Patient Comfort: Tradition merges with innovation
It has been said by many a dental hygienist, “The more comfortable the patient, the more efficient the clinician.
It has been said by many a dental hygienist, “The more comfortable the patient, the more efficient the clinician.” Never have we had as many options to increase patient comfort and reduce dental anxiety as we do today. Anesthesia by injection is still a great option and warrants review, since 35 states license hygienists for this procedure. For those who are not licensed to give anesthetic, or for those who practice in a state where injected anesthetic is not within the dental hygiene scope of practice, there are exciting alternatives. These include aromatherapy and anti-anxiety breathing techniques.
There are two types of local anesthetic agents - ester and amide. Esters metabolize rapidly by cholinesterases in the blood through hydrolysis, and include procaine (short-acting) and tetracaine (long duration of action). Amides, used widely in dentistry, are metabolized through a biotransformation in the liver by microsomal enzymes. The most common amides are lidocaine and prilocaine (short-acting), mepivacaine and articaine (short to moderate duration of action) and bupivacaine (long duration of action).1,2
Many hygienists are interested in the use of epinephrine in local anesthetics. According to Dr. Stanley F. Malamed, “There is no difference in the depth, duration, or onset of anesthesia, whether it be 1:50,000 or 1:100,000; there is no reason to use epinephrine in a 1:50,000 concentration for pain control. By doing this, you are simply giving the patient twice as much epinephrine without any benefit relative to the depth of anesthesia.
“So for pain control purposes, 1:100,000 concentrations are much preferred. The only reason to consider using epinephrine in 1:50,000 concentrations would be for hemostasis. If any hemostasis is required, you can either keep the 1:100,000 or switch the epinephrine to 1:50,000 and then locally infiltrate just enough local anesthetic into the papilla (the soft tissue) to produce the degree of necessary ischemia. With lidocaine, when the tissue turns white, you stop. Mepivacaine is now available as a 2 percent concentration with levonordefrin, which is available as a 1:20,000 concentration. Levonordefrin is a synthetic vasoconstrictor. It is not epinephrine but it has epinephrine-like properties. However, it is only one-fifth as potent as epinephrine; therefore, it is available in a 1:20,000 concentration, which is equivalent to an epinephrine 1:100,000 concentration or five times more concentrated. At 1:20,000, levonordefrin is as effective as epinephrine in a 1:100,000 concentration, so the indications and contraindications are the same as those for epinephrine.”1,2
To facilitate comfortable delivery of injections, DENTSPLY/Professional introduced the Comfort Control™ Syringe (CCS™) in 2001, an electronic, preprogrammed delivery system for local anesthesia that dispenses the anesthetic in a slower, more controlled and consistent manner than a traditional manual syringe. The injection begins slowly to minimize the discomfort associated with rapid injection. After 10 seconds, CCS automatically increases to the injection rate for the selected technique. There are five different injection rates preprogrammed into the CCS system. The design of the CCS is such that it is easy to convert from a manual syringe while allowing the benefit of a slow and consistent injection. In short, the Comfort Control Syringe makes injections easier for the dental professional and more comfortable for the patient.3
Two of the most effective topical anesthetics are EMLA cream and Oraqix periodontal gel. In 1999, EMLA cream 5 percent (lidocaine 2.5 percent and prilocaine 2.5 percent) was rated superior to all other topical anesthetics by Roghani S, Duperon DF, and Barcohana N. of the Department of Pediatric Dentistry, University of California, Los Angeles. Because it’s a cream, EMLA must be applied to the oral mucosa with an applicator or carried into the pocket with an instrument. As the cream warms to body temperature, it has a tendency to become liquid and runny, which makes it difficult for the clinician to control. EMLA is the best choice, however, for clinicians who cannot use Oraqix.
Oraqix, also lidocaine 2.5 percent and prilocaine 2.5 percent but in a periodontal gel, made its debut in 2001 and has proven very effective. Oraqix has a 30-second onset and lasts up to 30 minutes. One of the unique features of the product is its ability to change from a liquid to a gel at body temperature, which allows the clinician more control during placement. According to Dr. Stanley F. Malamed, “The gel can be used in combination with injectable local anesthetics. There are no contraindications. It is not absorbed to any significant degree, so blood levels of its components (lidocaine and prilocaine) are not significant. Indeed, the area of tissue exposure to the gel is quite limited. Overdose from combining the periodontal gel plus an injectable local should not be a significant consideration or problem, assuming the injectable drug is used appropriately.”3
The comfort of aromas
Anesthetics are not the only way to increase a patient’s comfort. Aromatherapy, the art and science of using essential oils extracted from aromatic plants to promote and enhance health, is becoming popular in many dental practices. These oils are believed to have physical benefits and subtle effects on the mind and emotions, and therefore are becoming more common in dental offices across the country.
The use of aromatic, perfumed oils dates back thousands of years to ancient Egypt, China, India, Greece, and Rome. In Egypt, essential oils were used after bathing. The Chinese compiled an encyclopedia of information on plants, herbs, and wood thousands of years ago. In ancient India, aromatic massage was part of ayurvedic (holistic) medicine. The Greeks and Romans used fragrant oils for medicinal and cosmetic purposes. However, it was the medieval physician Avicenna who first extracted these oils from plants. During the middle ages, the antiseptic and bactericidal properties of essential oils, as well as their positive effects on the immune system, were recognized during the European plague. In the 19th century, European scientists began researching the antibacterial effects of essential oils.4,5
French chemist Rene Maurice Gattefosse originated modern aromatherapy. He published his first thesis on “Aromatherapie” in 1928, and a book by the same title in 1937. Aromatherapy was revived in the 1960s by French homeopaths Dr. and Madame Maury, and aromatherapy was incorporated into the traditional health care community in Europe. Aromatherapy was introduced to the United States in the early 1980s, and most practicing aromatherapists in the United States are trained as massage therapists, psychologists, or chiropractors who incorporate the use of essential oils into their practices.4,5
Essential oils are extracted through the process of distillation from aromatic plants, flowers, herbs, woods, and fibers. These oils not only give the plant their scent, but are essential for the plant’s biological processes. There are currently over 70 essential oils used for aromatherapy. Each has its own aroma and profile of therapeutic effects that include soothing, invigorating, relieving mental conditions such as depression and anxiety, having direct physical effects on organ systems, and possessing antibacterial, antiseptic, antifungal, and anti-inflammatory properties.4,5
There are four different routes by which essential oils access the body. These are direct absorption through the skin, inhalation by the lungs, inhalation by the olfactory system, and direct ingestion. The most appropriate use in dentistry and the most widely accepted theory regarding how essential oils access the body is through olfaction. We know how powerful aromas and odors can be; they possess the ability to generate emotion and change behavior. Currently, scientists believe that olfaction can influence many aspects of our physiology including mood, thought, sexual behavior, cognition, vigilance, mental health, and possibly general overall health. With such influences, considering aromatherapy in dentistry bears examination.4,5,6,7
Let’s take a look at the physiology of the olfactory system. It is a complex web of mucous membranes, cilia, nerve cells, nerve fibers, and parts of the central nervous system. The chemical components of essential oils access the olfactory system via the cilia of the nasal epithelium. These cilia then project the smell into the nasal cavity from the receptor cells. The other end of the receptor cell projects to the olfactory bulb, which then transmits the signal to the limbic system of the brain, made up of the amygdala and the hippocampus. The amygdala mediates emotions and the hippocampus is responsible for memory. Together they control emotional, hormonal, metabolic, and stress responses, all of which are influenced by smell.4,5,6,7
Aromatherapy has proven beneficial during dental procedures in reducing stress, pain, and anxiety. The most important aspect in selecting aromatherapy and essential oils is making sure they are a therapeutic grade. The JP Institute has recently released a spa product line designed specifically for dental practices that features antibacterial soap, hand lotion, muscle rub and lip balm that include therapeutic grade essential oils such as citrus, lavender, and peppermint. Visit their Web site at www.jpconsultants.com for product details. Various studies have revealed that olfaction and the sense of smell can have positive effects on mood and the perception of wellness. The easiest way to dispense essential oils is to place a few drops in steaming water, atomizers, humidifiers, or a heatproof diffuser dish over a candle or other flame to diffuse the scent.8,9
Some precautions are needed when using essential oils. They should never be taken internally because many are poisonous. Some oils can cause allergy or irritation if applied undiluted to the skin. Aromatherapy oils have been reported to cause headaches, nausea, and allergic reactions. Don’t be fooled by products labeled “natural.” There is a difference between what the FDA allows manufacturers to call “natural” and products including therapeutic grade essential oils. Almost all adverse reactions to aromatherapy are due to the use of synthetic or low-grade oils. For more information on aromatherapy, visit www.altmed.creighton.edu and select aromatherapy and pain, or visit www.cancer.org and type aromatherapy in the search engine.5
Taking a deep breath
As clinicians we can help patients reduce their perceived dental-related stress and tension through a simple breathing technique called the Sigh Breath. The Sigh Breath, also called the Instant Tranquillizer, is a simple breathing method that releases tension in the chest, diaphragm, and neck, and reduces the symptoms of anxiety, stress, or panic.
The Sigh Breath yields the following benefits:
• Interruption of the common reaction to anxiety to become absorbed with thoughts and feelings (internal stress-building loop).
• Engages attention. When used regularly, provides momentary interruption of the internal stress-building loop, taking a person out of the loop and into action.
• Interrupts any tendency to hold or restrict breath.
• Reduces accumulated physical tension throughout the body, especially in the throat, chest, neck, and abdomen.
This technique (see related sidebar) enables patients to instantly reduce their tension level by temporarily raising their blood carbon dioxide level. This technique is also helpful for clinicians experiencing workday stress.10
It is well within our scope of dental hygiene practice to use all techniques available to give patients quality care in a comfortable and relaxed environment. Now more than ever, consumers are seeking technically skilled clinicians who go above and beyond the call of duty to keep them comfortable and relaxed. I can think of no greater gift a dental professional can give his or her patient!
1. Chen, Andrew H., DDS, Toxicity and Allergy to Local Anesthesia, 1998 Journal of the California Dental Association.
2. Malamed, Stanley F., DDS, Dimensions of Dental Hygiene, June 2005; 3(6): 22, 24, 26.
3. Oraqix(r), The Comfort Control(tm) Syringe, DENTSPLY Professional /Oral Pharmaceuticals, York, Penn.
4. Vignaroli, Laura, MD, Creighton University Medical Center, School of Medicine, Complementary and Alternative Medicine.
5. The American Cancer Society Web site, complementary therapies, www.cancer.org.
6. Ariniello, Leah, Science writer, Society for Neuroscience.
7. Olfaction, a tutorial on the sense of smell, compiled by Tim Jacob, Cardiff University, UK.
8. Clark, Marge, founder of Nature’s Gift Aromatherapy Products.
9. Lawless, Julia, The Illustrated Encyclopedia of Essential Oils.
10. The ‘Instant Tranquillizer’ Using the Sigh Breath, Pegasus NLP, 4 Lyon Close, Yaxley, Suffolk IP23 8BE England.