Sleep through the drill

[drsushant]

Is there an alternative to those painful visits to the dentist? Yes, describing the advantages of sleep dentistry, especially for those who are afraid or have multiple health problems.

“Had he sought dental intervention earlier, we could have saved more teeth,” says Dr. Elavazhagan, facio-maxillary anaesthesiologist. He has just overseen the sedation of 50-year-old R. Subramanian for the elaborate dental ‘flap surgery’ done on him. Subramanian had slept through the procedure without experiencing any pain, but curiously, all through the surgery, he was conscious enough to open and close his mouth as instructed by his dentist, and give coherent answers to his anaesthesiologist’s probing questions.

Apparently, it doesn’t have to be general anaesthesia where the patient is unconscious in order for him to undergo a dental procedure painlessly. There is a middle path — sleep dentistry. In fact, once the individual who has undergone sleep or sedative dentistry wakes up, he will have no memory of the procedure. “A short while later, he is in total control of himself and can even drive himself home, if he wishes. “That is the beauty of sleep dentistry,” says Dr. Elavazhagan.

Who is it for?

Fear of the dentist’s drill had held Subramanian back from seeking treatment for years. Hearing about sleep dentistry finally gave him the courage to visit the dentist. Sleep dentistry can be a good solution for people like Subramanian who are extremely anxious or dread dental procedures. It is also a solution for elaborate or multiple procedures that need to be done at one go. Subramanian’s upper and lower jaw bones had worn out leaving his teeth mobile, and the only solution was to replace the worn-out portions.

If this procedure were to be done under general anaesthesia, it would require hospitalisation, which is both expensive and time-consuming. If done without sedation, the procedure would have required many sessions, as a person who is awake cannot keep his mouth open for the long time it takes for flap surgery to be performed on both the jaws. Sleep dentistry is how Rajagopal had multiple dental procedures done on him at one go — two root canals and the extraction of his wisdom tooth.

So then, can anybody who is short of time or anxious about dental treatment opt for sedative dentistry? Not really. It is case specific, and the decision has to be arrived at by the dentist and the anaesthesiologist after evaluation of the patient. But generally, it can be a boon for people with acute anxiety, cardiac problems, blood pressure, diabetes, bronchial asthma or cerebral palsy. Dr. Elavazhagan explains, “The stress brought on by dread of a procedure can trigger an epileptic attack in those who have epilepsy, and raise blood sugar levels in some diabetic persons. In a cardiac patient, this stress can increase the heart rate and blood pressure which, in turn, can worsen myocardial ischemia. It can precipitate asthma in a patient with a history of the disease. Meanwhile, a person with cerebral palsy will have uncontrolled movements that could make the dental procedure very difficult without sedation.”

In the case of children, inhalational/intravenous sedation is not popular because all children cannot be treated effectively under sedation and because they show varied behavioural response to sedation. Likewise, sleep dentistry cannot be employed on people who are mentally challenged and who may not be very co-operative. General anaesthesia is a better option for them. “If it is indicated, sleep dentistry can be a good solution. As with all technology, however, it should be judiciously employed,” says Dr. M. B. Aswath Narayanan, Professor and Head, Public Health Dentistry, Government Dental College and Hospital, Chennai.

Leave it to the experts

Sometimes, a paradoxical situation could emerge, as some individuals are stimulated by sedation. Since control and evaluation of the sedation levels is tricky, it must be done only by someone who is trained and can expertly monitor pulse, blood pressure, etc., and rescue the person in case there is an emergency that’s a result of sedation. As with general anaesthesia, mistakes can be fatal. Meanwhile, intravenous sedation is the mode considered best for sleep dentistry.

“There is lack of awareness about sleep dentistry. But with proper evaluation and if executed by trained anaesthesiologists, it is perfectly safe,” says orthodontist and dental surgeon Prof. Dr. S. Venkateswaran, who performs sleep dentistry.

FACT FILE

The American Dental Association has established very clear guidelines for sedative dentistry:

* During sleep dentistry, the patient is in a sleep like state and doesn’t perceive the procedure, but is conscious enough to respond to instructions.

* It enables time-consuming/multiple dental procedures in a single session.

* It is a good option for people with acute anxiety, cardiac problems, blood pressure, diabetes, bronchial asthma, cerebral palsy, etc.

* Sleep dentistry is an individual-specific option, opted for as per the dentist and the anaesthesiologist’s evaluation of the individual.

        

[Drsumitra]

There is a growing demand for dentist anesthesiologists to treat pediatric patients but a lack of available practitioners able to meet it in every region of the U.S., according to a study in Anesthesiology Progress.
"This shows that there’s definitely a need for more dental anesthesia programs," co-author James Jones, DMD, PhD, a clinical associate professor at the department of oral medicine, pathology, and radiology at Indiana University’s School of Dentistry, told DrBicuspid.com. "There are only about 10 or 11 dental anesthesiology programs in the U.S., and state legislatures have to make the decision to allow dental anesthesiologists to work."
Dentistry
Anesthesiology Progress published the work of Dr. Jones et al along with another study, also conducted at Indiana University, examining the demand for sedation and general anesthesia in pediatric dentistry (Spring 2012, Vol. 59:1, pp. 3-11). After surveying directors of dentist anesthesiologist and pediatric dentistry residencies, the researchers’ findings support Dr. Jones’s position.

"Pediatric dentistry residency directors perceive a future change in the need for deep sedation/general anesthesia services provided by dentist anesthesiologists to pediatric dentists," they wrote. "Sixty-four percent anticipate an increase in need for dentist anesthesiologist services."

Likewise, dental anesthesiology directors observed an increase in requests for the services of dentist anesthesiologists by pediatric dentists: 56% saw an increase in the past two years; 63% saw an increase in the past five years; and 88% have seen an increase in the past 10 years, the study authors noted.

Limited training programs

Dr. Jones and his colleagues wanted to compare two models of office-based sedation used by pediatric dentists: self-administered and via a dentist anesthesiologist. To accomplish this, they sent an email to all 4,300 active members of the American Academy of Pediatric Dentistry (AAPD) requesting their participation in the survey; 494 out of 1,927 practitioners that responded completed the survey.

The survey revealed that women dentists were more likely than men to use a dentist anesthesiologist, at 39% and 23%, respectively. Age was also a factor.

"The 51+ year old respondents were less likely, compared to all other age group respondents, to administer IV sedation and use a dentist anesthesiologist, and would less likely use a dentist anesthesiologist if one were available," the researchers wrote.

Similarly, those in practice for more than 21 years were the least likely to administer IV sedation or use a dentist anesthesiologist. However, there was no statistically significant difference regarding age and the likelihood of administering some form of in-office sedation.

Nassim Olabi, DDS, study co-author, chalked up the difference in preference to two main factors.

"It’s all about comfort; if you’ve been using oral sedation for ages, you’re more likely to continue using it," said Dr. Olabi, who launched the study as part of his residency. "Also, a lot of pediatric dentists don’t use IV sedation partly because they haven’t been trained in it."

Practice type also impacted responses. Sixty-three percent of group practice doctors responded that they did not administer some form of in-office sedation.

"Finding out ‘why is that?’ was one of the challenges of this study since there weren’t others like it before," Dr. Olabi explained. "But a lot of group practices go to the hospital. There are certain patients that aren’t good candidates for office-based sedation, so some offices just take them all in so they don’t have to spend time making those decisions."

Regional variations in preference appeared in the results, as well. The southwest had the highest number of respondents who administered some form of in-office anesthesia, while the west had the highest percentage of practitioners administering IV sedation or employing dentist anesthesiologists.

And "in every region of the country, the desire to use a dentist anesthesiologist, if available, is consistently higher than the number of pediatric dentists providing their own anesthesia," the researchers wrote.

John Liu, DDS, immediate past president of the AAPD, was "not surprised" by that conclusion and outlined three reasons for the dearth of dentist anesthesiologists during an interview with DrBicuspid.com.

"The first is that a lot of these states don’t have provisions within their dental practice acts that would allow it," he explained. "Second, there are a limited number of dental anesthesia training programs in the country. Third, which is out before the ADA’s upcoming House of Delegates in the early fall, is recognition of dental anesthesia as a specialty within dentistry. I think once that happens, dental schools will be more inclined to open up dental anesthesia residency programs."

There are significant advantages to using a dentist anesthesiologist, according to the doctors whom DrBicuspid.com spoke with.

"We’ve come to realize that it’s a safety issue," Dr. Jones said. "If you have somebody managing the anesthetic part and then we’re doing the dentistry, I believe that, overall, there is better care."

Dr. Olabi agreed, noting that variables such as a child’s metabolism and whether or not a very young patient is going to drink their medication are among the disadvantages that make oral sedation so unpredictable.

"The old ways were, you fight and wrestle with young patients," he said. "Why do we want to do that when we can use something like office-based sedation to do better dentistry?"

He pointed to ear, nose, and throat doctors placing ear tubes in young patients as an example of the medical field’s usage of sedation.

"It takes five minutes, if that, to place an ear tube," Dr. Olabi said. "What do they do with those kids? They put them under."

There are cost advantages, too. "At minimum, there is 50% less cost in comparison to taking the child to the hospital and going into the operating room," Dr. Jones stated.

While the advantages are clear to some, when will a nationwide shift toward the greater usage of dentist anesthesiologists take place?

"The time frame is a tough one to predict," said Dr. Liu. "In this economy, dental schools are going to be hesitant to open new programs unless they see a return on their investment, so to speak. I think this study will help convince deans of dental schools that there is a need out there, and that will make deans more likely to go out on a limb and start a new program."

 

        

[drmithila]

A new study conducted by scientists at the Rey Juan Carlos University of Madrid highlights the important role that parents play in the transmission of dentist fear in their family.
Previous studies had already identified the association between the fear levels of parents and their children, but they never explored the different roles that the father and the mother play in this phenomenon.
América Lara Sacido, one of the authors of the study explains that “along with the presence of emotional transmission of dentist fear amongst family members, we have identified the relevant role that fathers play in transmission of this phobia in comparison to the mother.”
Published in the International Journal of Paediatric Dentistry, the study analysed 183 children between 7 and 12 years and their parents in the Autonomous Community of Madrid. The results were in line with previous studies which found that fear levels amongst fathers, mothers and children are interlinked.
A key factor: the father
The authors confirmed that the higher the level of dentist fear or anxiety in one family member, the higher the level in the rest of the family. The study also reveals that fathers play a key role in the transmission of dentist fear from mothers to their children as they act as a mediating variable.
“Although the results should be interpreted with due caution, children seem to mainly pay attention to the emotional reactions of the fathers when deciding if situations at the dentist are potentially stressful,” states Lara Sacido.
Consequently, transmission of fear from the mother to the child, whether it be an increase or reduction of anxiety, could be influenced by the reactions that the father displays in the dentist.
Positive emotional contagion
Amongst the possible implications of these results, the authors outline the two most salient: the need to involve mothers and especially fathers in dentist fear prevention campaigns; and to make fathers to attend the dentist and display no signs of fear or anxiety.
“With regard to assistance in the dental clinic, the work with parents is key. They should appear relaxed as a way of directly ensuring that the child is relaxed too,” notes the author. “Through the positive emotional contagion route in the family, the right attitude can be achieved in the child so that attending the dentist is not a problem,” she concludes.

        

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