Very Clinical: Getting People Really Numb with Mohamed Abo-Basha

[00:00:01] This is a production of the Very Dental Podcast Network.

[00:00:16] Welcome to the Very Clinical Podcast. In about the time it takes to do an MO on three, we will entertain and amaze you with tips and tricks on regular daily dentistry. Here's Kevin and Zach.

[00:00:28] Very Dental student listeners and Very Clinical listeners, I have a very cool announcement for you.

[00:00:35] So, if you listen to the whole feed where you listen to all the different shows that we put out here at the Very Dental Podcast Network, you know that the Very Clinical show is our Tuesday show.

[00:00:46] And it features Dr. Kevin Fryer and Dr. Zach Miners as the hosts. This has been going on for years, years and years.

[00:00:54] And then more recently in the last couple years, we also have a show called the Very Dental Student Podcast, which features our host Mohamed Abo-Basha.

[00:01:02] He's currently a third-year student at Oklahoma in dental school.

[00:01:07] So, each of these shows kind of has their own sort of way of doing things.

[00:01:13] I've had the honor of being on both shows multiple times in a lot of different capacities.

[00:01:18] But what's interesting is Zach and Kevin and Mo, I don't think have ever podcasted before now.

[00:01:25] So, what we have is this epic crossover between Very Clinical and the Very Dental Student Podcast.

[00:01:32] And today and tomorrow, actually, you're going to hear kind of like two sessions worth of that interaction.

[00:01:40] And they talk a little bit about dental school.

[00:01:42] And it's very cool.

[00:01:43] It's really exciting to hear all three of these guys.

[00:01:45] Because maybe at some point, the four of us can get on an episode and, I don't know, do like Dental Jeopardy or something like that.

[00:01:54] That would be epic.

[00:01:54] In any case, you have a lot.

[00:01:57] Actually, they have multiple episodes that they've recorded.

[00:02:00] Like I said, the next two days, you'll be hearing from them.

[00:02:04] I'm just going to put it in one day is going to be a Very Dental Student episode.

[00:02:08] The next day will be very clinical.

[00:02:09] But they'll be kind of consistent.

[00:02:11] There's sort of one after the other.

[00:02:12] So, don't be too surprised by that.

[00:02:14] And so, with that, I give you the Very Dental Student and the Very Clinical Podcast.

[00:02:19] Hello, everybody.

[00:02:20] Welcome to another episode of the Very Dental Student Podcast.

[00:02:25] We're out here again one week later with Kevin and Zach, the Very Clinical guys.

[00:02:32] Kevin and Zach, how are you guys doing this week?

[00:02:34] I'm great.

[00:02:35] How are you, Zach?

[00:02:37] Well, I think the Chiefs are 8-0 now.

[00:02:39] You know, or maybe 9-0.

[00:02:40] I don't know.

[00:02:41] I don't even know how good it's going.

[00:02:43] We'll see.

[00:02:43] I'm going to have football next week.

[00:02:45] You know, so, yeah.

[00:02:46] We'll see how it goes.

[00:02:47] Perfect.

[00:02:48] Probably a lot.

[00:02:49] No.

[00:02:49] I'm not even watching the Browns anymore.

[00:02:51] I didn't watch.

[00:02:52] They won last week.

[00:02:53] I wouldn't.

[00:02:53] Yeah, they actually did.

[00:02:55] I think you got hope now.

[00:02:57] So, we'll see.

[00:02:59] I don't care.

[00:03:01] I don't care.

[00:03:01] I don't watch a lot of pro football, but I'm from Oklahoma State.

[00:03:05] We're going to convert you to a pro football fan.

[00:03:11] Why don't you just join the Chiefs bandwagon?

[00:03:14] The bandwagon?

[00:03:14] Yeah.

[00:03:15] The bandwagoner.

[00:03:16] Do you like Taylor Swift, Muhammad?

[00:03:19] I don't listen to any music at all.

[00:03:21] What?

[00:03:22] Yeah.

[00:03:22] Oh, that's going to change.

[00:03:24] I listen to podcasts.

[00:03:26] I listen to you guys on while I'm driving.

[00:03:28] Have you actually listened to this?

[00:03:28] Oh, man.

[00:03:29] Oh, yeah.

[00:03:30] Okay.

[00:03:32] Wow.

[00:03:33] I think it's always fun to...

[00:03:34] He even wanted to talk to us after listening, Kevin.

[00:03:35] Can you believe that?

[00:03:36] It's so weird.

[00:03:38] Yeah.

[00:03:38] That's wild.

[00:03:40] I'm sure people have told you this before, but whenever you listen to a podcast enough,

[00:03:46] you feel like you actually really know them.

[00:03:48] And then you guys, I'm even on the same podcast network as you guys, but I've never talked to

[00:03:55] you guys before until last week.

[00:03:57] So, it's always really weird talking to somebody that you've listened to before.

[00:04:01] I don't know.

[00:04:02] Sure.

[00:04:02] Yeah.

[00:04:03] Yeah.

[00:04:03] I think it's weird talking to Zach every week.

[00:04:06] Every single week.

[00:04:07] It's just a weirdo.

[00:04:09] Yeah.

[00:04:09] But I was going to say, I am an Oklahoma State football fan, but we're doing really horrible.

[00:04:15] We've lost every conference game of the season.

[00:04:18] So...

[00:04:18] Yeah.

[00:04:19] We'll accept you as the Ohio State fan.

[00:04:21] If you want to become a Buckeye, you can be an honorary Buckeye.

[00:04:24] We win a lot.

[00:04:25] Yeah.

[00:04:26] The OSU.

[00:04:27] Instead of just OSU here in Oklahoma.

[00:04:31] Right.

[00:04:31] That's why.

[00:04:34] That's part of the reason why.

[00:04:37] Yeah.

[00:04:38] All right.

[00:04:38] And I think we were going to talk about some restaurants that you guys are like hangout

[00:04:43] spots that you guys enjoyed going to in dental school.

[00:04:46] So, who wants to start us with that?

[00:04:49] Go ahead, Gavin.

[00:04:50] I've got two.

[00:04:50] Are you waiting?

[00:04:51] Oh, you got two.

[00:04:52] Go.

[00:04:52] I got two.

[00:04:53] Can I have two?

[00:04:53] Please.

[00:04:54] All right.

[00:04:55] So, first year of dental school, I lived in the grad dorm.

[00:05:00] That was kind of sexy.

[00:05:01] And then after that, I was actually married.

[00:05:05] And I lived in an apartment all within the same couple blocks.

[00:05:09] And there was this place called Freddy's that was on the corner.

[00:05:13] I could walk there.

[00:05:14] And a typical night of studying for me involved, you know, like pouring over some anatomy notes

[00:05:23] or biochem or whatever.

[00:05:25] And then like, I'm a little hungry.

[00:05:26] So, I'd walk down to Freddy's and I'd get a Dr. Pepper and some Cheetos because nutrition

[00:05:31] was high on my list.

[00:05:33] Boy, have things changed.

[00:05:36] But that was a good time.

[00:05:41] I was there almost every day around 730 or 8 p.m.

[00:05:47] And you had a Dr. Pepper and Cheetos every day?

[00:05:50] I can't believe you're alive.

[00:05:51] You look that good.

[00:05:52] Maybe not every day, but every other day.

[00:05:54] But there was also a pizza place called Catfish Biff's that's famous at the Ohio State University.

[00:05:59] I don't know if it exists anymore, but I was so happy when my son was going to Ohio State

[00:06:07] and ordered a Catfish Biff's.

[00:06:10] And it's great pizza.

[00:06:13] And I liked it a lot.

[00:06:15] So, shout out to Catfish Biff's if you're still in business.

[00:06:18] Freddy's is not in business anymore.

[00:06:20] I know that for a fact.

[00:06:22] Your turn, Zach.

[00:06:25] The dental school hangout that was the most famous for us is that on Tuesday nights at a little bar called Harpo's,

[00:06:33] which actually when we interviewed Tarun, he also mentioned that as one of his favorite places to go.

[00:06:39] So, I knew it was definitely a UMKC vibe.

[00:06:41] It was $5 cover and then 25 cent beers.

[00:06:45] It was in the late 90s, early o's.

[00:06:49] They do not have that deal anymore, as you can probably imagine.

[00:06:52] Probably not in Bitcoin.

[00:06:54] Yeah, Bitcoin.

[00:06:55] But that was where you went.

[00:06:57] They had a massive, huge patio deck.

[00:06:59] So, it was especially popular mostly in the good weather months.

[00:07:05] But that's where you went to hang out, to have a beer, to have a burger.

[00:07:10] That's where the girls were if you were looking to talk to them.

[00:07:14] So, that's where we went.

[00:07:16] I have great memories of that place.

[00:07:18] It's still open.

[00:07:19] But apparently, it's not as cool of a place to be as it used to be.

[00:07:24] Interesting.

[00:07:25] Yeah, we don't really have like a hangout spot.

[00:07:29] Or maybe we do, and I'm just not cool enough to know about it.

[00:07:33] They didn't invite you, huh?

[00:07:35] Tough look for our guy.

[00:07:37] Yeah.

[00:07:39] But yeah, I think we usually just hang out like in the school.

[00:07:44] We have like a little common area that we –

[00:07:47] I mean, you'll see people there on the weekends and late nights and everything.

[00:07:50] That's where people like study and stuff.

[00:07:53] But no like cool spots of downtown or anything like that.

[00:07:58] All right.

[00:07:59] One thing – the next thing we're going to talk about last week, if you tuned in,

[00:08:03] we talked about posterior direct restorations.

[00:08:06] Talked about some composites mostly and some other materials for different indications.

[00:08:12] This week, we're going to go even kind of a little bit more basic than that.

[00:08:15] We're going to talk about anesthesia.

[00:08:19] So, I don't know where to start really.

[00:08:22] Where do you guys want to start in terms of talking about anesthesia?

[00:08:25] We're going to turn it back on you.

[00:08:26] Yeah.

[00:08:27] What do they teach you?

[00:08:28] We're going to say – let me pose it to you this way, Mohamed.

[00:08:32] You need to get number three, Nam, or a crown.

[00:08:35] Tell me what you're going to use.

[00:08:37] Like everything.

[00:08:38] Detail it out.

[00:08:40] Well, so I'm going to get some topical.

[00:08:42] Yep.

[00:08:42] And I'm going to rub that in for a little bit and probably leave it in, let them close for five or so seconds, 15 seconds, something like that.

[00:08:53] And then I don't really let the topical sit as long as they taught us to.

[00:08:58] Why?

[00:08:58] I'm usually kind of excited to get started.

[00:09:02] So, then I'll just do a local infiltration.

[00:09:06] With what?

[00:09:06] Just right buckle to the tooth.

[00:09:08] We always start with lidocaine, 2% lidocaine.

[00:09:11] Why?

[00:09:12] That's just the standard, what we're expected to start with.

[00:09:16] And what gauge of needle?

[00:09:19] I think it's 27.

[00:09:21] 27 is the middle, right?

[00:09:23] It's the middle-sized one.

[00:09:25] Long or short?

[00:09:27] Yeah.

[00:09:28] So, if I'm doing number three.

[00:09:29] That's kind of personal, Zach.

[00:09:31] Ooh.

[00:09:31] It was a little personal.

[00:09:32] Sorry.

[00:09:33] If I'm doing number three, I'll get the short needle unless I already had the long needle on for whatever reason.

[00:09:41] Like if I was doing a block before that.

[00:09:44] But I'm just doing local infiltration on the buckle.

[00:09:47] And when it comes time to pack cord, I'll do a little palatal infiltration as well.

[00:09:53] So, you're only using lidocaine?

[00:09:58] Well, so if I want to request another anesthetic, I have to fill out a slip and get it signed.

[00:10:05] I have to do that too at my office.

[00:10:08] I'm going to make that a requirement.

[00:10:10] I'm going to hand my assistant a slip tomorrow.

[00:10:14] So, to avoid like a time suck of waiting for a faculty just for a signature to get another carpule, I am trying to do...

[00:10:24] We're doing single teeth.

[00:10:26] So, wait a minute.

[00:10:26] You can't even get more than a carp without getting something signed off?

[00:10:30] No, it can't get more than a carp.

[00:10:31] Oh, man.

[00:10:32] You got to buy your own box or something like that and just have something in the pocket.

[00:10:35] With surgery, it's a lot easier.

[00:10:38] Okay.

[00:10:39] Yikes.

[00:10:40] All right.

[00:10:41] I don't remember anesthetic being that kind of an issue in school, but I guess times have changed.

[00:10:45] Kevin, how would you get the same tooth numb?

[00:10:47] I think I know, but go ahead.

[00:10:50] So, I would use a 30-gauge needle.

[00:10:55] Yep.

[00:10:56] And I would use 4% septicane, one to one, 100,000.

[00:11:02] And I would give what I have termed a Kevin Fryer PSA and that would mean basically depositing the anesthetic over the distal buccal root or over...

[00:11:18] We're doing number three, right?

[00:11:19] Yep.

[00:11:19] In the number two area.

[00:11:21] How's that?

[00:11:22] Okay.

[00:11:22] And then another carpule over the museal buccal root and that is going to get that tooth dead nuts numb, including the palatal unless there's some perio or inflammation for almost everything that I do.

[00:11:38] And my comment on this is that I want dead nuts numb teeth so I don't have to stop.

[00:11:49] There is nothing more of a production killer than having to stop.

[00:11:57] And I believe that I could probably get 70% of a number three numb with one carpule, but that's 30% of the time it's not going to happen.

[00:12:10] And I just don't want to stop.

[00:12:13] So, I'd rather overuse the anesthetic because it's not going to kill anyone.

[00:12:18] And the other thing I'm going to say to everyone listening to this is I think that anesthesia in itself is there's some sort of voodoo here and everyone has their own recipe.

[00:12:29] And it's like religion.

[00:12:31] Everyone thinks they're right.

[00:12:33] And the bottom line is, is your patient comfortable and can you work efficiently?

[00:12:38] Teaching at 3D Dennis has let me see what other people do en masse, like a lot of people.

[00:12:46] And it's very tedious to watch someone kind of fumble through getting someone numb for an implant procedure versus just, you know, let's just go for it.

[00:13:02] That's my opinion.

[00:13:05] So, let me say that I learned it the exact same way Muhammad did and then proceeded to do that in private practice for years and then would just run into frustration after frustration when the too high of a percentage of the time, that's not going to work for you.

[00:13:28] And when you get enough reps, you're going to figure that out also.

[00:13:31] And I got to be honest, it took me years to actually like back up and change a lot of my current anesthesia principles I've learned from Kevin, you know, and it was just like, why didn't I think of this a long time ago?

[00:13:44] But I'm going to do the same thing except for I use 1-200 on the septic cane just because I feel like I've had less post-op issues with it.

[00:13:54] But I'm going to use septic cane.

[00:13:55] I'm going to also do a PSA and then bring in most of a second carp on that mesial buckle.

[00:14:03] And then still, there's going to be some times because I'm a cord packer.

[00:14:08] There's going to be some times where I might have to stop and add a few drops to a paddle or on someone that's just a little bit, a little wimpier.

[00:14:18] So, I would say that that happens maybe 30, maybe 25% of the time.

[00:14:25] Add to the lingual.

[00:14:26] Yeah.

[00:14:27] It's like magic that you don't have to on a lot of these people.

[00:14:31] I think your 1-100 feels like it's probably a little stronger than my 1-200.

[00:14:36] Correct.

[00:14:36] And I'm willing to take that, I'm willing to accept that reduced strength for, I don't know, for a variety of reasons.

[00:14:45] But yes, that's how I would do it.

[00:14:49] Your patients lose confidence if they're not numb.

[00:14:53] Yep, that's true.

[00:14:54] They start getting nervous, which makes it more difficult for them to get numb.

[00:14:58] All of that sort of stuff.

[00:15:01] But right from the beginning.

[00:15:03] Once they feel something and start to complain about it, the rest of the procedure goes worse.

[00:15:09] Yep.

[00:15:09] You know?

[00:15:10] It's a compounding effect of bad.

[00:15:16] Yeah.

[00:15:17] I mean, it all makes perfect sense.

[00:15:18] I wish they weren't so stringent on how we give anesthesia because we have to explain why we want more than one carp.

[00:15:29] We have to explain what we think we did wrong.

[00:15:31] What is the dental school's take on septicane?

[00:15:37] What myths did they tell you?

[00:15:39] What lies, what propaganda have you been fed, young man?

[00:15:43] So it's very, I would say it's very faculty dependent.

[00:15:46] So in our actual course, we were taught by the oral surgery faculty who taught us the pain control course.

[00:15:55] He said it's fine to use even for IANs.

[00:16:00] However, he did mention like you're going to run into a lot of people who think it's not okay to use it in an IAN.

[00:16:07] And I have noticed like when I request an additional carpule, if I do need one, if I request articane, they'll be like, why don't you use lidocaine?

[00:16:19] Like, I don't know why, what it is.

[00:16:22] One carp, that's such a weird restrictive rule.

[00:16:27] Oh, that makes me mad, actually.

[00:16:30] Yeah, something must have happened at some point.

[00:16:33] Someone OD'd on the, they were taking it home and drinking it or something.

[00:16:38] Yeah.

[00:16:41] Go ahead, Zach.

[00:16:42] No, go ahead.

[00:16:43] Okay.

[00:16:44] Let's move to the anterior because I feel like that's like the area that I hate numbing the most.

[00:16:50] That is like the most sensitive area to numbing.

[00:16:52] Yeah, sorry.

[00:16:53] Yes, that's what I meant.

[00:16:55] Like, it's like a bad day is like all they've got to do is like a, you know, like a mesial lingual on seven and eight or something like that.

[00:17:05] I hate that.

[00:17:06] Not just because of the poor production part of the appointment, but I just, that shot, no matter how much I put the topical on there, that shot always goes bad.

[00:17:15] It doesn't go my way.

[00:17:15] I'm curious if you do something that I don't do.

[00:17:18] And so, I want to hear how you would get like seven, eight numbing.

[00:17:21] Go ahead, Kevin.

[00:17:23] Or Muhammad, you go first, actually.

[00:17:24] Muhammad, you go first.

[00:17:25] You got to get seven and eight numbing.

[00:17:27] Go.

[00:17:28] One carpalitacaine infiltration.

[00:17:31] I would probably give about, I would probably do about three quarters of the carpule, buccal infiltration.

[00:17:37] I have noticed that it definitely stings more for the patient.

[00:17:41] And I even noticed that when we were giving it on each other in StavLab.

[00:17:44] So, I tell them, I'm like, this one tends to sting a little bit more just so that they don't think it's my technique.

[00:17:51] That's like I tell them, hey, this one tends to sting a bit more.

[00:17:53] And I try to do more of the distraction stuff when I'm doing it.

[00:17:58] Like shake the lip kind of stuff?

[00:17:59] Like shake the lip.

[00:18:01] Tell them to count to 17.

[00:18:02] I always tell them to count to 17.

[00:18:04] 17?

[00:18:04] I don't know why.

[00:18:06] And still a 27-gauge needle?

[00:18:08] Yeah, it's the same.

[00:18:10] We only have 27-gauge needles, I'm pretty sure.

[00:18:12] Okay.

[00:18:14] All right.

[00:18:15] So, yeah, it's going to hurt more for particularly number eight.

[00:18:21] Let's think about it.

[00:18:23] Your nose is there.

[00:18:25] Yep.

[00:18:25] Your lips are there.

[00:18:27] I mean, that is one of the most highly innervated parts of your body.

[00:18:31] That's why kissing feels good.

[00:18:33] And that's why it hurts really bad if you get punched in the nose.

[00:18:39] So, if I'm going to get seven and eight, I'm not going to put the needle anywhere near seven and eight.

[00:18:45] I'm going to put it above six and work my way over there.

[00:18:51] So, it's hard to explain.

[00:18:52] Like at an angle?

[00:18:53] Yes.

[00:18:54] So, I'll go in above six, deposit some there, and then I will angle myself towards seven and eight so that the tip of the needle ends up in that area.

[00:19:07] Okay.

[00:19:07] And I would say 95% of the time I'm good to go there.

[00:19:11] Occasionally, I'll have to give a little bit more above the central incisor, but they're not going to feel that.

[00:19:17] The soft tissue is numb.

[00:19:18] Mm-hmm.

[00:19:19] Are you still using septicane on something like that?

[00:19:22] Like just, let's just say it's a basic operative.

[00:19:24] Okay.

[00:19:25] Yes.

[00:19:25] Okay.

[00:19:26] One carpule for that.

[00:19:27] Yes.

[00:19:28] Interesting.

[00:19:30] I might have to try that.

[00:19:31] You will have to try that.

[00:19:33] So, to avoid...

[00:19:34] Might not work with your lidocaine as well.

[00:19:35] It'll get seven numb.

[00:19:37] It'll probably get both numb.

[00:19:38] So, I haven't tried what you're talking about, but I also tend...

[00:19:42] Because of the...

[00:19:43] To reduce the sting, I've tended to use like a mapivacaine plane.

[00:19:48] Some without any...

[00:19:49] Because I know I'm not going to...

[00:19:50] I don't need them to be numb long.

[00:19:52] And I know that that anesthetic traditionally doesn't have quite the burn because it doesn't have the epinephrine in it.

[00:19:59] So, I've used that, but man, it still seems like the shot sucks.

[00:20:04] So, I may have to try Kevin's angle technique on that.

[00:20:07] Go above the canine and angle towards the corner of their nose, basically.

[00:20:12] Okay.

[00:20:12] I mean, it's going to get numb.

[00:20:13] Especially with...

[00:20:14] Do it with septicane.

[00:20:15] Oh, yeah.

[00:20:16] All right.

[00:20:16] Okay.

[00:20:17] Please.

[00:20:17] I'm going to do it next time.

[00:20:19] Yeah.

[00:20:19] It's on the list.

[00:20:21] All right.

[00:20:21] Have you...

[00:20:21] Oh, go ahead.

[00:20:22] Go ahead.

[00:20:23] I was going to ask, have you guys experimented with these alternate...

[00:20:27] Like the buffering, your anesthetics at all or...

[00:20:30] Yeah.

[00:20:31] I'm going to tell you right now.

[00:20:32] I have not...

[00:20:33] Because that's a problem I don't need to solve.

[00:20:36] Okay.

[00:20:37] I messed around with the buffering stuff for a while.

[00:20:41] And...

[00:20:41] Because I...

[00:20:42] We have buddies in our dental group that Kevin and I yap with that say it's good stuff.

[00:20:50] It was a waste of time and money.

[00:20:53] And it didn't...

[00:20:54] And the results weren't good enough to mess with it.

[00:20:59] And you can...

[00:21:00] You'll hear plenty of people say that you absolutely should and that I did it wrong.

[00:21:03] But I gave it a whirl and it wasn't for me.

[00:21:07] Okay.

[00:21:08] Good technique and good volume solves a lot of problems.

[00:21:13] Yeah.

[00:21:13] Makes sense.

[00:21:14] Yeah.

[00:21:15] And having a plan.

[00:21:16] Having a plan of like...

[00:21:18] Having a plan.

[00:21:18] Love it.

[00:21:19] What are you going to do when this doesn't work for you?

[00:21:23] You know?

[00:21:24] What are you going to do?

[00:21:25] Let's come back to that.

[00:21:26] Yeah.

[00:21:27] Yeah.

[00:21:28] So, like I said, having something in mind.

[00:21:29] Especially when it comes to things like...

[00:21:31] When you're dealing with hotter teeth for endo extraction.

[00:21:35] So, you got to have like...

[00:21:37] A couple different ideas of backup things you're going to do when the usual technique doesn't fly for you.

[00:21:46] All right.

[00:21:47] Mohamed, how are you going to get number 19 numb for a crown?

[00:21:51] So, number 19, I would...

[00:21:54] In this, I would use three quarters of a carpool, long needle this time, IAN.

[00:22:00] Mm-hmm.

[00:22:00] And then I would save probably a little more than three quarters of a carpool, probably like 90% of it.

[00:22:05] And I would save 10% to do a little buckle infiltration.

[00:22:08] Oh, Lord.

[00:22:09] With one carpool?

[00:22:10] One carpool.

[00:22:11] Yes.

[00:22:11] What's your success rate, honestly, with one carpool?

[00:22:15] I haven't done very many mandibular crowns.

[00:22:19] Okay.

[00:22:19] So, that's one thing that I have to say.

[00:22:22] I've only done a couple.

[00:22:23] Mm-hmm.

[00:22:24] Or maybe three now.

[00:22:25] This rule that your school has is setting you up for disappointment and frustration.

[00:22:31] Mm-hmm.

[00:22:31] Big time.

[00:22:32] Yeah.

[00:22:32] Mm-hmm.

[00:22:33] Big time.

[00:22:34] Because there is...

[00:22:35] I would never be able to do a crown on a vital tooth with one carp of anesthetic.

[00:22:44] I'm going to have a bad time.

[00:22:45] Kevin, you're going to have a bad time, aren't you?

[00:22:47] I...

[00:22:47] 100%.

[00:22:48] I couldn't do it.

[00:22:49] Yeah.

[00:22:50] I wouldn't do it.

[00:22:51] In the three instances where I was doing a mandibular crown prep on a molar...

[00:22:55] Or anything.

[00:22:56] Operative anything.

[00:22:57] Any of those.

[00:22:57] Yes.

[00:22:57] It's not going to work.

[00:22:58] Yeah, yeah.

[00:22:59] Right.

[00:22:59] Two of the times I went back for a second carpool.

[00:23:02] Mm-hmm.

[00:23:02] And the third time it was an endotreated tooth.

[00:23:04] So...

[00:23:05] All right.

[00:23:05] So, you're...

[00:23:05] Essentially, you're 0 for 2.

[00:23:07] Yeah.

[00:23:07] Yeah.

[00:23:08] It doesn't work.

[00:23:09] Yep.

[00:23:09] Yeah.

[00:23:10] Yep.

[00:23:12] That's what I do.

[00:23:13] Kevin, what are you...

[00:23:14] How are you getting that 219?

[00:23:16] I'm not going to recommend this for a student, but I am going to use the 30 gauge needle.

[00:23:22] And I'm going to use my 4% arcticane with mepinephrine 100,000.

[00:23:29] And I'm going to give two blocks with a plan, as Zach mentioned before.

[00:23:35] And here's my plan.

[00:23:36] I'm going to give a traditional IAN, you know, like textbook, the way they tell you to do it,

[00:23:50] with one carpool.

[00:23:51] One carpool, boom, right down the middle there.

[00:23:54] Yep.

[00:23:55] And then the second carpool, I'm going to aim higher than what you should aim for.

[00:24:03] And then the...

[00:24:05] And I'm going to give half of that.

[00:24:06] And then the second half, I'm going to aim lower and give that.

[00:24:11] And here's my rationale.

[00:24:13] This is going to be hard to describe on a podcast, but here's my rationale.

[00:24:17] You don't know where the foramen is, correct?

[00:24:22] This is blind...

[00:24:23] No, even if you feel for it, you're...

[00:24:25] You have no idea.

[00:24:26] You don't know where...

[00:24:26] You don't know.

[00:24:27] Right?

[00:24:27] So, you are doing this blind.

[00:24:30] And in my mind, if I think about the needle and the syringe as a fire hose or some sort of hose,

[00:24:40] I'm going to...

[00:24:41] And I'm trying to find a hole in a wall somewhere that I can't see.

[00:24:45] I'm going to aim where I think it should be, where the textbook says it should be.

[00:24:50] Then I'm going to aim higher than that and lower than that with a whole other carpool and just flood that area.

[00:24:57] And I would say 95% of the time, we have a completely numb tooth that we can rock on.

[00:25:06] Yep.

[00:25:06] Makes perfect sense to me.

[00:25:08] Do you go back and do a long buckle as well?

[00:25:11] Not generally.

[00:25:12] Okay.

[00:25:14] So, I...

[00:25:15] Sometimes.

[00:25:16] I've got a slightly different technique than Kevin on that.

[00:25:19] I also start with a 30-gauge needle.

[00:25:22] And my...

[00:25:23] I do warm my anesthetic for what it's worth, Mohamed.

[00:25:26] I mean, I know that's also...

[00:25:27] People will say you don't need that either.

[00:25:30] Anecdotally, that has been a winner on the pain control front of things.

[00:25:34] Not necessarily for anesthesia efficacy.

[00:25:36] But I've had less complaints of shots.

[00:25:40] Oh, here's another one.

[00:25:41] Stand up when you give your anesthetic.

[00:25:43] Yes.

[00:25:44] Oh, I love that.

[00:25:44] Stand up when you give your...

[00:25:45] I sat for years.

[00:25:47] Especially if you're a slightly shorter person.

[00:25:51] You know, I'm not very tall.

[00:25:52] I know there's a lot of female dentists that aren't very tall.

[00:25:55] Stand up to give your anesthesia.

[00:25:56] That's a very sexist comment.

[00:25:59] Okay.

[00:26:00] All right.

[00:26:00] I'll accept that.

[00:26:02] By the way, though, stand...

[00:26:04] When I move to standing for giving my anesthetic...

[00:26:08] And I'm talking like almost all of it except for maybe on kids.

[00:26:11] Top and bottom.

[00:26:12] Top and bottom.

[00:26:13] I stand and I get a better angle and I can move my head around with my headlamp better.

[00:26:20] I didn't do that for 15 years.

[00:26:23] And ever since I started doing that, everything's been better.

[00:26:26] So, I stand up to give my anesthetic.

[00:26:28] If you want to...

[00:26:30] The only way I can know visually that I'm parallel to the floor is if I'm standing up and the patient is sitting up.

[00:26:38] Yeah.

[00:26:39] So, that...

[00:26:40] I know, again, this is hard to see, but my angle is now more on target because I'm parallel with the floor.

[00:26:48] If they're laying back...

[00:26:50] Yeah, no.

[00:26:50] The patient's never fully reclined when I'm doing this.

[00:26:52] They're like some recline, but not fully reclined.

[00:26:56] Yeah.

[00:26:56] They're laying back just a little bit, but you're...

[00:26:59] Not like you are right now.

[00:27:00] Right.

[00:27:01] But you're standing up.

[00:27:03] Yep.

[00:27:03] If they're laying flat on their back, I don't have any point...

[00:27:06] I'm going to miss that block.

[00:27:07] I feel like I have a point of reference.

[00:27:09] I'm going to miss that block every time.

[00:27:11] So, I use my 30-gauge needle.

[00:27:13] I use my Pivacane plane to just kind of give like...

[00:27:17] I'm basically numbing the soft tissue on the way to the block.

[00:27:20] And I also use half the carp to do my long buckle.

[00:27:23] Then I load my long needle, my 27-gauge.

[00:27:26] And now I'm going to be able to put that needle basically to the hub without the person, you know, ooching or gooching.

[00:27:33] And now I'm going to be able to put the whole carp back in, you know...

[00:27:38] And I do go kind of high and low, just like Kevin's talking about.

[00:27:41] A little bit high, a little bit low.

[00:27:44] What are you using for the second carp fuel?

[00:27:47] The Septicane 1-200.

[00:27:49] Okay.

[00:27:49] Here's another thing.

[00:27:50] I think that there's a lot more pain and potential trauma if you reuse a needle.

[00:27:57] I will occasionally do that and break my own rule.

[00:28:00] But for my setup for both situations that we described, number three and number 19, I have two syringes.

[00:28:10] Like two of them.

[00:28:12] One goes in, the other goes in.

[00:28:15] Yep.

[00:28:15] So, I'm not reusing, particularly on a block, especially with a 30-gauge needle.

[00:28:20] You're going to...

[00:28:21] You can feel it rip and tear back there.

[00:28:23] Yep.

[00:28:24] And then you're going to get someone call back and say, you know, they have trismus or they've been ooching and gooching.

[00:28:30] I had to say that.

[00:28:35] They're not going to be happy.

[00:28:37] Yep.

[00:28:37] So, don't...

[00:28:39] I mean, that just hurts.

[00:28:41] It does.

[00:28:42] It does.

[00:28:43] So, anyway, there you go.

[00:28:44] That's how I would...

[00:28:46] That's a lower block for you.

[00:28:48] All right.

[00:28:49] Real quick.

[00:28:52] So, let's go over both scenarios.

[00:28:55] Let's say you listen to Kevin Fryer and your number three doesn't get numb with that technique.

[00:29:02] Like they're still feeling something.

[00:29:04] What are you going to do next?

[00:29:06] You're...

[00:29:06] Muhammad, you're out of this equation because you can only use one car fuel because although...

[00:29:12] You're screwed.

[00:29:13] You've only seen 20 patients in your whole lifetime.

[00:29:17] Your faculty thinks you're a magician.

[00:29:19] You're...

[00:29:20] The whole school is full of wizards that can make people numb with one car fuel.

[00:29:25] But, Zach, if your number three doesn't get numb after doing what I described, what's your go-to move here?

[00:29:31] Okay.

[00:29:32] Have you given a...

[00:29:33] Have you done a palatal?

[00:29:34] Because that...

[00:29:35] Like I'm going to do that first.

[00:29:36] Okay.

[00:29:37] Now.

[00:29:37] That's fair.

[00:29:38] And what?

[00:29:39] Okay.

[00:29:39] Now I'm going to go four corners.

[00:29:41] I'm going to do my...

[00:29:42] Like a PDL kind of a thing.

[00:29:44] Okay.

[00:29:45] All right.

[00:29:47] So, I think that you need to be aware of that MSA or whatever that is.

[00:29:53] I'm going to go over the bicuspids and give them some extra.

[00:29:57] Oh, you're going to go more...

[00:29:58] Well, see, I figured I've already covered.

[00:30:00] Okay.

[00:30:00] So, I'm going to go even more anterior and just see what happens.

[00:30:04] And then if that doesn't work, then I'm going to start doing some PDLs.

[00:30:09] So, you wouldn't go to the palatal first?

[00:30:11] You wouldn't go palatal?

[00:30:11] I might.

[00:30:12] I might.

[00:30:13] It depends on where they're feeling it.

[00:30:15] Okay.

[00:30:16] It kind of depends a little bit on the procedure as well.

[00:30:19] The crown prep may be a little different than like an endo or a auto.

[00:30:24] Yes.

[00:30:25] Yeah.

[00:30:25] They definitely have a palatal if I'm doing an extraction.

[00:30:28] Oh, sure.

[00:30:29] Sure.

[00:30:30] How about endo?

[00:30:31] Are you numbing the palate on an endo?

[00:30:34] Not generally.

[00:30:35] I'll just give them an intrapalpal.

[00:30:37] Okay.

[00:30:37] They feel it.

[00:30:38] I'm ramming it in there.

[00:30:39] That kills it quick.

[00:30:41] You're moving on.

[00:30:42] That's true.

[00:30:42] That's not for the faint of heart, but it does work.

[00:30:45] And I've certainly had to pull that one out.

[00:30:47] That's not a fun day.

[00:30:48] I have no heart.

[00:30:51] Okay.

[00:30:52] Okay.

[00:30:53] All right.

[00:30:54] I've had to give one intrapalpal.

[00:30:57] I was at an extraction clinic and it was a hot tooth.

[00:31:01] I actually wanted to pose this question on you guys.

[00:31:03] It was a hot tooth.

[00:31:04] It was a lower molar.

[00:31:05] I think it was number 31.

[00:31:07] And it, I mean, it had a pulp polyp.

[00:31:09] So, like.

[00:31:10] Are you taking this tooth out?

[00:31:12] Is this an endo or auto?

[00:31:14] It's an extract.

[00:31:15] It was an extraction.

[00:31:16] Okay.

[00:31:17] But since it had a pulp polyp, I had access to the pulp chamber.

[00:31:22] So, I tried a couple things and I just, I ended up just going for it because nothing

[00:31:27] else was working.

[00:31:28] So.

[00:31:29] Did it work?

[00:31:30] Yes.

[00:31:30] It worked, but they definitely jumped.

[00:31:32] Oh, yeah.

[00:31:33] For sure they did.

[00:31:34] For sure they did.

[00:31:35] Yeah.

[00:31:37] I mean, that's the right thing to do in my opinion.

[00:31:39] So, what would you do for.

[00:31:40] So, you guys talked a little bit about what you do for kind of, it's not working in the

[00:31:45] maxillary.

[00:31:45] What would you do in a mandibular molar kind of like that?

[00:31:49] Zach, you go first.

[00:31:52] I'm going to, I'm going, I'm going to go to some, some PDL.

[00:31:56] I already did my, I've already done my long buckle.

[00:31:58] So, I've done that.

[00:31:59] I might add more to that infiltration area with septicane, but in general, I'm probably

[00:32:03] going to go to my, I'm going to try to get some, you know, PDL anesthesia for four

[00:32:08] quarters with, don't use septicane on that.

[00:32:11] Lidocaine works better for that in my opinion.

[00:32:14] I think you'll get too much tissue necrosis with septicane.

[00:32:17] That's been my experience with it.

[00:32:18] Maybe Kevin's got, does not have that experience, but that's been my experience.

[00:32:22] So, I'll use lidocaine and I'll go four corners on it and, or try to get some down in the

[00:32:29] furcation area.

[00:32:30] And that's going to, that's going to solve the majority of my problems.

[00:32:35] If it goes beyond that, we've got a real problem.

[00:32:38] Like, yeah, yeah.

[00:32:39] We may not be able to get that procedure done that day.

[00:32:41] What about you, Kevin?

[00:32:42] How do you troubleshoot that?

[00:32:43] So, I guess a little differently.

[00:32:45] I think you need to have a plan, right?

[00:32:47] So, you need, and you need to troubleshoot what's happening.

[00:32:50] So, we've all had patients.

[00:32:52] You give them a block.

[00:32:54] I give them two carpules.

[00:32:55] I ask them, does your lower lip feel different?

[00:32:58] Does this side feel different than this side?

[00:33:00] And they say, yes, but it's not really.

[00:33:03] They're either wanting to be agreeable with you or whatever they're feeling.

[00:33:10] They felt something from the topical.

[00:33:13] They're, they're really not numb, right?

[00:33:15] They don't have a lip sign.

[00:33:17] Okay.

[00:33:18] If I miss the lip, I might do something different than what I described.

[00:33:22] Yeah.

[00:33:23] I would probably give another block in another direction.

[00:33:25] But that's the plan.

[00:33:26] So, I'm going to give them another block and I'm going to let them sit there for a few minutes.

[00:33:31] And nine times out of ten, they're numb.

[00:33:33] We're, we're moving on.

[00:33:35] If they tell me that their lip is numb and I know it's numb because I jammed an explorer in between 22 and 23 in this scenario and they don't flinch, now we've got a problem.

[00:33:48] So, my go-to move there would either to be, to give an infiltration, even though it's number 19, I'm going to put a half a carpal or three-fourths of a carpal in the buccal vestibule.

[00:34:01] Let that sit there for just a little bit and see if they're feeling anything.

[00:34:04] I'd say, you know, maybe 70, 60 or 70% of the time, that's all they need.

[00:34:09] And then, like Zach, after that, I'm going for the, for the PDL.

[00:34:14] Do you use septicane or lidocaine on those PDLs?

[00:34:18] Septicane.

[00:34:19] Oh, you use septicane.

[00:34:20] Okay.

[00:34:20] All right.

[00:34:20] Very good.

[00:34:34] I've got one of those fancy PDLs.

[00:34:36] And I, I, and I'm sure those are wonderful and probably better than what I've got.

[00:34:41] I've done okay enough with the, with the regular syringe.

[00:34:45] And it sounds like Kevin has also.

[00:34:46] I've done okay enough also.

[00:34:47] Yes.

[00:34:47] Yeah.

[00:34:48] Okay.

[00:34:48] And then, um, if the tooth isn't numb and you go to the PDLs, does the patient usually feel that?

[00:34:56] They're going to feel some pressure.

[00:34:57] I tell them they're going to feel some pressure because you're going to be pushing that needle in there and then you're going to be putting a lot of pressure on the, on the, uh,

[00:35:05] on the syringe.

[00:35:06] And, and I think you're going to get some tissue.

[00:35:07] Like, I think he's just going to be a pressure.

[00:35:09] Almost like when you're given a palatal and you're like, Hey, a lot of pressure is coming your way.

[00:35:12] So I think it's like that.

[00:35:14] Okay.

[00:35:15] I think it's like that.

[00:35:16] Good to know.

[00:35:17] Um, and then I do have one question that I have to ask.

[00:35:20] Do you guys ever go to like a Gal Gates or an Akinosie or anything like that?

[00:35:24] So my higher injection technically is a Gal Gates.

[00:35:29] Wait, Gal Gates is when they're closed, right?

[00:35:32] No, that's the Akinosie.

[00:35:33] Gal Gates is the one that's like, you're almost given like a PSA, but not quite.

[00:35:37] Yeah.

[00:35:37] So, um, the part of the reason I do what I do is because I'm aiming higher, um, for that reason.

[00:35:47] I have, believe it or not, I've occasionally had, wait, which one is Akinosie's closed mouth?

[00:35:53] Yeah.

[00:35:54] Yeah.

[00:35:54] I've, I've, in my younger days, I resorted to that and had pretty good success with it when

[00:36:01] I couldn't get someone numb, but I haven't done, I totally jinxed myself for tomorrow,

[00:36:06] but I have not had to do that for a long, long time.

[00:36:10] Never do that, Zach?

[00:36:11] No, never.

[00:36:11] I've never done that one.

[00:36:12] It's a fun injection, man.

[00:36:13] If they're closed.

[00:36:15] If you line that.

[00:36:16] So think about where that's lined up.

[00:36:18] It's lined up with the, uh, gingival margin of the upper teeth.

[00:36:24] Yeah.

[00:36:24] Of the maxillin.

[00:36:25] That's pretty high.

[00:36:26] Yeah.

[00:36:27] You draw a line back there.

[00:36:28] That's pretty high.

[00:36:29] So.

[00:36:30] I'm going to go my whole career and not do that injection.

[00:36:33] I'm just going to, I'm just going to say that.

[00:36:35] I'm not, I'm not going to do that.

[00:36:37] You're not going to do a V2 block either?

[00:36:39] No.

[00:36:40] Nope.

[00:36:40] I'm going to go my whole career without doing that too.

[00:36:42] Lock it up.

[00:36:43] Okay.

[00:36:43] I have an anesthesia question for this is probably more for Kevin because I don't know if Muhammad's had the reps and plus he doesn't get enough anesthetic to even get a tooth numb anyway.

[00:36:53] Uh, Kevin, do you do anything to like test a tooth before you start, you know, drilling in?

[00:36:59] Do you like do a cold test or an air test or anything?

[00:37:02] Or do you just, after you, after you get the like, okay, my lips numb or this is just, it's go time.

[00:37:08] It's just go time for me.

[00:37:10] And the flaw in that is, you know, people telling you that their lower lips numb when it's not.

[00:37:18] I mean, that's in the course of a week or a month, that's going to happen a couple of times, but that's overcomable.

[00:37:24] Oh, I'm really sorry.

[00:37:25] You know, you're not numb.

[00:37:26] Let me give you a little bit more.

[00:37:28] Right.

[00:37:28] We're going to get this tooth comfortable for you.

[00:37:31] I do not go to the extent of like, you know, using the, uh, like the, the endo ice on a tooth to really test it.

[00:37:38] But I will take my air water syringe and put it, you know, just right into a spot and I will blast some air, maybe a little bit of water and just ask them if like, if, does this just feel like air passing by your tooth?

[00:37:50] Or do you feel any like temperature associated with it?

[00:37:54] And if they feel, if it feels cold, if it doesn't, if that doesn't feel good, it gives me an opportunity to troubleshoot the, the anesthetic right then before I picked up a handpiece.

[00:38:05] And so that, that's, that's been an efficiency helper for me because it's like once the handpiece comes gone, I want to, I want to keep going.

[00:38:13] I don't want to have to stop at that point.

[00:38:15] So that's, that's been a help for me.

[00:38:18] I guess an important question that I, that I never thought to ask until just now is how long are you letting it sit, um, on both the mandible and the maxilla before you get started?

[00:38:29] So, uh, you know,

[00:38:34] and the maxilla that septic cane is going to work in three to five minutes by the time I get the rubber dam on or sit down and chit chat or whatever.

[00:38:42] That, that's going to be numb very, very quick.

[00:38:45] Okay.

[00:38:46] So here's the, here's the pro tip there.

[00:38:47] The anesthetic comes, comes first before you do anything else.

[00:38:52] It's like other than greeting the patient and asking them if they have any questions about what you're doing today.

[00:38:59] The anesthesia comes first.

[00:39:01] Then you can get all the other stuff.

[00:39:03] Like if you're doing a crown prep, then the, you get your pre-op impression for your temporary.

[00:39:08] Then you get your, your scanning done.

[00:39:10] Then you get your shade done, but just get the anesthetic in.

[00:39:14] And then most of the time you'll be ready to go by the time everything else is done.

[00:39:18] Same on, on the, on the operative, the rubber dam, get that in.

[00:39:22] And then by the time that's in, that's that you're good to go or get the tooth polished off or something like that.

[00:39:28] By the time the pre-op scans are done, they're numb.

[00:39:33] Yes.

[00:39:33] Top or bottom.

[00:39:34] So, but if you're asking a time, a proc, you know, between seven and 10 minutes on the lower and three to five minutes up on top, I'm ready to go.

[00:39:43] Let's do it.

[00:39:44] One of the, one of the keys, and this is not something, this is not a school thing.

[00:39:48] This is a private practice thing is to like, have like a logical sequence to your day.

[00:39:52] Like you give that anesthetic and then go check your hygienist.

[00:39:56] So that, that way that's done.

[00:39:57] And then you can come back and then you're not going to have to do that.

[00:40:00] You know, like, you know, there's ways to like use the time rather than just sitting there in the operatory having to, you know, God forbid, talk to your patients or something like that.

[00:40:12] So, I mean, that comes back to my premise is that we're selling time.

[00:40:17] So we're going to make good use of the time by getting them numb quickly or in the front of the appointment and then doing all of those other things while you're utilizing the anesthesia time.

[00:40:31] And I don't know that I was taught that in dental school.

[00:40:34] That was certainly taught that the first day of my first real job.

[00:40:38] I don't think, I don't even think I picked up some of that.

[00:40:40] I mean, I think, I feel like I would waste a bunch of time like going over some like answering all their questions.

[00:40:46] But like sometimes they got a bunch of, it's like, I can answer these questions while you're getting numb.

[00:40:49] You know, I mean, like, like just get the, get the juice flowing, you know?

[00:40:54] So that's my advice there on that, especially in dental school when you're hurting for time and stuff like that.

[00:40:58] Although I guess, you know, you don't want that anesthetic wear off since you only get, you know, half a car, you know?

[00:41:03] So beware.

[00:41:05] Yeah, precious working time.

[00:41:07] Well, we have to wait for, for permission to proceed or whatever.

[00:41:11] You have to get your start check first before you can even think about getting anesthetic going.

[00:41:17] So it's, it's those kinds of things that make my head hurt when I'm thinking about school.

[00:41:24] It's like the memories that I know exactly what you're saying.

[00:41:27] I don't remember being restricted on anesthetic.

[00:41:30] I don't remember just having it in my little cart that I had.

[00:41:33] I just, I think I feel bad for you in that, in that respect, because that is a true disservice on multiple levels.

[00:41:41] I really think in the Malamed book, he says that one carpule for an infralveolar block is like successful 80% of the time.

[00:41:51] So that, yeah, 20% is a huge percentage.

[00:41:54] Well, yes, for one, that's a huge percent.

[00:41:56] And then that's an experienced user, not someone who's given less than 20 blocks in their life.

[00:42:01] Yes.

[00:42:01] Yeah.

[00:42:02] You're right.

[00:42:03] You're right.

[00:42:04] I agree.

[00:42:05] I might, I might send this a podcast link to the Dean's office.

[00:42:09] Actually, I definitely won't do that.

[00:42:11] I bet you, do you get any, do you get any shade for doing this show?

[00:42:15] Do you get any, any heat?

[00:42:17] I want Muhammad to be called to the principal's office.

[00:42:20] Yeah.

[00:42:21] Yeah.

[00:42:22] I've only had a couple faculty mention the podcast to me.

[00:42:26] Okay.

[00:42:27] All right.

[00:42:27] So I'm thinking that most of them are not listening to any podcasts.

[00:42:31] Well, if they are listening, Muhammad,

[00:42:33] it's the coolest person we've met ever podcasting.

[00:42:37] And he's a really good, diligent student.

[00:42:39] And he should get more than one carpool.

[00:42:41] That's right.

[00:42:42] Slip him one on the slot on the fly.

[00:42:44] Yeah.

[00:42:44] Here's, here's one.

[00:42:46] Wink, wink.

[00:42:47] I feel like I'm going to send you a box, man.

[00:42:49] Just give me your address.

[00:42:50] I'm going to send you a box.

[00:42:51] You just keep those bad boys in your pocket and we'll just keep it between us.

[00:42:55] Yeah.

[00:42:55] So keep them in my pocket.

[00:42:56] It'll be, that'll kind of give it the warming.

[00:42:58] Yeah.

[00:42:59] That's your, that's your anesthetic warming.

[00:43:00] You, you warm them up for us.

[00:43:01] So, yep.

[00:43:03] Perfect.

[00:43:03] All right.

[00:43:04] Well, I think we covered all things, um, anesthesia.

[00:43:07] Um, and I think we're, we're doing pretty good on the segment.

[00:43:11] I've been enjoying them.

[00:43:12] Um, so tune in next week to see what we got next.

[00:43:17] See you guys.

[00:43:18] We'll see you.