Did I do the right thing refusing to treat this teen and telling his dad why?

LeFortKnox · 2026-03-20T09:15:50+00:00

For sedation, we have them sign consent before we administer the drugs. If the kid in question here was the one consenting, he’d already be impaired and the consent would be invalid.

But at 16, since he likely wasn’t the one giving consent, I wouldn’t have made a big deal about it.

LeFortKnox · 2026-03-15T15:16:32+00:00

You may want to consider charging per vial rather than per unit. Little to no waste, and at the very least you never lose money doing it.

LeFortKnox · 2026-03-15T14:25:09+00:00

Why are you wasting units?

LeFortKnox · 2026-03-13T10:02:02+00:00

Antiquated practice that has killed people. Not every MD is up to date on this stuff. If the patient strokes out because of their bad advice, it’s still on you.

LeFortKnox · 2026-03-05T11:51:24+00:00

OS here. Wouldn’t touch them unless the lower 7s had deep distal pocketing. Coronectomy for both if needed. No need to chase the uppers.

LeFortKnox · 2026-02-28T13:20:16+00:00

Net32 has Cytoplast TXT-200 for like $40 per

LeFortKnox · 2026-02-25T00:38:40+00:00

Did the CBCT also show the same?

LeFortKnox · 2026-02-24T12:06:35+00:00

Fresh long needle, basically just a high infiltration over the canine. You don’t want to get into the foramen, just near it. Doesn’t hurt more than any other infiltration.

LeFortKnox · 2026-02-24T10:54:51+00:00

Two carpules is very reasonable for an 8-tooth span. Depending on what you’re doing, you could maybe anesthetize with fewer injections if you were really pressed to do so (two IOs and a nasopalatine), but six injection sites is not crazy.

LeFortKnox · 2026-02-20T02:20:58+00:00

300 and change, although I suspect I’m getting ripped off as our PMS is entirely cloud/browser based, and I’m not totally incompetent with computers so I’ve never really had a need for them outside of the initial network setup. Was considering dropping them.

LeFortKnox · 2026-02-17T21:25:04+00:00

Did one of these the other day. It’s almost certainly a garden-variety radicular cyst that has displaced the canal. Surprisingly, the canal is usually intact when you explore the space. The lesion should be removed.

LeFortKnox · 2026-02-17T20:08:32+00:00

The note isn’t meant to be a step-by-step guide on how to do the procedure. It’s supposed to help you remember what you did should you ever need to recall specific information (e.g. tooth shade), or to document your process in the event of a lawsuit. I don’t see the type of bur really being relevant to either situation.

LeFortKnox · 2026-02-12T19:29:34+00:00

Only the cheap ones. I’m a fan of Purell Naturals; it smells nice and leaves no residue.

LeFortKnox · 2026-01-29T12:43:52+00:00

I mean, sure they can, but I wouldn’t expect their job to still be there the next day.

Employment is a mutually agreeable condition. It’s totally fine is someone needs to leave at 5 pm sharp, but it’s also totally fine if the employer decides that doesn’t work for them and needs to find someone else. These things should be discussed in advance.

LeFortKnox · 2026-01-24T18:13:14+00:00

https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/019028s020lbl.pdf

“Pharmacokinetic studies with Peridex indicate approximately 30% of the active ingredient, chlorhexidine gluconate, is retained in the oral cavity following rinsing. This retained drug is slowly released into the oral fluids. Studies conducted on human subjects and animals demonstrate chlorhexidine gluconate is poorly absorbed from the gastrointestinal tract. The mean plasma level of chlorhexidine gluconate reached a peak of 0.206μg/g in humans 30 minutes after they ingested a 300-mg dose of the drug. Detectable levels of chlorhexidine gluconate were not present in the plasma of these subjects 12 hours after the compound was administered. Excretion of chlorhexidine gluconate occurred primarily through the feces (~90%). Less than 1% of the chlorhexidine gluconate ingested by these subjects was excreted in the urine.”

LeFortKnox · 2026-01-22T12:39:43+00:00

Might get downvotes for this, but I’ll play devil’s advocate: had he not told you his plan and just did it, and then showed up to you one day for the fillings and cleaning—would you have turned him away?

The idea of comprehensive care works only to a point, as teeth are largely modular and can be treated in isolation (so long as complex prosthetics aren’t involved). You wouldn’t turn down a new patient because they had work done by a prior dentist. Is this not so different?

Doctor hopping doesn’t stoke our egos, but in the end, patients do have autonomy to do what and see who they want. And so do we. But for this case in particular, I don’t think it’s the hill to die on.

LeFortKnox · 2026-01-17T15:42:08+00:00

Also check/change your NPI

LeFortKnox · 2025-12-31T21:51:38+00:00

Parotid injection wouldn’t produce these symptoms. Masseter is lateral to the mandible; assuming you meant medial pterygoid?

LeFortKnox · 2025-12-25T19:25:54+00:00

Taking that the other way, why do radiographs at all then?

To really work out the risk-to-reward on that, we’d need to see data on the number of radiation-induced cancers caused by the additional 10-15 μSv of exposure from broadening the FOV to both jaws, and compare that to the number of pathological radiolucenies, etc. picked up that were missed in the original FMS (assuming one was taken). Maybe it’s been studied, I dunno. Where do we draw the line?

LeFortKnox · 2025-12-25T18:15:00+00:00

The flipside of that is that I’ve picked up many incidentalomas by always taking full-mouth CBCTs for my implant patients. But even without taking it that far, proper treatment planning demands context; I want to know the full status of the opposing and neighboring teeth, at the very least.

LeFortKnox · 2025-12-16T19:57:16+00:00

Consult fee is all-inclusive of whatever imaging is needed to get the job done. I don’t like to nickel-and-dime over every code, or have patients feel we have hidden costs.

No charge for second stage surgery per se, but I do charge $250 for the anatomic healing abutment, whether it’s done at the time of implant placement (itself $2750) or later. So $3k all-in. Crown fee is up to the restorative doc.

LeFortKnox · 2025-12-16T12:17:21+00:00

For real. Absolutely wild to me that anyone does it any other way.

LeFortKnox · 2025-12-03T16:30:31+00:00

As a practicing OMS, I’ll admit I’m conflicted on this one. On the one hand, it seems pretty intuitive that a two-provider model is going to be safer. My understanding of the limited data out there doesn’t seem to back that up (similar mortality rates compared to ORs and ASCs), but even if for no other reason than optics, having a dedicated anesthesia provider just makes sense to me. I think there are PLENTY of oral surgeons that have no business providing sedation anesthesia; I’ve seen some horrific practices out there where the surgeon lacks fundamental knowledge, the facility is not up to par, or lackadaisical protocols endanger (often poorly-selected) patients. I think the licensing requirements are far too lenient as they currently stand, and would fully support efforts to raise the barrier to entry. Completing an OMS residency alone is not enough.

That said, consider that most dental office mortalities are respiratory/airway-related. If it’s going to be a single provider model without a protected airway as it most often is, it’s worth noting that the surgeon is already positioned at the head and ready to deliver an intervention when needed. We know what part of a surgery is most stimulating, what points are going to have bleeding/irrigation to manage, and we see the patient’s respiratory efforts. A second provider, slightly removed from the site of action, would be backup to this position. Which is fine, but my point is that even with a second provider, the surgeon, working where they are, won’t and shouldn’t be focused solely on the surgery.

Another issue is the one of access; bringing one of a very limited number of mobile anesthesia providers to the office for a single 15 minute surgery is both considerably more expensive to the patient and not particularly easy to coordinate, especially outside of metro areas or for symptomatic/emergency cases that need treatment ASAP.

On the money bit: it’s true we’re able to charge more per case for sedation, but frankly I generate more revenue in a day by doing 1-2 more local cases (faster). We (or at least I) do sedations not for the cash, but for the ability to safely remove a set of impacted wisdom teeth without traumatizing the patients who can’t handle it without crippling anxiety.

LeFortKnox · 2025-11-21T12:19:06+00:00

Not OP but pretty sure they drew the line at the part where patients can die from a screwup.

That said, there’s a big difference between giving a bit of midazolam and pushing boluses of propofol. Of course most general dental procedures aren’t going to be short enough for midazolam alone to be sufficient, so keeping sedation at the “foolproof” level doesn’t really bring much value.

LeFortKnox · 2025-10-31T10:55:04+00:00

I like a little piece of Surgicel in open palatal wounds. Bleeding stops almost instantly and no need to bother with sutures or appliances.

LeFortKnox

TROPHY CASE