Monday, February 16, 2009

Children's Dental Expert Gives His Thoughts on "David After Dentist" Video

As a dentist, I was mildly distuburbed after watching the David After Dentist YouTube video that's making the rounds of Twitter and the blogosphere. As of this writing, the video has over 9 million views.

My friend, Dr. Lance Kisby, director of Pediatric Dentistry at Geisinger Hospital in Pennsylvania, however, was more than mildly disturbed -- he was downright mad.

Here are his comments about why this video is so bad with regard to children's dentistry -- and why it gives completely inaccurate information about the role of pediactric dentists (or pedodontists, as they are known).

The 2006-2007 Pedodontic Sedation Guidelines are REALLY clear regarding sedating children. The guidelines state that before the patient is dismissed from the office he/she must be:
1. verbal
2. alert
3. awake
4. able to walk under their own power
5. given verbal tests (say the alphabet or count to 20) to determine level of recovery.

The guidelines are crystal clear on this: if the patient is none of the above (you really need all five to send the patient home), the patient must stay in office until FULLY recovered.

And, according to Sedation Guidelines, parents are not allowed to premedicate kids at home before dental appointments. Once you premedicate a child and put him or her in the back seat of a car, you run the risk of the child falling asleep, having his head fall forward and dying due to:
a)Seat belt on the neck
b)The anatomical variation in kids'airway anatomy . . . it is conical, narrow at the cricoid cartilage (adults are wide and parallel).

In addition, sedating young children is not as simple as giving a kid nitrous. When doing sedation on children using nitrous, the tragus of the ear HAS to be parallel to the sternum. If not, the airway gets blocked due to anatomy.

And, most important when it comes to sedation -- kids are not adults!

Here is an equation:

Cardiac output = Heart rate X stroke volume



Children, unlike adults, cannot vary their stroke volume. Thus, in the equation, stroke volume is a constant. Thus,


That means, blood pressure is heart rate dependant.

Decreased O2 causes bradycardia (in adults it causes tachycardia). Bradycardia (decreased heart rate) causes decreased blood pressure.

Decreased blood pressure in a child is dangerous. This is because children go FAST -- as in, they die.

In the 4-day simulation course I took last year on Sedation, we found out all too well that decreased PG means decreased 02 and then it spirals out of control. Big time. In our course on the $1 million dollar dummies we worked on, and which are true to live, the "child" was dead in 30 seconds.

Adults have 02 levels that go like this: 100-99-98-96-93 . . . etc.

A child's 02 levels go like this: 100-92-88-70. Yup, that fast.

Now, here is the kicker. Since children's heart rates are higher, here is the rule: if a child's HR is 80, you must start CPR immediately.

Let me put it in real life terms for you. You're a dentist with a child in the chair. You are talking and he is talking about your good looks, your dress, the Patriots, and the weather. His heart rate is 80. He is lucid. He is talking. No problems noted. You immediately level your chair, insitute CPR with chest compressions and breathing and call 911. I am not kidding!

Here at the hospital, we have a sedation team and they sedate kids for me in the PICU rather than me worry about all this stuff. Last Thursday, a child's O2 went: 100-99-82 . . . that fast. I had to stop and the sedation team did their thing.

I get aggrevated when dentists and parents say 'Aw, just sedate the kid.' I have been doing children's dentistry forever, and I don't sedate.

Now you know why I find this David After Dentist video highly aggraviating.

Well, I guess that sums up why dentists are truly health care professionals, why modern dentists keep up to date with technology and advanced techniques, and why really good dentists leave advanced procedures, such as sedating children, to real experts.

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