"The Block Stops Here" Regional Dental Anesthesia and Leading Your Team

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Every dental and oral surgery procedure starts with a decision most teams make in seconds and rarely revisit.
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Are we blocking this patient?
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And is the whole team actually ready for what happens next?
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Today's guest has spent his career providing the nerve block and briefing before it are just as important as the procedure itself.
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I'm talking with Dr.
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Chris Snyder, Associate Dean Hospital Director, ABDC founding fellow in oral maxylfacial surgery, and one of the most published voices in veterinary regional anesthesia.
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About pain control that actually works, the team leadership that makes it stick.
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This is Positive Veterinary Dentistry Podcast.
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If you've ever second guessed whether a regional block was worth the extra five minutes, Chairside, or wondering how to get a whole dental team growing in the same direction, today's episode is for you.
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My guest is Dr.
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Chris Snyder.
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He's a diplomate of the American Veterinary Dental College and the European Veterinary Dental College.
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He is also a founding fellow in oral maxillofacial surgery.
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He currently serves as a clinical professor and associate dean for clinical affairs and hospital director at the University of Wisconsin-Madison School of Veterinary Medicine.
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And his research on regional nerve blocks has shaped how general practitioners and specialists alike approach dentistry and oral surgery pain management in dogs and cats.
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He's published in the Journal of Veterinary Dentistry, in JAVMA, and other publications.
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So welcome to the show, Dr.
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Snyder.
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Thank you.
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Thank you for having me.
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Absolutely.
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When I saw you last, we were in Porto, Portugal, and I sat in and listened to a lecture on this very subject.
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And your ears must be burning all the time because as I go out into the world and teach veterinary dentistry to general practice professionals, I'm often asked a lot of questions about the methodologies, the medications, the drugs, the everything.
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And I'm usually talking a lot about regional nerve blocks because I'm talking about dental sensor safety.
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So dental radiology using a very expensive sensor, I always tell people nothing you wrap on the outside of that sensor is going to keep it safe.
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What keeps it safe is our ability to provide adequate pain management and monitoring for these patients.
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So usually that's where the talk starts regarding regional nerve blocks and how incredibly important that is to our success when it comes to doing these procedures.
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But my primary motivation is actually the patient.
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I don't want them to be painful.
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And I worked in this profession long enough to remember a time when we didn't do a very good job of pain management.
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So I feel this episode is going to be super helpful for everyone out there to clear up some controversies, to understand the science behind what you're doing and what your future research is going to look like and just really get us prepared so we can actually do these nerve blocks.
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Absolutely.
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Yeah, I think that, you know, my journey with regional anesthesia and why it was something that I was so interested in really came from my time during my residency here at Wisconsin.
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Um Bill Gangler, who was my mentor, when we would go to the annual American Veterinary Dental Forum in order to be able to help keep costs down, he would always sign the residents up to be able to give a lecture in lab.
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It just happened that I fell into the regional anesthesia lab that we would teach.
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And I would show up to this lab.
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It was mostly general practitioners and veterinary technicians, but there was always one or two diplomates that seemed to be in these labs as well.
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And I would pull them aside and say, Are you here to make sure I'm teaching the right stuff?
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Like, what are you doing here?
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And they would say to me that when they had gone through their residency training, regional anesthesia was nothing that was ever really impressed upon them as being important.
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So they would actually look at it from the perspective of they were here to learn something too.
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And I thought that was really interesting that we could have been at a place where we didn't necessarily appreciate that the patients feel pain and are uncomfortable from the procedures we're doing under anesthesia.
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And I would end up doing is basically convincing myself that there's probably even a lot more that could be done.
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I mean, my wife is a veterinary anesthesiologist, my dad, he's now a retired human anesthesiologist.
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Like I got anesthesia coming every which way growing up, and once I met my wife, and it really made sense.
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And to be able to talk to these other specialists who, you know, and some of the ones that didn't practice regional anesthesia would actually say at these meetings when I would ask them what they used, what techniques they preferred and approaches for the blocks, they'd say, I don't actually use it in my practice, but I would if there was research that showed it.
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So for me, that was my marching order is to head right back up to Wisconsin and see what we can do to actually test and evaluate to make sure that that this actually works.
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So that's really kind of where it all started was um being able to prove that just because we do things in human medicine and then we mimic it on the veterinary side, actually looking for where is that objective data that says that yes, this is actually works and this actually makes a big difference.
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So that's kind of where things um started for me.
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And, you know, it's just kind of taken off from there.
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It's like a lot of things in vetmed.
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Once you start down a rabbit hole of learning more, you just start questioning other things that you do, and then all of a sudden you have a career laid out before you if it's something you're interested in.
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Yeah, and about you and your wife have lots of interesting dinner time conversations about pain management and anesthesia in these animal patients.
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So you live and breathe it, and it sounds like you're born into it.
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I like the fact that when you get thrown into participating and helping teach a wet lab, that you're like, oh gosh, I need to hone in my skills on this and get better at it.
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I have the privilege of teaching with a lot of veterinary dentists, and I will absolutely listen to everything you tell the doctors that you're teaching or the teams.
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And it's interesting to note that everybody teaches it a little bit differently.
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So it doesn't mean that there's a right or wrong way specifically, but sometimes it can be what someone's personal experience is.
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I have a lot of veterinarians though looking for proof of concept.
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So what you said about the research, I feel is so important because they could listen to me or anyone say X, Y, and Z and you should do it this way, but then they often want to have some research to back it up.
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So I'm really excited to hear more about that today.
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But before we get into today's topic, my last guest, Dr.
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Kendall Taney, who is also a fellow in oral maxillofacial surgery, and did a talk with me on cleft pallets and puppies and kittens, left you a question.
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So her question for you is what is your favorite procedure to do?
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What gets you excited when you see that procedure on the schedule?
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Oh, that's a great question.
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I think it's easier to come up with thinking of the procedures that I don't like to do.
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I think for me, I really do like the surgery.
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I like the hands-on piece.
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I think what attracted me to dentistry in general was as opposed to a lot of the different medicine topics and specialties within vetmed, is the dentistry piece is so hands-on.
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There's a lot of instant gratification of when you've done something successfully and correctly in the end, that it's done and you can kind of walk away.
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I think from that perspective, anytime I can improve a patient's quality of life, even if it's something as straightforward as extractions, knowing that there are vet students there that are watching me that are really paying attention to how I hold the instruments, how I'm talking my way through flap creation, recognizing that those patients, when everything is all said and done, should be in a much better place than when they came in.
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I think the instant gratification piece of that is probably my day-to-day.
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I think I do really like the trauma cases.
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I like being able to put the pieces back together again and work through the mental gymnastics of figuring out how do I need to line things up, how do I hold them there, how do I make sure this patient is a cooperative collaborator in the healing process.
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And I got to get the clients on board too.
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So that's that extra step of having to be able to convince them your pet's gonna feel really good if my pain management works and my surgery repair works, your pet's probably gonna want to ruin everything that I've just done.
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So, you know, how do I get that and communicate that to the client to be able to get them on board to know this is what we really need to work on in these next few weeks to get things to heal and have the outcome we're really looking for?
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I love it.
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I love the idea that you, even just with basic extractions, find the joy in being able to bring your expertise forward to the students and show them some things that will really change their future.
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So it sounds like you're getting a lot of joy out of helping not only the animals feel better, but also really helping people with their careers.
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So we're gonna talk a little bit about that as well.
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And we're gonna have a second segment that I'm gonna put together with some information Dr.
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Taney left for us in regards to what's it look like to become a fellow in oral maxillofacial surgery.
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But I'd love to learn a little bit more about what your journey into veterinary dentistry has been like after so many years in school to earn your degrees and expertise.
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Why did you decide to stay in academia and embrace an administrative role like you did?
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Yeah, that's a great question.
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Sometimes I ask myself the same question too, especially when I We all question our life decisions, right?
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When I get that when I get the message, there's a really cranky client who wants to talk about something that didn't go the way they expected.
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And I just think to myself, maybe I should be back and listening to the whirl of the high-speed handpiece in the clinic right now.
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No, I think that's a completely legit question.
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I had to go through really coming to the conclusion of what makes me tick, even in making my decision to want to stay in academia.
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So, you know, a lot of people will invest a tremendous amount of blood, sweat, and tears to go through the residency training.
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And as I was moving through the end of my first year, you know, when I signed up for residency, I really thought I was gonna come to town, wherever that was gonna be.
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I was gonna learn the craft, and then I was gonna go into private specialty practice when I was done.
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And I really found that I enjoyed working with the students and doing the teaching piece.
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And as I worked through the end of my first year of my residency, then into my second, I continued to be able to maintain a connection with the resident who was a year ahead of me and two years ahead of me.
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And when it came time to make the decision that I wanted to stay in academia, I reached out to them and said, you know, hey Matt, hey Don, I really think I want to stay in academia.
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Like the idea of teaching the students and training a resident, like, why didn't you want to do this?
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Like, what's wrong with me?
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Why am I what am I not seeing to want to pursue this avenue?
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And they both had really good insights in it, and I've heard it a lot even from the residents that I've taught.
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And that's that I just want to get out there, I want to practice, I want to get good at what I do before I even think about taking on a resident or start working with students.
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And I think for me, the opportunity to stay in academia and you know, actually I heard it and it sounded pretty cliche in the beginning, but I think I've really embraced it.
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It was Bob Fox from the AO who was a medical educator, and he said that you can have a positive outcome on more patients' lives by being a good teacher than you can by being a great surgeon.
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And I think what that translated to me was, yeah, when you sit down and you have a fantastic outcome of your patient treatments, those are just one-offs that pile up after each other, and that you could be a fantastic surgeon and help those patients one at a time, or you could impact more patients' lives by being just even a relatively good teacher.
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And that's where I think I really fell into line is that my desire to want to help patients through the education I provide to students, the education that I provide general practitioners or the veterinary nurses and technicians when I get an opportunity to teach them.
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That's what fills my cup, is I know it's not me with those patients down the road.
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It's me helping people help those patients down the road.
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Then I had to reevaluate things because I stayed in the university, I worked through the professorial pathway, then hospital director role came up.
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Bill Gangler was the hospital director when I did my residency.
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So I did see how to balance both sides.
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I did have an interest in the business and the interpersonal skills and client communication and how important that was.
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I did gather that even when I was in veterinary school.
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And I had to make a decision again.
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Did I want to step away from clinics and the teaching even more to do something like this?
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And really, where I've come to again feel like I am able to help my patients is even if I can help work through an efficiency scenario in the teaching hospital where the neurologists want to just get one more MRI done a week on a patient, if I can help them figure out how to do this in accordance with anesthesia or whatever other groups are involved, that's still me being a veterinarian.
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I'm still having a positive outcome on or effect on those patients.
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So, like the full circle piece of how do I continue to feel like I can flex that uh veterinary muscle, even though I'm a lot less hands-on opportunity with the patients.
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I feel like a lot of veterinarians and veterinary students may just think that their life is going to be working in a clinic and working with clients, working with the teams, working with the patients.
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But veterinary medicine over the years has really progressed to the point that there's a lot of roles that veterinarians play.
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And it doesn't necessarily mean that you won't wind up changing those roles as you progress through your career.
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I really feel like the vet students, they're gonna remember what they learned from you during those formative years that they're becoming veterinarians.
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So when we think about what you do at the university at such a high level of administration and supervision, we wanted to talk a little bit about the decision making when it comes to working on an actual patient.
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So, in the pre-planning for a case or interoperatively or postoperatively, what does that look like when you decide you're gonna have your preoperative discussion on this patient and having pain management be a part of that conversation?
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Yeah, that's no, that's obviously the very beginning of the true decision-making and procedural process for these patients.
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And it doesn't always happen the day of, you know, it can happen the day before, it can happen on a consult visit awake.
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The way we're structured is we do see our patients in advance, typically a couple weeks, unless there's something urgent, in which case we may see them same day, but usually there's at least 24 hours of time between when we initially see them and when they end up on the table.
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The structure that we use here at the university is it's heavily reliant on the residents who handle a lot of the client interaction and patient care side of things, with the faculty overseeing and working with the residents for the true procedural deliveries.
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So, in the most standard situations, with standard cases, there's going to be a good patient history that's taken.
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We've got medical records that have been sent in from the referring veterinarian.
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We have an opportunity to review those.
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And then there's a good dialogue that has to happen between the faculty and the residents.
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Being able to ask them what actually is in the medical records, what's in the patient's history, what kind of medications are they on.
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It actually, I think because I have to ask the questions and I have to evaluate their answers, it's probably made a lot more stuff stick fresh in my mind that I learned in Bet School that probably should have just dried up and weathered away.
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But being able to ask them questions about why this particular drug is going to interact with something else that we might use or prescribe really helps to kind of keep things fresh.
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So once we have a real holistic picture of what the patient's coming to us with their needs and what's in their medical record history in conjunction with the signs and symptoms that the client has told us about, it becomes the procedural planning side of things.
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Here, you know, we always get approval for local blocks and radiographs before we do any type of more invasive type of procedure.
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So even just from the get-go, what is the client approving on an estimate in a consent form?
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It's going to be the cleaning oral exam under anesthesia and radiographs and local blocks.
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And that really gives us a lot of flexibility from the perspective of patient gets under, as long as there's not just an overwhelming crazy amount of calculus.
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We can go ahead and try to do our oral exam if we feel like we can see what we need to see with what they come in with as far as accumulation goes, then get the radiographs and potentially uh incorporate the local blocks at that time while then the cleaning is taking place, and then we can call the client and say A, B, and C are an issue, and X, Y, and Z are your treatment options.
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There's a lot of flexibility, I think, that comes into play when we do that because it allows us to then, you know, if we're gonna mix or we're gonna use a long-acting, uh longer acting, um, delayed onset regionally anesthetic, then it's gonna give us that time for that medication to kick in and do what it needs to do so that when we do intervene and do our procedure, the patient has been able to be kept at a low level of gas.
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So here too, we have uh the vet students, they're a part of the whole process.
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Um, they do some cleaning, they do the positioning for radiographs, we teach them in a in a lab how to do the local blocks, they even get that before they hit the fourth year.
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So we've already kind of done gone through the process at least once, if not twice, with them.
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And then we're there to supervise and help them along the way.
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So I think a big piece from my perspective regarding local block techniques is that if you're using techniques that you feel comfortable and confident about your familiarity with uh anatomy, then these blocks that are being applied should be done and be able to be performed safely.
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So I think that's an important piece because when people worry about complications, and that's usually where fear of of regional anesthesia comes from, is that somebody knows somebody whose cousin's neighbor's dog woke up and chewed its tongue off during a dental procedure.
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And it's, you know, it ultimately comes down to, you know, in my mind, if you're using a small amount of of a sodium channel blocker and you're putting it in an accurate location, you don't need to shut down too many of those nodes of RAN BA, those are where the sodium channels open and close.
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You don't have to shut down very many of those to stop the propagation of that um that that signal to the brain of something's something's painful.
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So even using students um regularly and the worries and concerns about complications associated with anesthetizing things you don't intend to, knock on wood, if you pay attention to all of the good rules of thumb, then you should be safe.
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Yeah, we're gonna talk about some of those safety rules.
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And I love that you discussed the fear because if someone has had a complication during a procedure with a nerve block, it might that causes that veterinarian to decide they're never doing nerve blocks again.
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I feel really sad about that because then there's gonna be so many patients moving forward that don't have the benefit of having that additional pain management strategy, which is really night and day.
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I remember when we used to not do nerve blocks, we started doing them in 2005.
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And during the time before, our patients would wake up crying, paying at their face, restless, unable to be comfortable.
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And as soon as we did the nerve blocks, our patients would wake up comfortable when they weren't exhibiting all those signs.
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I don't want people to be scared away from doing regional nerve blocks.
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This episode really is to help us learn, educate ourselves, and become more aware.
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Yes, nothing's without risk or complication, but how do we minimize that risk to the point that we can start to do them so they're not painful when they wake up and we're able to do our surgeries with a much lower gas percentage, hoping to prevent some of those respiratory and cardiac negative things that happen when we talk about increasing the depth of anesthetic with these patients trying to combat the pain that they may be experiencing.
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Thinking more about how a general practice might plan this, I think what you said happens in the university is not that dissimilar from how I've experienced a general practice approaching things.
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I really love preoperative visits because then that gives us a chance to not only look at the patient, point out some things we're concerned about, things like bad breath, bleeding gums, missing teeth for no reason, tartar accumulation one side versus the other, and have a conversation about what we do under our general anesthetics, but also just the fact that we can go over what we do as a hospital to address pain.
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And it's not just that they're asleep, but just like when we go to the dentist, they might be filling a cavity or doing a root canal therapy or something, and they're gonna be doing a nerve block because that way we really don't feel anything.
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And also, what do we do after the procedure?
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Like, what are we gonna send home?
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What are we concerned about in regards to comorbidities or other things that might make us change our decision-making process when it comes to the drugs that we plan to use?
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What should the recovery be like?
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What should the client expect?
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And doing all this pre-preparing stuff really should be, in my mind, absolutely essential for dentistry.
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Nobody should just show up and say, I'm here for my dental, and you know, we haven't had any chance to talk to them about these things or have them sign permission forms.
00:21:09.680 --> 00:21:23.599
So I like that you mentioned that you do have them sign a permission form that we can do the nerd blocks because if the client doesn't even know we're doing them and we perform them, then that could also be an issue, especially if there was some sort of complication.
00:21:23.759 --> 00:21:25.519
So we need informed consent.
00:21:25.599 --> 00:21:28.240
And I love that you said that that should be a part of it.
00:21:28.480 --> 00:21:38.480
Do you have any suggestions for a general practice on how they could improve the process of discussing pain management before they anesthetized anything?
00:21:38.559 --> 00:21:47.920
But especially when they think, oh, it's just a dental, they don't even know that there's going to be any extractions, and they sort of just approach it like they might for every single patient.
00:21:48.000 --> 00:21:53.920
Like we give this pre med, we induce with this drug, we start them on gas, and then we start doing whatever.
00:21:54.079 --> 00:21:57.039
So, what do you think would be a good idea for them to consider?
00:21:57.359 --> 00:21:59.680
Yeah, I think that there's probably, you know, it comes back.
00:22:00.160 --> 00:22:19.039
To I think what you were saying in the beginning is that pre-op visit really is the opportunity to set expectations because we know that hands down, when clients are disappointed or there chance to be an issue that arises, it stems from communication, and that communication is usually associated with poor expectation setting or misaligned expectation setting.
00:22:19.200 --> 00:22:31.839
In the scenario where you're looking at patients and you want to have conversations with clients, I think it's real easy in my mind and in my experience to be able to make the connection with clients when you use the keywords they understand.
00:22:32.000 --> 00:22:34.160
They understand pain, they understand infection.
00:22:34.400 --> 00:22:45.359
Talking to clients about the fact that, hey, when you go to the dentist, this is, you know, walk in, you have a procedure done, and they need to set you up most of the time so you can go back to work when you're done.
00:22:45.519 --> 00:22:47.119
We want to do the same thing with your pet.
00:22:47.200 --> 00:22:53.680
We want to use a multimodal anesthesia, meaning we want to take pain management drugs from all different types of classifications.
00:22:53.759 --> 00:23:04.079
We want to use little bits of it here, there, and everywhere, because together at low doses, they're not going to have the same cardiorespiratory depressive effects that you mentioned with the high levels of gas.
00:23:04.160 --> 00:23:10.480
And this is going to help us be able to give that patient back to you or give your pet back to you much more like it came in.
00:23:10.559 --> 00:23:14.559
The last thing I want to do is send your dog or your cat home feeling dopey and dumpy.
00:23:14.720 --> 00:23:22.079
Certainly, if they had big, uh big surgery and keeping them quiet, that certainly can be an important thing, an important component to the healing process.
00:23:22.240 --> 00:23:24.799
Most of our patients aren't going to be having procedures like that.
00:23:24.880 --> 00:23:45.279
And being able to make sure that they can transition to those oral pain meds for home comfortably and easily really falls back on the fact that we want to make sure that that pain bus doesn't start rolling away from us because trying to stop that pain bus is going to be a lot more difficult if their mouth hurts, they don't want to take their treat with the pain med in it.
00:23:45.359 --> 00:23:46.720
It's going to help keep them comfortable.
00:23:46.880 --> 00:23:55.440
I think using the regional anesthesia piece and using those keywords of, you know, pain, treating infection, sending them home like they come in can all go a long way.
00:23:55.599 --> 00:23:55.759
Yeah.
00:23:55.839 --> 00:23:58.000
And we want the clients to say yes to us.
00:23:58.160 --> 00:24:05.920
So 100%, 1000% agree with you that if a client is disappointed or upset, it's usually a communication issue.
00:24:06.160 --> 00:24:10.400
And that we as veterinary professionals need to be so much more proactive.
00:24:10.640 --> 00:24:33.119
I know a lot of veterinarians, you know, because we need to be focused on the patient, are reluctant to call the client during the procedure or have someone call the client during the procedure, even if it's just to give a reassuring word that their pet's doing fine under anesthesia and that what we thought was what we need to treat is what we're treating today, and we'll call them when their pet's in recovery.
00:24:33.279 --> 00:24:50.000
I think those kind of things just really help bond these clients to us and also ensures that they're not going to feel like we didn't communicate effectively, especially regarding something that would be undoable, something that, you know, we need to get informed consent about.
00:24:50.240 --> 00:24:55.440
So getting a hold of them as soon as possible is always my strategy because what if they don't answer the phone?
00:24:55.519 --> 00:24:57.519
And what if we can't get a hold of them?
00:24:57.680 --> 00:25:02.319
So we don't want to be waiting with their pet under anesthesia, waiting for informed consent.
00:25:02.480 --> 00:25:10.559
So I I love that if we can talk to them as much as possible in that preoperative period when we have them as a captive audience in the room.
00:25:10.720 --> 00:25:12.960
We can go over everything, we can show them things.
00:25:13.119 --> 00:25:21.680
It's so worth our time to take the time it takes to do that rather than trying to rush and say, well, we'll call you later, we'll give you an estimate via email.
00:25:21.839 --> 00:25:29.519
I just none of those things I think are very successful when it comes, especially to dentistry, because inside the mouth is the great unknown, as you know.
00:25:29.680 --> 00:25:30.880
And there's so much to be found.
00:25:31.440 --> 00:25:40.559
And to me, I think that's where I think those pre-op visits are so valuable and important because yes, 50% to 75% of the tooth lives below the gum line.
00:25:40.640 --> 00:25:45.839
I can't 100% guarantee that what I think I'm seeing awake is really what I'm gonna see on radiographs.
00:25:46.000 --> 00:25:54.319
If I can invest the time and give the client the education of this is what I think we're gonna see, this is what I'm worried about, maybe visible on radiographs.
00:25:54.400 --> 00:25:57.200
Let's talk through it now, let's draw it on the dry erase board.
00:25:57.279 --> 00:26:08.960
I want you to ask me all the questions so that you feel comfortable that you know what I'm trying to explain, because that way when I call and your pet's under anesthesia, just like you said, it's gonna be a quick phone conversation.
00:26:09.119 --> 00:26:10.960
Hey, remember we talked about scenario two?
00:26:11.200 --> 00:26:13.200
This is actually what I'm seeing under anesthesia.
00:26:13.279 --> 00:26:15.039
So root canal is not gonna be an option.
00:26:15.200 --> 00:26:16.480
We have to go with extraction.
00:26:16.640 --> 00:26:24.799
At that point, like with those, you know, in being in specialty practice, we get those clients that are super heavily invested and they're usually educated by Dr.
00:26:24.880 --> 00:26:41.039
Google, and they come to the table trying to be a good advocate for their pet to be able to have them have a mental picture of what you've talked about and have them understand, okay, yeah, I really did want a root canal, but you did show me in the picture that it was a vertical fracture and you wouldn't be able to do it.
00:26:41.119 --> 00:26:42.319
So I'm not gonna question you.
00:26:42.400 --> 00:26:45.920
I just want you to, I'm gonna give you my blessing to go ahead and do that extraction.
00:26:46.000 --> 00:26:46.960
Let's just move forward.
00:26:47.039 --> 00:26:55.519
So I think that's also an important piece of that pre-operative visit as well as that description of being able to say, this is probably what we're gonna find.
00:26:55.680 --> 00:27:00.720
This is what I want to make sure is the case before we commit to making a procedural decision.
00:27:00.799 --> 00:27:12.720
And just like you said, if you can't get the client on the phone, the last thing anybody wants to do is drop their car off for an oil change and pick it up and find out the engine was rebuilt and have the charges associated with that, right?
00:27:12.880 --> 00:27:17.599
So it's it's again, it all comes down to that expectation setting piece.
00:27:17.680 --> 00:27:25.119
And I think what you said too about the informed consent, I think that's increasingly becoming important in um in day-to-day society.
00:27:25.200 --> 00:27:27.920
I think that many states are informed consent states.
00:27:28.079 --> 00:27:29.119
Wisconsin is one of them.
00:27:29.279 --> 00:27:36.400
All the client has to do is say, you never told me that this was an option and therefore I'm not gonna pay or I'm gonna bring a grievance to the state board.
00:27:36.559 --> 00:27:38.400
And in this state, that's a reality.
00:27:38.480 --> 00:27:42.480
So, you know, being good about your documentation and again, like you said, communication.
00:27:42.720 --> 00:27:46.240
Also, even if you have them sign something that says, Dr.
00:27:46.400 --> 00:27:47.920
Snyder, I trust you.
00:27:48.079 --> 00:27:52.079
You can extract all of my pet's teeth if you want and spend all of my money.
00:27:52.240 --> 00:27:57.039
I don't think they actually mean it because they don't even know a dog has 42 adult teeth, right?
00:27:57.279 --> 00:28:02.720
If there is something that you're gonna catch on the awake exam, I don't know that anybody could do it better than you, Dr.
00:28:02.880 --> 00:28:03.440
Snyder.
00:28:03.519 --> 00:28:13.279
So a lot of general practitioners are not gonna be looking for some of those red flags or those little subtle signs that you might catch in order to have that preoperative conversation.
00:28:13.519 --> 00:28:20.960
So some of those things are only gonna be realized when we do get the dental x-rays, we get the clinical evaluation under anesthesia.
00:28:21.039 --> 00:28:37.920
And now we really do need to talk to the client because otherwise we might have to just wake them up without actually treating what might be a very painful situation for that patient and doing our best to communicate sometimes isn't good enough when the client's expectations are completely different.
00:28:38.079 --> 00:28:45.599
So once the pet gets in the hospital, they're admitted, we should have a written plan for our pain management strategy for this patient.
00:28:45.680 --> 00:28:50.960
And that plan could be altered in the face of finding something that we didn't expect.
00:28:51.119 --> 00:29:06.960
So we get in there and oh my gosh, I've certainly had these things happen to us where we thought it was one extraction, and then we get in there and find out that there's 20 extractions, and that's that's a huge different situation where maybe we didn't budget enough time for that.
00:29:07.119 --> 00:29:19.119
We can certainly talk about staging patients and things, but also just how we're approaching the pain management, especially if someone thought it's just a dental, and then they realize, oh gosh, we have to do all this additional treatment.
00:29:19.279 --> 00:29:33.359
And that could even be saving teeth because doing root planing, especially open root planing, but really any root planing can send sort of these electrical shocks across the nerves of the cementum through the dentinal tubules, right?
00:29:33.440 --> 00:29:41.279
So I don't want us to think that nerve blocks are just for extractions or some fancy oral maxillofacial surgery.
00:29:41.440 --> 00:29:46.880
So could you tell us a little bit more about when you would consider nerve blocks appropriate?
00:29:47.039 --> 00:29:47.759
What procedures?
00:29:48.160 --> 00:29:57.039
Yeah, I would say that in my mind, anything other than just a routine cleaning has an absence of any work being done below the gum line.
00:29:57.200 --> 00:30:02.319
I think anything beyond that, we're probably starting to look at needing to be more aggressive with our pain management.
00:30:02.480 --> 00:30:14.480
I would even say that, you know, very early on when I finished veterinary school, even my wife was an advocate for the fact that even just the dental cleaning, these patients maybe would benefit from like an injection, a torb coming off of the table.
00:30:14.640 --> 00:30:33.359
It really was only in the past year and a half that even through my dentist, I went in for a cleaning and there was a new hygienist I hadn't worked with, and she used the ultrasonic, and I was white-knuckled grabbing on to the arms of that dental chair because just the ultrasonic was uncomfortable for me being awake.
00:30:33.519 --> 00:30:38.400
So I haven't gone back to that hygienist since I've switched and I'm back to somebody with hand instruments.
00:30:38.559 --> 00:30:44.079
But nonetheless, so in my mind, all those other procedures are gonna benefit from regional anesthesia.
00:30:44.160 --> 00:30:54.960
I think that there's a very limited number of scenarios where I would elect to use and be more heavy-handed with my systemic pain meds than to rely on the benefits of the regional anesthesia.
00:30:55.039 --> 00:31:07.359
And I think the easiest way to think about what those collection of procedures would be are gonna be the procedures where there's a surgery done and there's gonna be like some flap that's pulled over and it's not supported by bone.
00:31:07.519 --> 00:31:11.920
And it's not supported by bone, and on the other side of that flap is the nasal cavity.
00:31:12.079 --> 00:31:43.200
So for me, oral nasal fistulas, or if there's a maxilectomy, or if there's a cleft palate, those are all gonna be situations where I will do my best to stay away from regional anesthesia because what I don't want that patient to be numb, which is a good thing, because they can't feel the surgery I did, but they can still feel the sutures with their tongue, and then they end up rubbing their tongue up against those sutures, which creates tension, which if there's no bone on the other side, means that tongue could just push right through that flap closure into the nasal cavity.
00:31:43.279 --> 00:31:45.680
And now we're stuck with a big oral nasal fistula.
00:31:45.920 --> 00:32:02.240
So in situations where the anesthesia people are feeling that there really needs to be something more than what they can do with gas or with um CRIs of additional pain meds, in those situations, I would reach for lidocaine because I know it's the shortest acting.
00:32:02.319 --> 00:32:08.160
But you know, even in my own personal experience, 12 hours after having a lidoclain block, I couldn't feel part of my face.
00:32:08.319 --> 00:32:13.039
The lidocaine's guaranteed to work for two to four hours, but it could work longer than that.
00:32:13.119 --> 00:32:22.000
And that could be that could end us, that could put us back in that situation where the patient's still numb and then are self-traumatizing their surgery site when they're done.
00:32:22.240 --> 00:32:30.000
So um, yeah, it's the that list of patients or cases that I would try to stay away from local blocks is pretty small.
00:32:30.079 --> 00:32:36.160
And I guess the other big one would be any tongue type of procedure, whether it's a biopsy or any sort of resection.
00:32:36.319 --> 00:32:44.960
Those guys, again, I would not want to block them because as a human dentist described it to me one time, it's kind of feeling like you've got a big gummy bear in your mouth.
00:32:45.039 --> 00:32:50.799
And if you can't rationalize and know that you shouldn't chew on that gummy bear, you're just gonna traumatize the tissues that are there.
00:32:50.880 --> 00:32:52.240
And that's not where we want to end up.
00:32:52.559 --> 00:32:53.440
It's really interesting.
00:32:53.599 --> 00:33:05.039
I'd never thought about the fact that there would be some fairly major surgery that you actually would not want to use regional nerve blocks for, such as where you mentioned the oral nasal fistula.
00:33:05.200 --> 00:33:13.680
Others may not be approaching some of those bigger surgeries that you mentioned, but oral nasal fistula repair is often done in a general practice setting.
00:33:14.000 --> 00:33:24.400
So that's great advice to consider not using a nerve block in that situation to avoid self-trauma and to instead utilize something like CRIs.
00:33:24.799 --> 00:33:30.640
And we use CRIs and regional anesthetic blocks in a general practice setting.
00:33:30.799 --> 00:33:41.119
And I realize what a match made in heaven CRIs are with dynasty and that multimodal approach when it comes to how you're addressing the pain management in these patients.
00:33:41.359 --> 00:33:51.839
When you're choosing the drug to use for these nerve blocks, what are your thought processes in regards to the difference between bupivacaine?
00:33:52.000 --> 00:33:57.599
There's what, rhopivacaine, metivacaine, like there's all these different canes out there.
00:33:57.680 --> 00:34:07.279
And I understand because bupivacaine isn't often used in human dentistry, that that may contribute to its lack of availability in the veterinary market.
00:34:07.440 --> 00:34:08.719
Is there any trace to that?
00:34:08.880 --> 00:34:13.440
Or why is it that bupivacaine sometimes goes on back order and people can't get it?
00:34:13.519 --> 00:34:19.199
So I know that's like two questions, but drug choices and when we're left with few choices, what do we do?
00:34:19.679 --> 00:34:21.519
So I think it's I think you're spot on.
00:34:21.599 --> 00:34:38.960
I think the whole cane family of drugs are sodium channel blockers, where how tightly they bond to the fatty tissue, the fatty myelin that insulates those nerves is what differentiates a lidocaine from a mepivacaine, ripivacaine, carbocaine, all of them.
00:34:39.119 --> 00:34:48.320
I'm not familiar, I guess, with the bupivacaine maybe not being used as much on the human side as it contributes to a back order of its availability.
00:34:48.480 --> 00:35:03.599
I do feel like when I was doing some of my initial research looking at and actually, you know, preparing for lectures, talking about the wide cane range of drugs, it did seem like that maybe bupivacaine was used in other parts of the body for different um types of blocks.
00:35:03.760 --> 00:35:20.960
But regarding how tightly they bond to the bind to the myelin, how long therefore the effects work, bupivacaine, I don't it I can't explain to you why we've settled on that one over the ropivocane, mupivacaine, carbocane, all those other ones, except maybe there's probably a price to that in vetmed.
00:35:21.199 --> 00:35:29.920
But I think just remembering and keeping in mind that lidocaine is going to be the shortest acting, quickest onset, everything else is gonna last longer, bind more tightly.
00:35:30.079 --> 00:35:33.840
And then I think it probably comes into that cost-benefit ratio.
00:35:34.079 --> 00:35:36.719
Okay, or maybe even what's available to someone.
00:35:36.880 --> 00:35:56.960
I often will tell them if bupivacaine seems to be on back order, they could look at ropivacaine or it maybe even a different strength of the bupivacaine because most people are looking for uh 0.5% rate, and they can use it maybe interchangeably, which I would love to hear your official word when it comes to actual dosages.
00:35:57.119 --> 00:36:13.519
So, in your practice experience, do you favor one of the canes over another when it comes to what a general practice might be considering for extractions or maybe gingivectomies or deeper cleaning below the gum line, root planing, things like that?
00:36:14.000 --> 00:36:19.519
I guess I don't really have strong opinions about choosing alternatives or which alternative to use.
00:36:19.679 --> 00:36:28.079
I think that in my mind, the toxic dose of that lidocaine family of drugs tends to run pretty similar across the board.
00:36:28.239 --> 00:36:33.280
So the percentage of concentration of those medications does vary.
00:36:33.360 --> 00:36:38.320
So, right, so we have lidocaine, it's a 2% solution, it's 20 mics per mil.
00:36:38.400 --> 00:36:43.280
If we have bupivacaine that's 0.5% solution, that's a five mic per mil.
00:36:43.440 --> 00:37:02.800
So one ml, you could get you'd have the same binding capacity of those two drugs between taking one ml of lidocaine and taking a quarter of an ml of bupivacaine that's 0.5%, and they'd have the same risk as far as a toxic dose goes.
00:37:02.960 --> 00:37:14.239
So to me, it really doesn't matter which of the family members you want to use for the canes, as long as you know how to do the math for the toxic dose so that you know that everything's gonna be safe for that particular patient at that particular size.
00:37:14.400 --> 00:37:15.519
I think that's what really matters.
00:37:15.840 --> 00:37:16.000
Right.
00:37:16.079 --> 00:37:21.360
And especially for the smaller patients, we get to those patients that are greater than 10 pounds or so.
00:37:21.440 --> 00:37:31.599
Like we probably wouldn't even get close to even half the maximum toxic dose for that patient for any reason if we are blocking all four quadrants.
00:37:31.760 --> 00:37:44.800
So always calculate your toxic dose or your maximum dose for that patient and document that in your chart as far as your plan, and then stick to the plan if you had to block all four quadrants.
00:37:45.039 --> 00:37:48.960
Does that sound like a good strategy when it comes to the drug that you pick?
00:37:49.280 --> 00:37:58.559
Yeah, and I'm a big believer too of the the benefit that having a little bit of opioid mixed into that local block also extends its duration of action.
00:37:58.639 --> 00:38:04.000
So, and what we've done some investigations into is the use of buprenorphine.
00:38:04.159 --> 00:38:10.719
So just using 0.05 mls is 15 micrograms of buprenorphine.
00:38:10.800 --> 00:38:17.119
And that's, you know, unless you've got a one kilogram animal, 15 micrograms really shouldn't be much of anything for those patients.
00:38:17.360 --> 00:38:31.039
But using that small microdose of opioid mixed into the syringe and whether it goes into one local block location or that syringe is distributing across four blocks across the mouth, um, it does seem to extend the duration of action.
00:38:31.119 --> 00:38:32.480
Those patients stay comfortable.
00:38:32.559 --> 00:38:38.960
So that was a research paper that you published in the Journal of Veterinary Dentistry, I believe, in 2016.
00:38:39.199 --> 00:38:40.159
And your wife, Dr.
00:38:40.239 --> 00:38:50.880
Lindsay Snyder, was also a part of that research and really changed the discussion around using bupivacaine and adding in something like buprenorphine.
00:38:51.119 --> 00:39:06.719
Now, when you did this particular study, it was meant to reduce the MAC of these patients when it comes to the gas anesthetics that we were using and decreasing the cardiorespiratory effects of the gas anesthesia.
00:39:06.960 --> 00:39:21.840
What do you think was your biggest takeaways from working with buprenorphine, adding it to bupivacaine, and bringing forward the scientific research to give us some better information on whether we should be doing that or shouldn't be doing that?
00:39:22.079 --> 00:39:29.199
Yeah, I think that in that, you know, in that study when we did it was bupivacaine by itself versus the bupivacaine plus buprenorphine.
00:39:29.440 --> 00:39:40.639
And what we were doing was testing could the dog feel what we were doing before the block versus after the block, and then in subsequent days just anesthetize them and stimulate them to see if they would respond.
00:39:40.800 --> 00:39:56.000
I think for me, that paper really did kind of change the discussion, like you said, from the perspective that, you know, adding a little bit of opioid to your local block can make these patients feel comfortable for multiple days longer than just the bupivacaine by itself.
00:39:56.159 --> 00:40:07.599
I think the other important piece of information that came out of this was kind of like what I said earlier, where even my own lidocaine local block in my mouth, I couldn't feel part of my face 12 hours later.
00:40:07.760 --> 00:40:14.320
In that paper, even the dogs that just had the bupivacaine coming back a day later and they still couldn't feel what we were doing.
00:40:14.400 --> 00:40:18.000
And they were coming back the day after that and they still couldn't feel what was happening.
00:40:18.159 --> 00:40:29.599
So I think what really that should also ingrain in us is the fact that if I'm going to put this medication and make this patient numb in a particular area, I want to make sure I'm only making the structures numb that I'm intending to.
00:40:29.679 --> 00:40:35.679
Because if I end up anesthetizing something I don't want to, like the tongue, is the worst case scenario everyone thinks of.
00:40:35.840 --> 00:40:42.239
Even if I just use a bupivacaine, that patient's tongue might be numb for multiple days.
00:40:42.480 --> 00:40:45.280
And that's never what I intended in the first place.
00:40:45.440 --> 00:40:47.599
So and you can't reverse that.
00:40:48.400 --> 00:40:53.119
So you found that the bupivacaine actually lasted longer than you thought.
00:40:53.199 --> 00:40:55.519
And I I did read that in that article.
00:40:55.599 --> 00:40:58.880
We think, oh, four to six hours, that's been commonly published.
00:40:59.039 --> 00:41:00.639
But that may not be the case.
00:41:00.719 --> 00:41:08.159
And they may actually feel that lack of sensation for way longer, maybe a couple of days, you said.
00:41:08.880 --> 00:41:22.159
And I think it comes down to like when we talk about these medications and how long they last, I think it ends up being that these are the label indications for how long the company feels confident to say this medication lasts for this long.
00:41:22.400 --> 00:41:27.199
They don't tell you the maximum time it's gonna last, they only tell you what the minimum time is.
00:41:27.360 --> 00:41:35.360
And then that's where each patient's gonna be a bit different, how long it takes them to absorb it and clear it's gonna be different and can extend its effects longer than that.
00:41:35.679 --> 00:41:42.480
How did you come up with the 15 micrograms of biprenorphine to be spread amongst all four quadrants as needed?
00:41:42.639 --> 00:41:43.440
I've always wondered.
00:41:43.679 --> 00:41:49.360
Yeah, it ended up just being a translational application from what seemed to be used on the human side.
00:41:49.519 --> 00:42:02.000
I think using, you know, when I got into the literature and human medicine and human dentistry put an awful lot of money and research time into figuring out what I can add and how long will it extend the duration of action.
00:42:02.159 --> 00:42:10.800
The naysayers early on in these studies were like, of course, your patients are more comfortable for longer because they've got opioid cruising around their system.
00:42:10.880 --> 00:42:16.079
And when it gets to their brain, it numbs this fact that the signals are being sent that there's discomfort.
00:42:16.239 --> 00:42:22.639
And that's when the literature started to move to actually testing how much opioid was detectable in their serum.
00:42:22.800 --> 00:42:33.280
Those patients that were saying that they were pain-free and not feeling discomfort, when their blood work was evaluated for how much opioid was cruising around, it was like not detectable.
00:42:33.440 --> 00:42:43.920
So the fact that working locally, and we know that if you have chronic pain scenarios in the peripheral nervous system, opioid receptors will be, they'll just develop in those sites.
00:42:44.079 --> 00:42:50.639
The small doses of the opioid work at those receptors in those local locations, and that's where the comfort is managed.
00:42:50.960 --> 00:42:53.360
So we're still thinking local anesthetics.
00:42:53.440 --> 00:43:14.639
We're not thinking about systemically affecting the patient as a whole, which I think is really important because we don't want the pet to go home being drugged out and and just not behaving properly as far as the client thinking their mentation is normal or they may be vocal or something that sometimes these drug categories can cause dysphoria.
00:43:15.119 --> 00:43:16.239
This isn't gonna affect that.
00:43:16.400 --> 00:43:21.920
This is really staying in a localized area to affect the pain sensation that's perceived.
00:43:22.079 --> 00:43:30.320
When you think about it, I always tell people it's not that their face is numb for an extended period of time, hopefully, but it's just that they're not painful.
00:43:30.480 --> 00:43:32.800
So we're sending them home, not painful.
00:43:32.880 --> 00:43:43.599
And then you could add an additional class of drugs as their go-home medication, which do you prefer, if it's possible, to send home some sort of NSAIDs or something like that post procedure?
00:43:43.840 --> 00:43:52.079
Yeah, I think most of our patients are gonna be pretty comfortable going home on an NSAID, plus or minus, maybe some gabapentin or pregabalin to top things off.
00:43:52.239 --> 00:43:59.760
I feel like I learned pretty early on during my internship that by giving the client some ownership in the decision making process.
00:44:00.079 --> 00:44:06.079
Of whether or not they think their pet is painful or not really will cut down on the client calling with concerns.
00:44:06.159 --> 00:44:08.719
So it's pretty, you know, the NSAIDs are pretty straightforward.
00:44:08.800 --> 00:44:14.559
You're either giving them once a day or twice a day, but then, you know, some flexibility with whatever else you're going to use with it.
00:44:14.719 --> 00:44:23.599
Like I said, the pregabalin, gabapentin, tramodol, whatever it may be, and say give half to one pill every six to eight hours.
00:44:23.920 --> 00:44:28.880
You've all of a sudden given a client a wide range of them being, and they know the pet better than we do.
00:44:28.960 --> 00:44:31.280
Like we only see them at a one-off short period of time.
00:44:31.440 --> 00:44:38.079
They can recognize if they know their pet's uncomfortable and be able to address it, always knowing, let's start with the lowest dose first.
00:44:38.239 --> 00:44:38.960
Let's see if it works.
00:44:39.039 --> 00:44:41.119
You can always give more, you can't take it back.
00:44:41.360 --> 00:44:45.360
And then um that helps to make make them have a better experience, I feel like.
00:44:45.840 --> 00:44:48.719
We got to keep the client as a part of our team.
00:44:48.960 --> 00:44:51.599
And I did a really great episode with Dr.
00:44:51.840 --> 00:44:56.400
Chris Bannon, and the episode was titled Dentistry is a Team Sport.
00:44:56.559 --> 00:44:58.800
And one of the people on our team is the client.
00:44:58.960 --> 00:45:04.960
So we really have to get their feedback because when we send this pet home, we're not watching them.
00:45:05.199 --> 00:45:08.639
And we need to get some information on do they seem comfortable?
00:45:08.800 --> 00:45:23.920
So even using some basic pain-scoring artwork, like the little grimace pictures, to help the client better assess their own pet at home to discern whether or not the pain management strategy that we're employing is actually working.
00:45:24.079 --> 00:45:27.679
Is that something that you do as well when it comes to setting the pet home?
00:45:27.840 --> 00:45:42.239
Give the client some information on what to expect and the fact that we're using something that's hopefully going to keep them comfortable for didn't your research tell us that it was up to 48 hours with the addition of the buprenorphine to the bupivacaine?
00:45:42.320 --> 00:45:46.239
Or what what's the parameters on the addition of the buprenorphine?
00:45:46.400 --> 00:45:47.599
Yeah, the buprenorphine.
00:45:47.679 --> 00:46:03.679
So the when you looked at this small number of dogs that we worked with, eight dogs that saw both bupivacaine by itself or bupivacaine with plus buprenorphine, at 48 hours, half of the dogs that had the combination of opioid plus bupivacaine still couldn't feel what we were doing.
00:46:03.840 --> 00:46:09.119
So one or two of the dogs actually made it out to 96 hours and still couldn't feel what was happening.
00:46:09.360 --> 00:46:20.079
The challenge, I think, with evaluating studies that have small numbers like that is that we didn't have statistical significance because we were only working with eight trials of each application.
00:46:20.239 --> 00:46:31.199
The other thing that was interesting that I think would have probably separated the bupivacaine from the bupivacaine buprenorphine group even more was that these dogs were not, they didn't have existing dental disease.
00:46:31.280 --> 00:46:37.760
They didn't have a reason for opio uh mu receptors to be upregulated in their peripheral nervous system.
00:46:37.920 --> 00:46:47.760
So we were basically taking patients that were naive from that perspective, and we didn't, they didn't really have mu receptors in all likelihood to have the opioid acton.
00:46:47.920 --> 00:47:00.639
If we had a selection of eight dogs that did have reason to have upregulation of the mu receptors, we might have seen the opioid group being numb for a lot longer because they had receptors to actually bind to.
00:47:00.719 --> 00:47:11.519
So, yes, in general, I think you can say if you use an opioid with your um lidocaine family of drug, the hope is you can get at least two days of comfort out of it.
00:47:11.760 --> 00:47:16.480
Very likely longer, but there's really no good numbers to be able to prove it at this point.
00:47:16.639 --> 00:47:23.840
And until our veterinary patients can start talking, tell us I don't feel good or this hurts, I think we're gonna struggle to try to get those numbers up.
00:47:24.159 --> 00:47:24.400
Sure.
00:47:24.480 --> 00:47:38.639
And you know, when they're home, how we judge that sometimes is basically they're eating, they're drinking, they're acting happy, and sometimes just fixing the dental pain that they were already in is a huge benefit to their mentation and how they're feeling.
00:47:38.800 --> 00:47:43.119
So I think there's more potential research to be done, it sounds like.
00:47:43.360 --> 00:47:47.519
Some people talk about adding other drugs besides buprenorphine.
00:47:47.599 --> 00:47:51.599
I don't know if dexmetatomidine or some other drugs out there.
00:47:51.760 --> 00:47:59.360
Do you have anything to add in regards to that specifically if someone's considering using something different than buprenorphine?
00:47:59.599 --> 00:48:12.880
Yeah, I would just, you know, from my familiarity with the human literature, is that even when you looked at trying to add things like even ketamine or any of the alpha 2s, like you were just talking about, nothing outperformed the opioid group.
00:48:12.960 --> 00:48:16.639
So people kind of default fall back to the opioids over and over again.
00:48:16.800 --> 00:48:24.559
I'm not familiar with veterinary literature that looks at the effectiveness of using an alpha 2 solely as your local anesthetic.
00:48:24.639 --> 00:48:36.079
I think that's where the human side has gone to using these alpha 2s specifically and exclusively for regional anesthesia, not even using any of the sodium channel blocking drugs.
00:48:36.159 --> 00:48:37.199
So I don't think it's out.
00:48:37.440 --> 00:48:39.039
I don't, I'm not familiar that it's out there.
00:48:39.199 --> 00:49:06.400
I certainly don't believe that I've seen it in the veterinary dental literature, but we do know from the human side that there are these other classes of drugs that can work, maybe don't work quite as well or as long, but for different reasons, like maybe patients that can't be, you know, they're intolerant to opioids or they can't have exposure to opioids, then having these other drugs to choose from can be effective, but it's a different menu of concerns that we have with our patients.
00:49:06.800 --> 00:49:15.199
It will be interesting to see what other research comes out, but sounds like we should stick with what we know has been proven to be effective.
00:49:15.440 --> 00:49:22.639
Another thing is that there's always been this tendency in veterinary medicine to mix drugs together.
00:49:22.880 --> 00:49:34.000
And in my early days, my veterinary dentist that I was mentoring with, they recommended that if we were in a hurry, we could mix lidocaine and bupivacaine together to get the best of both worlds.
00:49:34.159 --> 00:49:37.760
Can you tell us about whether that is or is not recommended?
00:49:38.000 --> 00:49:41.519
Yeah, certainly the mentality and the philosophy seems to be right.
00:49:41.679 --> 00:49:44.239
I want the quick acting onset of lidocaine.
00:49:44.320 --> 00:49:48.719
I want the extended duration of action of the bupivacaine or mupivacaine or opivacaine.
00:49:48.880 --> 00:50:09.519
If I mix them both together, then I should get the quick onset with the extended duration of action from everything, and I'm not a pharmacologist and I'm not a pharmacist, but from what has been explained to me by those groups is that how those the how the chemical mixtures of those drugs actually start to cancel each other out in the formulations that they're in starts to become problematic.
00:50:09.679 --> 00:50:22.639
So by mixing the two together, where you think you're getting the benefits of both drugs, what you may actually be doing is rendering both of them to be less effective at what they should be good at doing in total.
00:50:22.880 --> 00:50:30.159
So from that perspective, I really try to discourage people from that the mixing of the lidocaine and the bupivacaine together.
00:50:30.239 --> 00:50:42.800
And I think probably where the other piece of that could come from is again, I'm not familiar in the human literature where they commonly mix those two drugs together, and it might very well be because of the way that they start to chemically cancel each other out.
00:50:43.119 --> 00:50:47.440
Yeah, and we as humans don't like our face feeling numb for several days.
00:50:47.760 --> 00:50:50.880
We need to go get our milkshake that we really deserve.
00:50:51.039 --> 00:50:58.639
So on the human dental side, they're more likely to use something like lidocaine, I understand, so that hopefully it won't make us numb for too long.
00:50:58.800 --> 00:51:08.239
So I often tell people that when the pets under anesthesia, just like us, they actually have the ability to raise their little paw and tell us that they're actually feeling pain.
00:51:08.400 --> 00:51:18.639
And what I mean by that is they're not actually raising their little paw like the dentist might tell us we can raise our hand if we've got our mouth propped open and they're drilling and suddenly we feel the pain.
00:51:18.800 --> 00:51:25.440
But how they do that is by a sudden change in their vital signs, spike in heart rate, respiratory rate, and blood pressure.
00:51:25.519 --> 00:51:27.920
And that's them telling us, ouch, that hurts.
00:51:28.079 --> 00:51:36.000
If I was a human in a dental chair getting a filling done or something, and I decided, oh gosh, I can feel that, and I raise my hand, they're gonna stop drilling, I think.
00:51:36.159 --> 00:51:46.800
And they're probably going to do something to make it so that I hopefully can tolerate this better, which is actually redosing me with some additional local anesthetic drug.
00:51:47.039 --> 00:51:54.719
So when we have a patient under anesthesia, they may be in chronic pain already from whatever dental conditions they're dealing with.
00:51:54.880 --> 00:51:57.840
And then we're gonna add surgical insult onto the top of that.
00:51:58.000 --> 00:51:59.679
They are under a general anesthetic.
00:51:59.760 --> 00:52:02.320
Hopefully, we've been able to give them some pre-medications.
00:52:02.480 --> 00:52:10.960
We've done our nerve blocks, we did the proper technique, which we're gonna talk about your preferred nerve block locations and your preferred dosage-wise.
00:52:11.199 --> 00:52:29.039
If we notice that even though we did everything to the best of our ability, the patient is reacting to that painful stimulus, is it something that you could redose, or would you approach it as in, okay, now we're gonna add a CRI or we're gonna dose in a different location?
00:52:29.199 --> 00:52:33.280
Like, what does that look like to you in a practical sense with the patient under anesthesia?
00:52:33.599 --> 00:52:34.639
Yeah, I think that's a great question.
00:52:34.719 --> 00:52:43.760
I think that if it seems like they're responsive in a way that the local block that we delivered didn't work, I think that redosing them and reapplying it makes sense.
00:52:43.920 --> 00:52:56.239
I think that if it's a type of a block like maybe it's an inferior alveolar, maybe we did it intraorally before, maybe they're responding more than we would like, maybe we'll try and do it extraorally for a redose scenario.
00:52:56.400 --> 00:53:01.760
I think there's an opportunity though to be critical of what's the stimulus the patient's actually responding to.
00:53:01.840 --> 00:53:13.440
Because I had primary care doctors come visit me from another institution, and they picked up the buprenorphine addition to the local block piece and they brought it back to their home veterinary teaching hospital.
00:53:13.519 --> 00:53:21.840
And I ended up getting a nasty gram from their anesthesia department who said, I can't believe you're teaching my primary care doctors to do this.
00:53:22.000 --> 00:53:26.960
It's the buprenorphine is reversing the premed pure opioids that we're giving.
00:53:27.119 --> 00:53:29.599
These patients are starting to wake up under anesthesia.
00:53:29.760 --> 00:53:31.280
You can't be doing this or teaching this.
00:53:31.440 --> 00:53:35.039
So I let them cool off a little bit and I asked for a phone conversation.
00:53:35.199 --> 00:53:50.159
And actually, what had happened was the patients were being done at that practice in lateral from one side to the other, and the patient would, and I've had this occasionally happen in my hands too, although our paint my patients are done in dorsal, but nonetheless, the principle is the same.
00:53:50.320 --> 00:53:53.679
The patient's comfortable, they're not feeling the surgery that's happening.
00:53:53.840 --> 00:53:57.440
The person monitoring the anesthesia keeps dialing down the gas.
00:53:58.000 --> 00:54:02.719
And then you get to the point where you do something that's enough stimulation that makes them want to wake up.
00:54:02.800 --> 00:54:09.280
And at that practice and that teaching hospital, it was the fact they were rotating the patient from one lateral side to the other.
00:54:09.519 --> 00:54:15.920
That patient had been dialed down so low on its gas that that stimulation of just moving them was enough to wake them up.
00:54:16.159 --> 00:54:49.440
So seeing the spike in the heart rate, seeing the respiratory rate go up, or if they're trying to buck a ventilator or something like that, if if all of that's happening in the course of a normal procedure versus a big change, like you're moving from one quadrant or you're putting tail clamps now on a different area, all should probably come into the equation to be able to say, is it that my local block didn't work, or is it that my local block works so well that I was able to turn the gas down so low that now this new stimulus is enough to want to wake the patient up?
00:54:49.760 --> 00:55:19.679
I think sometimes people get a little too zealous with decreasing the isofluorine rate to the point that just like you said, we don't want patients jumping off the table or suddenly having some sort of event where they weren't painful, everything seemed fine, and then suddenly there's something acutely painful or their brain is being twisted because now they're on the other side and that stimulus all of a sudden is causing them to suddenly be super light.
00:55:19.760 --> 00:55:29.679
And I talked to people about that as well when it comes to dental sensor safety, because that sensor, which is worth thousands of dollars, you know, those patients that shouldn't really hurt.
00:55:30.000 --> 00:55:42.159
But if the pressure against the tooth from the sensor and putting it somewhere where it needs to be to take a dental x-ray suddenly spikes that pain threshold, they're gonna chomp down on that sensor.
00:55:42.480 --> 00:55:51.119
So as an anesthetist or someone monitoring the patient, we've got to take all of this into consideration because it's not as straightforward as what someone might think.
00:55:51.360 --> 00:56:03.280
If you're doing a redose, would you do the same exact volume or milligrams that you gave with the initial dose, or do you use something less, or what would it look like for you?
00:56:03.599 --> 00:56:05.519
Probably for me depends on the location.
00:56:05.679 --> 00:56:10.000
I'm a big believer of using small volumes and placing them very accurately.
00:56:10.239 --> 00:56:17.760
So cats and small dogs 0.1 mLs, medium-sized dogs, 0.2 mls, and then large breed dogs 0.3.
00:56:18.559 --> 00:56:33.760
If it was a large breed dog and they were responsive to something I was doing in a max layery quadrant, I would have very little concern about redosing them with another 0.3 milliliters in that area.
00:56:34.000 --> 00:56:48.159
If I was doing something in a large breed dog and the mandible and they started to get responsive, another 0.3 mLs in an area that could anestheti the tongue inadvertently or by accident, I might dial back the volume.
00:56:48.239 --> 00:56:50.480
So I I guess I think of it from that perspective.
00:56:50.719 --> 00:57:00.000
Redosing a maxillary-esque block with the same volume, I'm much less concerned about anesthetizing things I didn't intend to in the mandible.
00:57:00.079 --> 00:57:02.880
I'll I'll I'll approach that a little bit more conservatively.
00:57:03.199 --> 00:57:05.920
Yeah, and that's a strategy that I've stuck with as well.
00:57:06.079 --> 00:57:11.280
Usually I'll use half the volume in a mandibular block as what I would use in a maxillary block.
00:57:11.440 --> 00:57:16.480
I wasn't taught with quite such a low dose that you're doing specifically.
00:57:16.639 --> 00:57:27.599
However, I've talked to you about this, and I know some veterinary dentists who are your residents and people that you've trained, and they understand the approach to being super accurate with the needle placement.
00:57:27.840 --> 00:57:33.199
So, what blocks do you feel a general practitioner should be able to perform?
00:57:33.360 --> 00:57:44.000
And how would you recommend that they get more accurate with their needle placement so that they can use a smaller amount of drug but affect exactly where they want to affect?
00:57:44.239 --> 00:58:05.920
Yeah, I think for a general practitioner, I think feeling comfortable and confident about being able to get into the infraorbital canal and placing the needle through the canal, keeping the needle parallel with the roof of the mouth should keep you away from the eye unless there's any eye disease that's happening, or you obviously wouldn't retropulse the eye when you're trying to do that, because that would run the risk of penetrating the globe.
00:58:06.159 --> 00:58:11.039
When it comes to the mandibular blocks, I think those are all fair game too, with in general practice.
00:58:11.119 --> 00:58:34.960
I think that making sure, you know, the single best thing I can tell somebody is to use the small volumes that we talk about and keep the needle right up against the lingual side of the mandible in that area of the ramus, because if we know we're right up against periosteum, we know we should be far away from the lingual branch of the mandibular nerve, and that's the one that we're going to be concerned about, anesthetizing sensation to the tongue.
00:58:35.199 --> 00:58:38.639
So I think everything tends to be fair game from that perspective.
00:58:38.880 --> 00:58:48.800
When I teach labs or when I give this lecture to a technician audience, though, I typically don't do the lecture piece about threading the needle and doing the maxillary block.
00:58:48.880 --> 00:58:54.559
And that really only stems from the fact that I completely trust my veterinary technicians in our hospital.
00:58:54.719 --> 00:58:58.079
I'd feel, like I said, the students are doing the blocks for us all the time.
00:58:58.239 --> 00:59:07.519
If inadvertently the globe gets penetrated by the needle, it's like almost a guarantee that it's going to get uveitis and it's going to have to be a nucleated.
00:59:07.599 --> 00:59:10.000
And that ultimately falls on the doctor's license.
00:59:10.159 --> 00:59:21.599
So in a technician audience scenario where I can't control the doctor oversight, I can't give you feedback to make sure that you're doing this in the safe way possible, just to make sure we're not going to have a problem down the road.
00:59:21.760 --> 00:59:26.400
I think that's the piece where the audience changes a little bit in how I deliver the information.
00:59:26.559 --> 00:59:36.079
The benefit of knowing how to do it doesn't change, but the risk of what happens when something goes wrong is going to be very different for a technician than it is for a doctor.
00:59:36.480 --> 00:59:36.639
Sure.
00:59:36.880 --> 00:59:50.800
I know the technicians that I teach, they're pretty squeamish, I guess, reluctant about taking the needle and advancing it very far into that infraorbital canal, but they can often feel really confident at least doing an infraorbital block.
00:59:50.960 --> 00:59:58.800
Now, the infraorbital block, if it's placed in more of a rostral area, will affect maybe some of the fourth premolar.
00:59:58.880 --> 00:59:59.519
Is that correct?
00:59:59.760 --> 01:00:04.880
Or do you feel like it doesn't really do much for the fourth premolar if you're placing it there just in the vestibule?
01:00:05.199 --> 01:00:16.480
Well, knowing where the nerve branches off into the bone and then travels through the bone to get to the pulp of all of those teeth in front, it I think it's I think you have to be less confident that it's going to be effective.
01:00:16.639 --> 01:00:24.719
I think probably in my hands, using the smaller volume, it's probably even less likely to be as effective as I'd want it to be.
01:00:24.960 --> 01:00:32.400
Knowing that there's some flexibility to use a little bit larger of a volume and the maxillaries because you're not worried about anesthetizing the tongue.
01:00:32.559 --> 01:00:47.280
You know, you could probably find a happy medium somewhere in say an infraorbital block with a little bit larger volume could give you a better sense of reassurance that you could get an anesthesia to the upper fourth.
01:00:47.440 --> 01:00:49.440
But certainly, you know, it's like cutting down a tree.
01:00:49.519 --> 01:00:54.880
The closer you get to the base of the tree to cut it down, the more likely you feel good you got the whole tree cut down.
01:00:55.119 --> 01:01:06.559
Um, any of these blocks that are rostral to the maxillary nerve, you know, it starts to get into just the branches of it and less confidence that you have.
01:01:07.119 --> 01:01:10.800
The inferior alveolar mandibular block is commonplace.
01:01:11.119 --> 01:01:20.800
There was a study that was published in the Journal of Veterinary Dentistry, I believe somewhere around 2011, that discussed how that's not very effective.
01:01:20.880 --> 01:01:35.360
And we kind of have abandoned the effort of doing the mental block in the years before we were doing them, especially if there was a larger patient where we could pretty easily find that foramen to place the block, the needle actually inside the foramen.
01:01:35.920 --> 01:01:42.000
But because of that study and specifically, we don't want to traumatize the nerve as it exits that area.
01:01:42.239 --> 01:01:50.320
Is that something that you guys also say the same thing, like let's just not worry about the mental block and just do the inferior alveolar mandibular block?
01:01:50.639 --> 01:02:10.480
Yeah, for the most part, I think, you know, when it comes to the risk-benefit, like if all I was coaching a student or a veterinarian on just treating incisors, you know, doing a mental block that doesn't work is gonna be less of a negative outcome than doing a mandibular block anesthetizing the tongue by accident.
01:02:10.639 --> 01:02:14.800
So I think it comes down to that risk-benefit evaluation as well.
01:02:15.039 --> 01:02:22.800
So the mental block could be considered if we're just thinking about working on incisors specifically because we don't really need to block the whole entire quadrant.
01:02:22.960 --> 01:02:30.480
Do you suggest the needle needs to go in the foramen or you can just blow up the drug over the foramen if you were to be performing that block?
01:02:30.719 --> 01:02:32.079
Yeah, and try to impress upon people.
01:02:32.159 --> 01:02:36.960
It's important to just try to put the local over the foramen as best you can.
01:02:37.119 --> 01:02:40.159
If not, then you know, right up against the periosteum.
01:02:40.400 --> 01:03:05.039
I do think that the questionable results of that study from the early 2010s stems from the fact, like you said, you know, the idea that local anesthetic needs to get into the frame and into the mandible where those little nerve fibrils branch off into the bone and then travel to the pulps by putting the bleb right over the frame, and you're really hoping that it just weeps in and gets penetration back to that space.
01:03:05.119 --> 01:03:14.639
I do think, and I agree that, you know, the risk of putting a needle through that frame and into the mandibular canal is probably way more traumatic than it's going to be beneficial.
01:03:14.960 --> 01:03:22.320
When it comes to your approach to the nerve blocks, do you prefer an intraoral approach or an extraoral approach?
01:03:22.480 --> 01:03:25.840
Because I know that there's a lot of mixed opinions about that.
01:03:26.159 --> 01:03:44.159
My personal opinion is that I think that if you're good at one or the other, you're probably going to be more accurately placing the needle where the nerve needs to be anesthetized versus it it might be really good in someone's hands, but then they try to do the other way and they're just not so accurate.
01:03:44.320 --> 01:03:47.519
What's your opinion on what the best approach is, intra oral or extraol?
01:03:47.679 --> 01:03:48.239
Yeah, I agree.
01:03:48.320 --> 01:03:55.519
I think that um as long as somebody's consistent and putting it in the right spot, I think that's the most important piece.
01:03:55.679 --> 01:04:05.199
I think also knowing when you run the risk of making the disease process or something worse, doing it the way that you're comfortable makes sense too.
01:04:05.280 --> 01:04:29.519
So I think most people are probably comfortable doing the intraoral approach, knowing that, hey, you know, if you're biopsying something that looks kind of ugly and it might end up coming back as a tumor, if your needle is going to be coursing through what that definitive surgery site is going to be, then we could end up seeding those tumor cells more distantly than we intended to, and really thinking about using the extraoral approach instead.
01:04:29.599 --> 01:04:39.039
So I think anybody who's most comfortable with the extraoral approach probably has fewer instances where they would need to convert to the intraoral.
01:04:39.119 --> 01:04:43.199
But I think people feel more comfortable with the intraoral because you can see the landmarks better.
01:04:43.519 --> 01:04:56.400
I don't think we'd be comfortable with our dentist coming from through our skin to do our, but I actually learned the extraoral approach for that inferior alveolar mandibular block and intraoral approach for the maxillary block.
01:04:56.480 --> 01:05:03.280
So it's kind of like what you learned, how you learned it in the beginning, how you practiced it, and then you just perfect your technique.
01:05:03.360 --> 01:05:09.119
So you probably are really successful as an individual delivering the drug exactly where it needs to go.
01:05:09.280 --> 01:05:16.639
And I am all with you about keeping that needle really close to the bone on that inferialveolar mandibular block.
01:05:16.800 --> 01:05:27.039
I would reach in with my finger intraorally to basically press that needle up right against the place that I needed it to be using an extraoral approach with the needle.
01:05:27.280 --> 01:05:38.880
And I'll knock on some wood somewhere, but I've never, you know, had a patient in 21 years of doing nerve blocks, you know, wind up having ties their tongue or cause that type of complication.
01:05:39.119 --> 01:05:59.599
So, and obviously, this is not, you know, a lab or lecture on how to do nerve blocks, but there's a lot more reading people need to do, and also really understanding the risks versus the benefits and how we can work safely when it comes to our drug dosages, our needle placements, making sure we're not injecting intravascularly, giving the block.
01:06:00.079 --> 01:06:06.320
Enough time to work before we actually start doing something surgical on top of whatever chronic pain that they're in.
01:06:06.480 --> 01:06:09.199
And that sometimes nerve blocks don't work, right?
01:06:09.360 --> 01:06:22.639
And so in those specific cases, we have to decide: was this something we want to approach from a different location, redosing the patient, or approach it more from the fact that we're gonna have to consider our other options when it comes to CRIs.
01:06:22.880 --> 01:06:25.920
And like you said, we don't want patients self-mutilating.
01:06:26.079 --> 01:06:36.000
And we know now through your research that some of these blocks could last a lot longer and even your personal experience than what we think, and the patients can't tell us, right?
01:06:36.239 --> 01:06:43.760
And other things that can happen too are traumatizing nerves and causing ongoing neuropathies and things like that.
01:06:44.000 --> 01:06:56.800
But these patients we know really benefit from the use of regional anesthesia and this multimodal pain approach and making sure that we consider benefits versus risks.
01:06:57.039 --> 01:06:59.760
So to summarize what we've talked about today, Dr.
01:06:59.840 --> 01:07:09.039
Snyder, what would you like to make sure that we don't miss or something specific that you want the listeners to take away from this conversation today?
01:07:09.360 --> 01:07:14.480
Yeah, I think that, you know, everybody's in veterinary medicine because we're there to advocate on behalf of the patient.
01:07:14.639 --> 01:07:22.559
So I think really being proactive and thoughtful about what I can do to make sure these patients are as comfortable and as safe as possible.
01:07:22.800 --> 01:07:44.079
I think in the best case scenario, you know, we have a holistic approach to managing that patient's discomfort, not only during the procedure with local blocks, but after the procedure with local blocks continuing to act, maybe their pre-meds take a while to get metabolized out, and then transitioning them to medications for home.
01:07:44.159 --> 01:07:56.159
And I think again, thinking about using a little bit of this medication, a little bit of that one, and where we can give the client some flexibility with how much they give or how frequently they give it is helpful.
01:07:56.320 --> 01:08:01.360
The only other prologue I'd throw along with that is I learned this the hard way during my internship.
01:08:01.519 --> 01:08:11.039
I I told a client to give uh patient came in on ER, I told him to give Tramodol, that's what we were using at the time, and I said they could give it three times a day.
01:08:11.360 --> 01:08:15.440
Patient, I saw it on a Saturday, on Sunday, they called me at 1 p.m.
01:08:15.679 --> 01:08:20.800
and basically recounted to me that the dog was painful again, and I was like, when's your next dose of Tramodol?
01:08:21.039 --> 01:08:22.479
And they were like, not till tomorrow.
01:08:22.640 --> 01:08:25.520
And I was like, I told you three times a day.
01:08:25.600 --> 01:08:26.319
What do you mean?
01:08:26.560 --> 01:08:34.239
And they said, Well, when I when I got up this morning at eight, I gave them the first dose, then they seemed pretty uncomfortable again at 10, so I gave them the second dose.
01:08:34.319 --> 01:08:41.199
And then by 12.30, they seemed not quite right, and I doing what we came in and saw you for, so I gave them the third dose.
01:08:41.279 --> 01:08:42.640
And I was like, Got it.
01:08:42.960 --> 01:08:44.319
Gotta give some parameters.
01:08:44.399 --> 01:08:48.960
Again, it comes down to expectation setting, communication, everything we talked about in the beginning.
01:08:49.119 --> 01:08:51.279
It circles right back around to all of that.
01:08:51.359 --> 01:08:58.880
And, you know, again, just recognizing that the clients are going to be a partner in our delivery of care for these patients, and everybody's here for the same reason.
01:08:59.199 --> 01:08:59.520
100%.
01:08:59.920 --> 01:09:01.279
We are here for the same reason.
01:09:01.359 --> 01:09:02.239
That's really great.
01:09:02.399 --> 01:09:10.800
And I feel like also we have to make sure that the instructions are clearly written down because they'll go home and they'll forget what we said to them.
01:09:10.960 --> 01:09:30.960
And so, you know, the label on the bottle of the meds, even I mean, you'd think that would make all the sense in the world, but sometimes they just need to have very specific, like, this is what you need to do, and also what to expect, because they might have thought their pet was painful, but maybe those weren't actually the signs that we would have read into that.
01:09:31.119 --> 01:09:32.640
So that's great advice.
01:09:32.720 --> 01:09:33.199
I love it.
01:09:33.279 --> 01:09:35.760
And I'm sure you have so much more advice as well.
01:09:35.920 --> 01:09:39.279
We can't possibly cover this all in in just one episode.
01:09:39.359 --> 01:09:43.680
So we might have to have you back on to talk some more about some of your experiences.
01:09:43.840 --> 01:09:44.399
So, Dr.
01:09:44.560 --> 01:09:47.439
Snyder, this has really been an amazing masterclass.
01:09:47.520 --> 01:09:52.000
But before we leave, you get to leave a question for our next guest.
01:09:52.239 --> 01:10:01.279
So, what question would you like someone like yourself, another boarded veterinary dentist, or it could be even be a technician like myself, a vet tech specialist in dentistry?
01:10:01.439 --> 01:10:03.760
That would be interesting for them to answer for us.
01:10:04.079 --> 01:10:13.199
My question would be looking back over your career, what innovation, idea, or shift in thinking has had the greatest positive impact on veterinary dentistry?
01:10:13.439 --> 01:10:15.520
What do you think the next breakthrough will be?
01:10:15.760 --> 01:10:16.319
Perfect.
01:10:16.479 --> 01:10:17.600
That's a great question.
01:10:17.760 --> 01:10:28.079
And that's, you know, future thinking as well, because we can reflect back on the history of our profession, our experiences, and then think about what does the future hold?
01:10:28.399 --> 01:10:30.800
Because things are changing really rapidly.
01:10:30.960 --> 01:10:38.079
And with new research and new thoughts and all these people working hard on these things, you know, what are we going to come up with for the future?
01:10:38.319 --> 01:10:38.800
I love it.
01:10:38.880 --> 01:10:40.079
So thank you so much.
01:10:40.399 --> 01:10:46.319
So, where can people learn more about your work and follow what you're doing there at the University in Wisconsin?
01:10:46.800 --> 01:10:55.680
Probably to follow and find out all that I've done and where I've published, you think, through my profile page through the University of Wisconsin.
01:10:55.920 --> 01:11:03.520
We can link that in the show notes so that people can find you there and the relevant publications that we discussed today.
01:11:03.760 --> 01:11:04.800
So that's Dr.
01:11:04.880 --> 01:11:05.760
Chris Snyder.
01:11:05.840 --> 01:11:08.079
Thank you so much for joining us to our listeners.
01:11:08.239 --> 01:11:16.319
If this episode changed how you think about your next dental block or your next team huddle, share it with a colleague and leave us a review where you listen.
01:11:16.479 --> 01:11:20.079
We'll see you next time on the Positive Veterinary Dentistry Podcast.
01:11:20.319 --> 01:11:21.520
Thanks, everybody.