his entire team used interrupted sutures exclusively when closing their incisions.
Key Lessons from Johns Hopkins Surgeons
Working in the OR with Dr. Manson, I heard him utter the phrase “running sutures are a sign of weakness” frequently. This piqued my interest, so I asked him and his colleagues to explain their philosophy.
They firmly believed running or continuous sutures have less integrity than interrupted. If a knot comes undone or the suture line is disrupted during the healing phase, the entire closure can catastrophically unravel and wound dehiscence can occur.
After exploring a spectrum of suturing techniques during oral surgery residency, I decided to adopt interrupted sutures for most closures in my own practice. Through repetition, I became highly proficient at efficiently placing interrupted sutures and securing them with instrument ties.
Additional Closure Techniques
While interrupted sutures are my workhorse, I integrate a few other techniques when indicated:
Figure eight sutures to secure grafted tooth sockets and prevent micromotion. The crossovers add stability.Horizontal mattress sutures in areas of thin, friable tissue without attached gingiva. These distribute tension over broader area.Rarely running sutures anymore given the plastic surgeons’ wisdom that they represent weaker closure.Suggestions for Listeners
I suggest listeners experiment with various suturing techniques early in their careers to find preferences. Eventually narrow down to just a few you can master through repetition. I welcome hearing from dentists about their own favored suture types and experiences at [email protected].
In closing, the mantra from Johns Hopkins guides my approach. While versatile in residency, I now reach for interrupted sutures in the vast majority of cases thanks to their reliability.
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In Episode 7, Dr. Kirk discusses the critical topic of preventing wrong tooth extractions during oral surgery. He shares how implementing structured “time outs” has helped avoid these devastating errors in his own practice.
The Wrong Tooth Experience
Russell opens by admitting he has extracted the wrong tooth before, as have colleagues he’s spoken to. He describes the sinking feeling when you realize an error occurred despite best intentions. Russell explains how reconstructing the process after the fact enabled him to strengthen his protocols.
Strategies to Avoid Errors
Russell outlines the specific strategies he uses to prevent wrong tooth extractions:
Confirm in advance which tooth/teeth the patient expects extracted. Have them point or verify.Empower staff to stop you anytime something seems amiss. Agree on a stop signal.Review x-rays, referrals, and consents to ensure the planned extractions match.Implement a “surgical time out” before starting any procedure, similar to hospitals.The Surgical Time Out
Russell details the step-by-step process for his oral surgery time out:
Verify consent form is signed by patient and surgeon before starting.Stop all activity and confirm key details verbally:Patient name and agePlanned procedureAny drug allergiesReferring doctor (if applicable)Gain verbal agreement from patient and/or clinical team before proceeding.Address any discrepancies raised before moving forward with surgery.Russell notes that patients appreciate these safety steps once the reason is explained. For sedated patients, the time out allows staff one final check before proceeding.
The time out process ensures all team members are on the same page with the surgery plan. Anyone who is uncomfortable can stop the procedure until addressed.
Conclusion
Russell will share a printable surgical time out resource HERE that listeners can use. He welcomes any other ideas around strengthening protocols to prevent errors. Email feedback to [email protected]. Russell thanks listeners and looks forward to the next episode.
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In Episode 4, Dr. Kirk covers the important topic of managing bleeding during and after oral surgery procedures. He provides an overview of key considerations and his techniques for controlling hemorrhage when it occurs in the office setting.
Prevention
Russell emphasizes that prevention is the first priority when it comes to bleeding. Steps include:
Thorough health history and medication review - look for anticoagulant use, bleeding disorders, etc.For warfarin patients, check the INR close to surgery and keep it around 2.8 if possible.Stop aspirin 7 days prior to prevent platelet dysfunction.Consult prescribing doctors about holding anticoagulants like Brilinta or Eliquis.Understand risks in bleeding disorders and have treatment plan (DDAVP, TXA, platelets, etc).Consider extent of surgery - more invasive procedures increase bleeding risk.Even with prevention, significant bleeding can still occur as Russell illustrates in a case example.
Managing Acute Bleeding
When bleeding arises despite preventive efforts, Russell uses a stepwise approach:
Direct pressure - Often stops minor bleeding within 5-10 minutes.Epinephrine - Infiltrate epi around surgical site for vasoconstriction.Hemostatic gauze - Pack extraction site and suture closed. Maintain pressure.Bone wax - For bony bleeding, apply bone wax for hemostasis.Diode laser - Russell's top tool for coagulating soft tissue, vessels, and bone.With brisk bleeding, Russell proceeds rapidly through these options until hemorrhage is controlled.
For post-op bleeding, he removes any dressings, explores the site, and employs these techniques again as needed. The diode laser reliably stops recurrent hemorrhage.
Rarely, a previously undiagnosed bleeding disorder is discovered when a young patient bleeds excessively after routine extractions. Quick action and referral is key.
Conclusion
While we strive to prevent surgical bleeding through vigilant pre-op planning and precautions, unexpected hemorrhage still occurs. Being equipped with a logical protocol and tools like a diode laser enables reliably controlling bleeds when they arise. Russell welcomes any other tips listeners have found helpful at [email protected].
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In Episode 3, Dr. Kirk answers a question he recently received from a dental colleague regarding removing impacted upper third molars. He provides a step-by-step walkthrough of his technique for these challenging extractions.
Case Background
Russell describes the specific scenario:
The upper third molars #1 and #16 are mesially angulated with the occlusal surface touching the distal of the adjacent second molars.The roots are positioned just below the maxillary sinus floor.The teeth are fully covered by bone on the buccal aspect.Russell notes this case presents multiple risks - root proximity to the sinus, plus potential damage to the second molars given the tight contact. He details his systematic approach to safely removing these teeth.
Soft Tissue Flap Design
After anesthetizing the patient, Russell creates an envelope flap:
Crestal incision from the tuberosity around the neck of #2 and releasing the interdental papilla between the first and second molar.Reflect a full-thickness flap with a periosteal elevator (#9 molt).With the flap reflected, the bone fully obscures visualization of the impacted third molars. Russell must remove the overlying bone to access the teeth.
Removing Buccal Bone
To remove the buccal bone and create a window to the teeth, Russell has two options:
Hall handpiece with a large round burHand instrumentationIn many cases, the bone is thin enough that hand instruments suffice without a handpiece. Russell's preferred instrument is the Potts elevator. The curved beak and hook allow precise bone removal in the tight space.
If the Potts won't fit between the teeth, a curved Cryer elevator can also remove bone with its sharp point and thin profile.
Once Russell creates a window through the bone, he can visualize and remove soft tissue follicles to fully expose the third molar crown.
Tooth Removal
With the third molar visible, Russell takes great care in selecting his elevator for extraction to avoid complications:
He avoids straight elevators like a #301, as this risks excessive apical force toward the sinus.Instead, he uses the Potts or Cryer to gently tease the tooth out to the buccal. This delivers the tooth away from the sinus and second molar.Finding the space between molars is ideal to get purchase on the third molar only. But the tight proximity can risk damaging the second molar during delivery if not cautious.Russell reiterates that recognizing when to pick up a handpiece is critical. He does not hesitate to use it when hand instrumentation alone won't provide efficient access and delivery.
In summary, Russell safely removes mesially angled upper third molars by:
Conservative buccal window using hand instruments.Meticulous elevator selection to deliver the tooth buccally away from vital structures.Judicious handpiece use when warranted for access and delivery.This systematic approach helps avoid potential complications like sinus involvement or adjacent tooth damage when extracting challenging upper thirds.
Conclusion
Russell welcomes any questions, suggestions, or alternate techniques listeners have for accessing and removing difficult upper third molars like this case. Email him at [email protected] to continue the conversation and exchange ideas. He reviews emails within 48 hours.
Russell thanks listeners for joining him on another episode. He hopes these tutorials provide helpful tips for tackling complex surgery in your practice. Russell looks forward to delivering further insights and discussions on future episodes.
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Dr. Kirk opens this episode by sharing that he frequently receives questions about soft tissue flap design, especially regarding impacted third molar removal. He will focus today's show on covering his approach to flap design fundamentals and specifics for accessing lower and upper third molars.
Russell first explains his background in learning flap design during dental school under Dr. Charlie Shannon. A key concept Russell learned was that incisions heal side-to-side rather than end-to-end. This taught him the importance of making incisions adequately long to create flaps with enough access and minimal tension. Russell says finding the ideal incision length takes experience but making flaps too short leads to complications.
Flap Design Fundamentals
Russell breaks flap design into four main types:
Envelope Flap
This is Russell's workhorse flap for most procedures. When created properly, the envelope flap provides good visibility and access without excessive soft tissue trauma. It involves reflecting a full-thickness flap off the associated bone.
3-Corner Flap
Adding a vertical releasing incision to one end of an envelope flap creates a 3-corner flap for additional access. This converts the envelope into a triangular flap.
4-Corner Flap
Two vertical releasing incisions from an envelope flap makes a rectangular 4-corner flap for maximum access.
6-Corner Flap (Dr. Sclar technique)
For large bone graft coverage, Russell learned a technique from Dr. Anthony Sclar involving a 4-corner flap with additional angled releases at the base through mucosa only. This provides passive advancement over large bone grafts.
Russell emphasizes some key principles when creating releasing incisions:
Make the flap base wider than the apex for ample blood supply.Consider scoring the periosteum at the flap base for passive flap movement.By thoughtfully incorporating vertical releases or periosteal scoring, the workhorse envelope flap can be adapted to provide the access needed for most procedures.
Lower Third Molar Flap Design
When removing lower third molars, Russell uses the following flap design:
Make a crestal incision off the distal of the second molar, wrapping around the neck of the second molar onto the buccal.Release the papilla between the first and second molars.This envelope flap allows access to lower third molars without further releases.
However, in some cases the keratinized tissue near the retromolar pad impedes visibility and access. Russell's trick is to make a periosteal incision at a 45-degree angle in this area without going full thickness. This provides substantial gain in access with minimal trauma.
Russell avoids full-thickness vertical releases on the lower as this single periosteal incision provides ample access in most cases. The flap typically lays back passively without suturing.
Upper Third Molar Flap Design
For upper thirds, Russell uses the following flap design:
Make a crestal incision from the tuberosity area to the distal of the second molar. Continue with a sulcular incision around the second molar while releasing the papilla between the first and second molar.Reflect a full-thickness flap using a periosteal elevator.Occasionally, the incision may need to extend more distally near the hamular notch if the third molar is trapped in soft tissue. This allows full access to deliver the tooth without catching in the soft tissue pocket and potentially tearing the flap.
Beyond this envelope flap, Russell finds no further releases are necessary on the upper as access is readily obtained.
Conclusion
In summary, Russell uses simple and reliable flap designs like the envelope flap that can be augmented with selective releasing incisions or periosteal scoring as needed. While many complex flaps exist, Russell has found these basic options work extremely well for him in most cases.
However, Russell is very interested to hear from other dentists on their preferred flap techniques and welcomes suggestions or insights his colleagues have learned over the years. This exchange of ideas can help the community continually improve their surgical skills.
Listeners can email Russell with questions or flap design tips at [email protected]. He will be sure to review submissions and respond within 48 hours. Russell thanks listeners for joining him on another episode, and looks forward to continuing the conversation.
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