By Kristine A. Hodson
In a book titled, "Worry: Hope and Help for a Common Condition." Edward Hallowell, MD, wrote, "Worry is amazingly common. At least one in four among us 65 million Americans will meet the criteria for an anxiety disorder at some point in our lifetime." When you worry excessively, you become afraid to take action. In dentistry and dental hygiene, this means that people don't undergo regular oral care because they worry about the pain.
As professionals, we have an abundance of resources, tools and technologies to ease our patients' worries about pain. Whether or not you are legally allowed to provide local anesthesia, you and your dental office can make strides in offering pain-free appointments that keep worry among patients to a minimum.
Here are some steps to help you make the transformation:
• Observe the worry — What are your patients' most common worries? Pay close attention to any actions or phrases that grab you and give you the feeling that your patients have anxieties. Being aware of patients' worry habits is the first step in the transformation to peace of mind hygiene and dentistry.
• Shift their thinking — After you've had a chance to analyze your patient's worry, begin to shift his or her thoughts to peace-of-mind beliefs. Many dental practices have embraced "health and luxury spa" models in their quest for dental relaxation. Taking patients' minds off the things that make them anxious through tangible amenities can replace anxiety with comforting thoughts.
The techniques that have worked successfully for many offices include tranquil décor and soothing colors, hypnosis, headphones, videos and DVD selections, TV, office music, chair and back massages, heated and vibrating chairs, aromatherapy, communication techniques, and relaxation and breathing techniques.
• Take action — Worry and fear can paralyze patients and prevent them from visiting our offices and/or completing diagnosed treatment plans. If patients are unable to reduce their anxiety by inducing their production of endorphins, the body's natural tranquilizers, then science and technology can help guide them to a more comfortable state. This is a perfect opportunity to learn the allowable functions with regards to integrating peace-of-mind techniques, analgesics, topical anesthesia, nitrous oxide, and local anesthesia.
Tips and technologies
• Pre-procedure sedatives: Valium taken orally the night before is recommended. Oral Triazolam can be used for pre-operative and peri-operative anxiety control one hour before the appointment. Oral Triazolam belongs to the benzodiazepine class of CNS-depressants. The recommended dosage pre-operatively is 0.25 mg. A second dose of 0.25 mg can be administered at treatment time if needed. Nitrous oxide can be used in conjunction with this medication (but is recommended only for injection, then placed on oxygen only before removal.)
• Nitrous oxide sedation: This can be used in conjunction with local anesthetic. When local anesthetic is less than 100 percent successful in blocking transmission of pain impulses, nitrous oxide may provide an increase in pain threshold so that the patient does not interpret pain. It is important to find out if the patient is already using CNS depressants before administering the nitrous oxide. This may affect the dosage.
• Sleep dentistry: A growing trend is to use injectable sedatives. Currently, only about 5 percent of general practitioners offer this in their practices.
• Hurricaine gel and spray (www.beutlich.com). These are generic topical anesthetics that routinely contain 20 percent benzocaine, a key ingredient in over-the-counter oral pain relief. Are you leaving it on long enough to be effective? It needs to be swabbed at the injection site for one to two minutes for best results. These come in a variety of flavors to suit personal preferences.
• Dentipatch, a lidocaine transoral delivery system. These are soft, pliable polymeric patches. They are like adhesive bandages that stick to an injection site prior to an injection. The area must be dried thoroughly to get them to stick properly. These work especially well for palatal injections combined with pressure anesthesia.
• Medajet. This is a spray which numbs topically without a needle for minor procedures. It can also be used before injections to make the needle stick more comfortable.
• Dyclone. This was originally designed for cancer patients undergoing chemo who get sores in their mouth. After application, this will leave the tissue very numb for half an hour. It's perfect for swishing before light to moderate periodontal therapy patients, especially when hygienists are not licensed to give local anesthetic.
• Zilactin Baby (www.zila.com). This is a safe and effective medication that relieves the teething pain for babies and younger children. The fast-acting ingredient (benzocaine 10 percent) relieves pain in seconds, as opposed to acetaminophen or ibuprofen, which may take a while to take effect. This comes in a grape flavor and provides a soothing and cool sensation on the baby's gums. It's an alcohol-free gel that contains no saccharin and no dyes.
• Mepivicaine, lidocaine, prilocaine and bupivacaine. Several choices are available in local anesthetics. Each contains specific choices for vasoconstrictors and different concentrations of both anesthetic and vasoconstrictors.
• Articaine (Septocaine, www.septodontusa.com). This is a new anesthetic that was introduced in July 2000. It has become quite popular due to rapid onset and consistent results. Dentists and hygienists who use articaine report deeper anesthesia and fewer misses.
What are the emerging trends? What type of local anesthetics are drug companies moving to and why? The standard has been to use 1:100,000 with both mepivicaine and lidocaine. The drug companies are now moving to 1:200,000 because it has very similar clinical effects and can be used more safely. Ask your supply representative about these changes.
Anesthetic delivery systems
Updates and improvements to the more conventional way of delivering anesthesia include needles and aspirating syringes.
• TruJect non-deflecting anesthetic needles (www.duxdental.com) have a unique construction that greatly reduces discomfort for the patient, yet allowing anesthetic to be placed exactly where it is needed. The patented Huber Point is centrally located over the lumen of the needle, eliminating coring of the tissue and aiding with non-deflection.
A thin wall design of the needle with a 21-gauge outer diameter and a 27-gauge inner diameter is convenient because it eliminates the need to stock several gauges for different areas of the oral cavity. Aspirating with the 28 gauge is a non-issue. The needles are offered in long and short lengths along with metal or plastic hubs, depending on preference.
• Septoject (www.septodontusa.com). According to company product information, each Septoject triple beveled needle is siliconized to help ensure a smooth motion during injection and to maximize patient comfort. In addition, Septodont markets Aspiject, a self-aspirating syringe, reported to be well balanced and comfortable to use. It is lightweight and extremely durable and provides excellent tactile sensitivity during local anesthesia injections.
Intraosseous injections have been re-introduced, helping practitioners treat teeth that are difficult to numb by conventional methods.
• The Stabident system (www.stabident.com). This is an intraosseous delivery of anesthetic for hard to anesthetize areas and is used mainly on the mandible. It requires pre-drilling of a delivery hole with a slow-speed handpiece. The hole is drilled into the cortical plate. A 27-gauge needle is inserted into the hole and anesthetic is administered directly into cancellous bone. Deep anesthesia can be achieved in less than 30 seconds, compared to 10 to 15 minutes with a traditional mandibular block.
• Hypo EZ-Aim intraosseous needles (www.dentsply.com). The IO injection achieves immediate, profound desensitization of hard to anesthetize teeth. There is no uncomfortable, slow-to-dissipate numbness afterwards. No pre-drilling of the delivery hole is required.
• X-Tip Anesthesia System (X-Tip Technologies Inc.) and Intraflow™ Anesthesia Delivery System have not been clinically evaluated by sources assisting with this column, but are additional options for readers.
Some practitioners are using computer-controlled local anesthetic delivery systems. Some users favor this method because they have found that the rate of injection is difficult to control when injecting manually. These machines take the guesswork out. It is all pre-programmed and can make even the most uncomfortable injections more palatable. This is especially true for palatal injections.
• Comfort Control Syringe, or CCS (www.dentsply.com). This machine has five pre-programmed injection modes that use a two-stage delivery rate designed to minimize anxiety and discomfort. The rates can be doubled at the dental professional's discretion. Injections requiring very slow anesthetic delivery — such as palatals and PDLs — can now be delivered comfortably. All controls are located in the ergonomic hand-piece that provide control where it's needed — at your fingertips.
• The CompuDent/Wand (www.milesci.com). This allows hygienists and doctors to administer controlled, highly effective and comfortable injections, even in resilient tissues.
• Softject (www.pearsondental.com). This system features a dosing wheel for slow, precise, and controlled injections without levers. Each dose delivered is less than 0.1 ml with each click. This minimal dose is reported to prevent iatrogenic injury. It has features that reduce pressure and eliminate pain. It is fully autoclavable and comes with 10 tips.
• VibraJect (www.vibraject.com). This is an add-on that can be attached to the barrel of conventional and disposable syringes to block injection pain based on the Gate Control Theory of Pain Management. It is a battery-operated motor with an autoclavable bracket clip. The motor creates a high-frequency vibration of the needle that stimulates the nerve endings when inserted during a conventional injection technique. It is said to be most helpful in reducing the pain associated with intraligamental, palatal, mandibular block, and infiltration injections. Topical anesthetic may not be needed prior to use. A 1.5V button-type battery is required and lasts up to 500 injections.
With all of these options in pain control, the dental office is evolving into a much more comfortable place for patients. It is important for hygienists to stay informed about proper techniques and new armamentarium relating to local anesthesia, anxiety control, and peace-of-mind hygiene.
When you can offer pain-free hygiene, your patients will not only appreciate you, they will tell everyone else how great you are and your practice will thrive even in the toughest times.
Author's Note: Special acknowledgement goes to Patti Sooy, RDH, BS, and Cris Duval, RDH, for supplying some of the information and clinical experience in this column. Patti and Cris practice dental hygiene in Washington state and offer in-office hygiene coaching services. They can be contacted via e-mail at [email protected] or [email protected], or call 888-347-4785.
Kristine A. Hodsdon, RDH, BS, is an international speaker, author, and software developer. She is the author of Demystifying Smiles: Strategies for the Dental Team. The book is available online at www.pennwell-store.com. She can be contacted about speaking or coaching at [email protected]. Visit her on the Web at www.reachhygiene.com.