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Monthly Archives: September 2011
Pain associated with dental treatment is managed effectively through the administration of local anesthetic drugs prior to the start of treatment. These chemicals prevent passage of the nerve impulse beyond the site at which they are received. Although the tooth or soft tissues have recieved a noxious stimulus, the nerve implulse will stop at the site where the local anesthetic drug was deposited. The action potential on the nerve axon is blocked, the impulse is terminated and the patient feels no discomfort.
Dental anxiety can be managed by inducing a state of consciousness (or, more precisely, altered consciousness) in which a person is more relaxed and carefree than previously. Over the years many names have been given to this state. Names such as chemamnesia, sedamnesia, twilight sleep, relative analgesia and comedication have been used to describe the state of consciousness that is now called sedation.
What are the causes of our patients’ fear of the dentist? Most persons harbor five universal fears:
1. Fear of pain
2. Fear of the unknown
3. Fear of helplessnes and dependency
4. Fear of bodily change and mutilation
5. Fear of death
Each of the above fears may easily be transferred into the dental situation.
The fear of pain is the most significant fear barbored by the typical dental patient. How often do I hear, “Is it going to hurt?” from a paient just before a procedure is to start? In fact, how do most patients select their dentist? Because of the superior quality of dental care or because the doctor has a repution for being “painless” and caring? I have heard “Its nother personal Doc, but I don’t like dentists” many times.
Fear of the unknown is present in varying degrees whenever a person is confronted with a new situation, be it attempting to cross a furnished room for the first time in the dark or facing anew and theatening dental procedure. Fortunately, this fear can be effectively diminished or or eliminated by the dentist by “preparatory communication.” Preparatory communication is when the dentist discusses the planned procedure with the patient, describing in nontechnical terms the nature of this planned procedure.
The fear of helpnessness and dependency is, unfortunately, more difficult to eliminate in dentistry. Because of the nature of dental care, the patient is both unable to observe the treatment and is usually placed in a very vulnerable position – the supine position. Most persons will experience a feeling of unease at this time, especially when they are receiving treatment from a stranger – a dentist or hygienist with whom they are not well aquainted. As the patient becomes more familiar with the dentist or hygienist, this feeling of helplessness should resolve.
The fear of bodily change or mutilation is common in all aspects of medicine but is especially evident in dentistry. The oral cavity is both a richly innervated and a psychologically improtant region of the body. All aspects of dental care have potentially great psychological overtones. Changes in the size and shape or configuration of the body may have a profound effect on the patient’s overall outlook and attitude. The loss of teeth, for example, in today’s society may represent the process of growing old, a situation that could prove to be extremely disturbing psychologically to the patient.
The fear of death is also ever present. Placed in a vulnerable position in the dental chair, patients next have a multitude of hands and instruments placed into their mouth. Drugs are injected that remove the patient’s ability to feel, and then a high-speed handpiece is placed in the mouth, with a bur rotating several hundred times per minute. Many sensations and feelings race through the patient’s mind at this time: Can I breathe with all this equipment and these hands in my mouth? Will I move my tongue too close to the drill and have it injured? Will the dentist slip and injure me?
Although I do treat many patients with severe dental anxiety, the vast majority of my patient population is the patient who does not harbor any irrational fears of dental treatment. However this patient does experience a degree of heightened anxiety as the scheduled dental appointment nears. This apprenhension over dental treatemt does not prevent the patient from appearing in the office, for this patient is genuinely concerned about maintaining oral hygiene and does not want to experience the pain of a toothache. This patient will be categorized as having low to moderate anxiety and will appear on a regular basis for scheduled dental care because such a patient knows that avoiding needed dental treatment will only lead to more significant (and painful) problems later. While in the dental office this patient may have sweaty palms and a more rapid heartbeat, and would admittedly much rather be somewhere else.
In the United States it is estimated that somewhere between 6% and 14% of the population voluntarily avoid seeking dental care because of their fear of dentistry. These individuals will put off treatment until they are in such pain that home remedies are no longer effective. They are categorized as severe anxiety patients and reprsent a dual problem in management, for the dentist will have to treat both the patients’ acute dental problem and their psychological emergency. I once attended a dental seminar entitled “The Pain of Fear.” This title aptly describes the dilemma faced by the acutely fearful dental patient: fear of pain keeps the patient from seeking needed dental care until the pain, which is exacerbated by this fear, ultimately forces the patient to the dental office. Such pattients present the dentist with a significant problem. Attempts to treat these patients without acknowledging their fear usually lead to great frustration and increased stress for the dentist as well as an increased level of fear for the patient. When surveyed, 57% of a group of dentists reported that the most stressful factor in their dental practices was the difficult patient.
Dentistry has indeed been at the forefront in the fight against pain. In the current age virtually all dental procedures may be sucessfully completed in the absence of any patient discomfort through the administration of local anesthetics and or other techniques. However, the dental patient, our consumer, may not be aware of this, or they may consider that the injection of a local anesthetic is the most traumatic part of the entire procedure. How then are we to manage these patients?
As dentistry developed, dentists gained the reputation of being tooth “doctors.” Dental education was for many years pedicated on the fact that the dentist was responsible for the oral cavity of the patient, and dental school cirricula illustrated this. Early dentists were trained to manage their patients’ dental requirements only. the possible interaction between dental treatment and the overall health of the patiet was either unknown or ignored.
As medicine became more sophisticated, it became very apparent that dental care could and indeed does have a significant impact on the overall health of patients. Dental schools amended their curicula, adding courses in medicine and physical evaluation. The dentist bcame even more alert to the fact that treatment in the oral cavity could profoundly influence a patient’s well being and conversely that the patient’s health could significantly affect the type of dental treatment offered. The use of the patient-completed medical history questionaire became a standard in the 1950′s. The direction today, in the 2000′s is toward a more in-depth understanding of the relationships between oral and systemic health and disease, ie periodontal disease, heart attack, diabetes, stroke.
The words “fear,” “anxiety,” and “pain” have long been associated with dentistry. Throughout the years the public has thought that dentistry hurts. The public’s image of the dentist has borne this out. Surveys have consistently shown that although dentistry as a profession is highly respected by the public, the image of the dentist as one who enjoys hurting people is still retained by many people. In a survey of the most common fears of adults, fear of going to the dentist ranked second only to the fear of public speaking.
Is this image of the dentist justified? I do not think so. Unfortunately, however, our predecessors in dentistry did not have at their disposal the array of equipment and medications for the management of pain and anxiety that are available today. History has recorded that members of the dental profession have consistently been in the forefront in the research and development of new techniques and medications for the management of pain and anxiety. Horace Wells (a dentist) and William T.G. Morten (dentist and physician), in the 1840′s were the founders of anesthesia and the first to employ nitrous oxide (Wells) and either (Morton) for the management of pain during dental or surgical procedures. Prior to this time dental care primarily consisted of the removal of root tips without any form or anesthetic, except for alcohol, which was frequently used preoperatively. Surgery, prior to the introduction of anesthesia, consisted almost exclusively of the amputation of limbs that had become infected and gangrenous. As in dentistry, these procedures were of necessity performed without the aid of ANY form of anesthesia.
In the area of intravenous (IV) medications and outpatient general anesthesia the dental profession again led the way. With the introduction of the IV barbiturates in the late 1930′s, Victor Goldman and Stanley Drummond-Jackson in England and Adrian Hubbell in the United States pioneered the techniques of IV General anestisia for ambulatory oral surgery patients. It was not until the 1970′s that the medical profession, realizing the merits of short-stay surgery, becgan to use the same techniques.
Hartford Connecticut, December 10, 1844 . . . Almost 167 years ago Samuel Cooley, a clerk in a retail store, ran around a stage in an intoxicated state, little realizing the major role he was playing in forever altering the degree of pain and suffering that patients throughout the world would experience during surgery. Cooley had come to attend a popular science lecture in which advances in science were demonstrated. One demonstration was of the intoxicating effects of “laughing gas,” which Cooley volunteered to inhale. Also in attendance on that fateful evening was Horace Wells, a local dentist who, on seeing Cooley injure his leg but continue to run about as though nothing had happened, considered there might be a clinical application for this “laughing gas.” On the following day, December 11, 1844, nitrous oxide (“laughing gas”) was administered to Dr Horace Wells, rendering him unconscious and able to have a wisdom tooth extracted without any awareness of pain.
The world had forever been changed.
In todays high tech age, the discovery of anesthesia is taken for granted. Local anesthetics are administered to patients when a surgical / dental procedure might be ever so slightly painful. Yet in 1844 these drugs DID NOT EXIST. When fearful patients require treatment a variety of techniques are available - intravenous conscious sedation; intramuscular sedation; oral, rectal, transmucosal, and intranasal sedation; and general anesthesia. These techniques of drug administration were not available in 1844. Drugs are available that are able to provide relief from extreme anxiety and fear while the patient retains consciousness; yet these drugs provide amnesia (memory loss) of the entire procedure. These drugs did not exist in 1844.
No longer does a patient about to undergo dental implant surgery, tooth extraction, root canal therapy, gum/periodontal therapy, dentures, partials or even fillings face that prospect with utter hopelessness and despair. Dentistry has long recognized that many persons are frightened of the dental experience, and to our credit, dentists have taken steps to recognize and manage these patients. In its approach to the management of pain and anxiety, the dental profession has remained in the forfront of all the health professions.
Success in life is in the eye of the beholder. It is common knowledge that true happiness is only acheived with balance in ones life. Work, worship, love, family/friends have been the commom thread of happiness for the “modern” human being. My work, dentistry in my Palm Harbor, Tampa area dentist office is a huge part of my life. I will address dentistry again.
Worship takes many forms. Being part of an organized religion is the most common form. One can be very spiritual without being religious. Respect for our fellow living creatures and our environment can be another form of spirituality.
Humans are social, not solitary creatures. Love is a part of life. Humans NEED interactions, love, touch. A child that is unloved rarely becomes a happy / healthy adult.
Family and friends, pictured is my daughter Kendall Jordan Caputo, with a friend of hers. I spent Labor day weekend 2011 with my children (Mathew and Kendall) and each child was allowed to bring a friend. I had such an incredible time with these adolesents. I also have a good friend, Michael Fackender who was at Little Gasparilla Island in his families vacation house. This gave me an adult companion.
It is possible to be very good at only one leg of the table of happiness and not acheive a succcessful / fulfiling life. This leads me to dentistry. To be a successful dentist, one needs to provide the best, most appropriate treatment possible for every patient, PERIOD. It is possible to be very good at one aspect of dentistry but to have complete enjoyment from my occupation over a long practice career, one must be a Comprehensive Dentist. To me, dentistry is one of the greatest professions in the world. There are not many professions that allow one to prevent, cure and/or repair disease in a single appointment.
I started practicing dentistry in 1985, and I opened my first Palm Harbor, Tampa FL area dentist office on April 23, 1988. I knew that technology would advance the practice of dentistry by leaps and bounds. the key is bsing able to understand IT (information technology), learn IT, buy IT and then use IT. This is my simple strategy with dental technology.
It is important to know when to add new (and often expensive) technology. In December of 2008, I purchased a Gendex GXB-500, Cone Beam Computerized Tomography machine (CBCT.) That purchase has been one of the best professional decisions of my dental career. It transformed my comprehensive dental practice. My ability to diagnose disease has been incredibly enhanced. My ability to treat (especially dental implants and dental surgery) has been moved ahead by light years!
For more information about the current cost of dental implants in my Palm Harbor Dentist office click: www.DentalImplantsCost.us
Paul L Caputo, DDS