My idea of being a stress-free dentist

Dec 11, 2018
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My idea of being a stress-free dentistMy idea of being a stress-free dentist

Dr Jane walked into her own practice like an employee under pressure. Dressed simplistically, not so keen about presentation. Her eyes were sunken from lack of sound sleep. Her morning started with popping an Asprin after tea. Her neck was hurting. Her mind wondering around yesterday’s patients. She was stressed, as the patients kept sending her emails and messages on WhatsApp. The dental lab kept calling her since morning to recall the patients, to repeat an impression. ‘Oh, I forgot to pour my casts of two patients who came last evening’, thought Dr Jane to herself. The implants which had been delivered the other day were not in conjunction with the sizes she ordered. One of the letters on the board light went off last evening. Waste had to be collected for three days. The material department kept asking for their payments. But instead she had to pay for the old dental chair repair. The finances just didn’t seem enough despite having a fair number of cases this month. Does this situation sound familiar to you?

Well if it is, it’s time for you to rearrange your style of functioning. A lot of things that require your attention has long past its due date. You’re under stress. So how does one make out that he/she is stressed?

Effects of stress on a dentist’s life

On your health

  • Back pain
  • Spondylitis
  • Chest pain
  • Muscle tension
  • Change in sleep patterns
  • Headaches and migraine
  • You tend to overeat
  • You may start consuming alcohol or start smoking often

On your moods

  • Anxiety on patients and staff
  • Restlessness making it difficult to be in clinic for long hours
  • Lack of motivation
  • Get irritated quickly
  • Sadness and depression
  • You avoid taking cases which otherwise interest you
  • You lack creativity

On your family

  • You carry your stress home, which making your spouse stressed
  • You avoid taking responsibility in family because you think you already have enough on your plate
  • Family fights

On your practice

  • Your staff finds you unapproachable
  • The ambience in your clinic is always tense
  • Patients start getting irritated
  • Patients withdraw from you, ask for other dentists instead
  • Colleagues avoid you and form groups
  • Your practice struggles

All this pain you go through just because you are not able to cope up with stress. In this article I will be discussing some strategies you can use in your daily routine to kick words like boredom, stress, anxiety out of your life.

Firstly, I did like to tell you to think out of the box. A growth mindset requires you to shift your thoughts from ‘I know everything already’ to ‘I want to know something new today’. Once you start seeing things from a new perspective, I can help you change any scenario from a stressful to a pleasurable one.

What is management?

Management stands for planning, organizing, directing and taking total control on yourself and your practice.

Having worked in several practices over 10 years of my career. I could see a wide variation in the management styles from one practice to another. From single chair dental practices to multi-specialty dental hospitals, the management style differs. But one thing that was common in all was the proprietor of the practice always remained calm and motivated. The success of most multi chain practices lies in the way the dentists are trained to channelise their skills and personality in day to day basis.

A stress-free ambience is a must have for any dentist to stay long in practice. A good balance in work and home affairs are key to being stress-free.

‘Failing to plan, is planning to fail.’

The most accomplished people in the world are not the most intelligent people but the best planners.

Here are some steps dentists can use to plan their daily practices to lead a stress-free life:

A dental practitioner has two sides of a life. One life is in practice, the other one is outside their. When there is a synchronization in your outside as well as inside life, that’s when you excel as a dental practitioner’s. Dentists who do not believe in this statement, are prone to stress.

Steps to follow in practice to reduce your stress levels

The crucial first hour:

Have you thought over what is the first thing you do as you enter the clinic. This is the most crucial hour for a dentist who works full time and you know you got to have energy reserved for yourself until 9pm.

A quick check in this order in the first one hour as a dentist

1. Clinic ambience

Make sure where you spend the next 12 hours of your life, looks clean and smells nice. A gloomy desk can make you depressed in a few hours. The stands, stationery are all in place. Keep some fresh flowers if it is possible.

Take a walk through your clinic and make sure the toilets and labs are spic and span. Your patients observe all this before they give you those five-star ratings, at the end of the day.

2. Front Desk

Talk to your front office or manage your appointments with a lot of attention.

Keep the tougher cases for the morning session and the easier ones which require less mind work for later part of the day. Prioritizing is the key to avoid stress as full time a dentist.

Delegate, Delegate and Delegate : It is essential for the staff to be told what exactly their job responsibilities to ensure the staff are doing productive tasks in practice. To avoid stress in practice, dentists need to delegate their work in a humble way, repeatedly and make sure the staff fulfills those tasks within the set timelines.

3. Awareness of surroundings

Read the news for about 10 minutes. Make sure your aware about things out of your profession as well like property rates, stock market, new books, movies etc., these make interesting talking point with your patients and colleagues.

Go through some websites in dentistry like Dental Reach. Be aware about the various continuous professional development courses, free webinars, conferences, exponents etc.

4. Temperature in clinic

The temperature in clinic or the weather influences your stress levels.

Make sure you have windows with lot of fresh air coming in instead of always staying in air-conditioned rooms. Having a lot of fresh oxygen and light works wonders on your moods.

Second half of the day

1. Recalls

Recall previous patients from the day before. Make sure each one is happy with your quality of attention the very next day. If not the day after, call after 48 hours in case it takes time to recuperate. Counsel them, so your patients will build their trust in you.

New recalls must be done in the later part of the day. Since it builds stress at times as the patients have many queries and complaints.  A recall a day before instead of the same day works better and helps patients and doctor to plan their appointment.

2. Payments and outstanding balance

Check on this and be reminded about your target for each day as you take in patients. A smart dentist will recover all what is needed by working harder on certain cases. And going easy when it’s done. Engaging a chartered accountant for your taxes and other support documentation is a must to grow as a practitioner

3. Check on important people in your life

Make time to call home – check on your parents, spouse, kids, house helps. Make sure everything is in place.

4. Prioritise people

Relatives can be taken in, in the later part of the day, as they take away a lot of your practice time chit chatting. Which in turn builds stress if other patients are waiting. Learn to say ‘No’ and know where to draw the line.

Fix a time when people can call you or you call back people to answer their queries.

As far as possible, tell your patients not to call or message after practice hours, since after practice hours should focus on your family and family.

Divide your appointment schedule with patients in such a way you give them the amount of time they require depending on the level of their ailment or condition.

5. Have ice breaker sessions in practice

These are strategies used in IT firms and management study schools to engage the team members and create a feeling of belonging. These are games played by all members in office to improve memory, escalate moods or create friendships in office. It seems like a silly thing to do as dentists, but it will start bringing the fun quotient in your practice.

For more ideas you could click on, Read more

Various self-management techniques for a dentist

The art of self-management is to take responsibility of one’s own behaviour and well being. Here we shall discuss the various personality traits in dentists, so we can further understand how to improve ourselves.

Personality

People come from various walks of life. People have their own unique perspective of a practice, they have different social, emotional, physical and financial needs. This fact helped me categorise as aggressive or competitive practitioners and conservative practitioners.

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DISCLAIMER : “Views expressed above are the author’s own.”

Party Gums – Turn it up with “The Pink Component”

Dec 3, 2018
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Party Gums - Turn it up with "The Pink Component”Party Gums - Turn it up with "The Pink Component”

Is your patient missing on a gratifying emergence profile despite your skilful efforts? Is there an aesthetic failure due to receded gingiva even after delivering a faultless prosthesis?

The answer to this failure might be the ignorance towards “The pink Component” which comprises:

1. Marginal Gingiva

2. Interdental Papilla

Most of the dental procedures aim to reconstruct the white entity of a dental restoration i.e. teeth, resulting in an aesthetic failure in patients with unsightly “Black Triangles”.

dentistrytoday Fig. 1 – The marked areas show areas of “Black Triangles”

The fallout of this condition may result in one of the following

  1. Difficulty in maintaining oral hygiene
  2. Altered consonant sound production
  3. Unaesthetic appearance of a flawless prosthesis
  4. Negative influence on the outline of the interdental soft tissues
  5. Further periodontal disease manifestations

Therefore, it is undisputed to restore these spaces in order to facilitate better periodontal health and hygiene.

What whips up your pink component?

dentistrytoday

There are two approaches to manage recession of gingiva depending upon the severity.dentistrytoday

In class III and IV gingival recession, mucogingival surgery is not usually preferred due to its failure to provide optimal aesthetic outcome and may even cause reoccurrence in some cases. Therefore, the preferred option is to make use of the artificial substitutes.

Party gums – an alternative to invasive surgical procedures

“Party Gums” is a thin, flexible, silicone or acrylic strip/prosthesis simulating natural gum colour used to mask the anterior defects hampering the aesthetics in a dentition thereby re-establishing the contour of gingiva. It can be fixed or removable and can be made of various materials such as self-cure and heat-cure acrylics, composites, silicone and thermoplastic materials.

Keywords: Flange Prosthesis, Black Triangles, Artificial Gums, Party Gums, Gingival Replacement, Gingival Epithesis, Gingival Veneer, Gingival Mask, Aesthetics.

Party Gumsdentistrytoday

  1. This type of prosthesis is retained with the help of the capillary action of saliva, support of lips and surrounding soft tissues along with the mechanical retention achieved by the extension of the epithesis in the buccal embrasures.Indications
    • To fill the unaesthetic gap between soft tissue and teeth
    • To restore the large black triangular spaces
    • To improve the length of the clinical crown by concealing the exposed root surface
    • As an interim prosthesis after periodontal therapy for healing.
    • To provide intra-oral bulk in patients who lack lip and cheek  support
    • To mask the exposed margins of A crown or implant-supported prosthesis

    Contraindications

    • Poor periodontal status
    • Increased carious activity
    • Smoking
    • Lack of maintenance of oral hygiene
    • Allergy to acrylic or silicone (used to make prosthesis)

    Easy to make, Easy to place – Fabrication technique

    • Mold wax sheet and place it on the palatal aspect extending only into the palatal embrasures of the teeth that acts as a barrier thereby preventing the flow of the impression material. Also, ensure that it doesnot cover the entire interdental space but cover enough to provide additional retention and prevent lisping.
    • Impression is made using an irreverible hydrocolloid material and carefully retrieved with inter-dental tags (as much as possible) after it is set (as per the manufacturer instructions)
    • A cast is obtained and a wax up is done on it which is then cured in an usual manner as a conventional denture followed by finishing and polishing.
    • Other materials that can be used for it’s fabrication are – cold cure or heat cure acrylics, thermoplastic  or comppsite resins, silicone based materials (Valplast, Cosmesil M51, Gingivamoll),  porcelain etc.
    • The fit of the final prosthesis is then evaluated in the patient’s mouth and the necessary changes are made before it is delivered.
    • Post operative instructions:
    1. Clean the prosthesis after every meal with a soft brush using a mild detergent.
    2. Prostheis should be kept in water at night to prevent warpage.
    3. Smoking excessive consumption of tea or coffee is not recommended.

    Regular follow up should done for evaluating the maintenance of the same.

    Advantages

    • Economical
    • Easy fabrication and fit
    • Comfortable to the patient

    Disadvantages

    • Discolouration and dimensional changes seen with time
    • Requires proper cleaning/maintenance and should be removed during night

    With minimum efforts and at no additional cost, this technique can be employed for eliminating “Black Triangles” which in turn provides psychological satisfaction not only to the patient but also to the dentist as a result of an aesthetic outcome and acceptance of the treatment by the patient.

    References:

    1. Greene PR. The flexible gingival mask: An esthetic solution in periodontal practice. Br Dent J 1998;184:536-40.
    2. Botha PJ, Gluckman HL. The gingival prosthesis — A literature review. SADJ 1999;54:288-90.
    3. Barzilay I, Irene T. Gingival prosthesis — A review. J Can Dent Assoc 2003;69:74-8.
    4. Antony V , Khan R. Gingival mask-restoring the lost smile. IOSR-JDM) 2013;5(3):20-22.
    5. Shenava A. Gingival mask: A case report on enhancing smiles. J Oral Res Rev 2014;6:68-70.
    6. Debnath N, Gupta R, Nongthombam RS, Chandran P. Acrylic gingival veneer prosthesis: A case report. J Med Soc 2016;30:121-3.
    7. Keyf F. Gingival epithesis in periodontally compromised patient for esthetic solution. SRM J Res Dent Sci 2016;7:255-8.

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DISCLAIMER : “Views expressed above are the author’s own.”

 

Platelet concentrate in periodontal regeneration

Nov 30, 2018
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Platelet concentrate in periodontal regenerationPlatelet concentrate in periodontal regeneration

Platelet concentrate is nothing but a centrifuged blood with only platelets and fibrin in maximum amount and less or very few leucocytes at the bottom. Other components get separated from the platelet concentrates in the upper layer. Several techniques for platelet concentrates are available. This is because of the commercialization and also their applications have been confusing, each method leads to a different product with different biology and potential uses. Development of bioactive surgical additives regulating inflammation with increasing healing is a great challenge and even after each intervention, surgeons face complex tissue remodeling phenomena affecting healing and tissue survival. To limit such consequences autologous grafting and regeneration have been researched.

Platelet concentrates are classified on their leucocyte, fibrin content and method of preparation.

  1. Pure Platelet-Rich Plasma (P-PRP), such as cell separator PKP, vivostat PRF or Anitua’s PRGF.
  2. Leucocyte-and Platelet-Rich Plasma (L-PRP), such as Curasan, Kegen, Plateltex, Smart PReP, PCCS, Magellan or GPS PRP.
  3. Pure Platelet Rich Fibrin (PRGF), such as Fibrinet and Leucocyte.
  4. Platelet-Rich Fibrin (L-PRF), such as Choukroun’s PRF, T-PRF (Titanium PRF), I-PRF (Injectable PRF), A-PRF (Advance PRF) all these variants are due to either differences between centrifuge speed or use of titanium as a collection tube instead of normal glass tubes or vacuum blood collection tubes.
  5. Concentrated Growth Factors (CGF).

Why platelets concentrate is so popular?

Platelets concentrate is popular because they contain growth factors essential for regeneration and early wound healing.

Growth factors present in platelets

Growth Factors Primary functions
Epidermal growth factors (EGP) Regulation of cell proliferation, differentiation, and survival.
Insulin like growth factors IGF Key regulators of cell metabolism and growth

Stimulates proliferation and differentiation functions in osteoblast

Platelet derived growth factor Mitogen for connective tissue cells and other cell types. Enhance the synthesis of collagen and structural proteins
Transforming growth factors alpha beta Regulation of cell proliferation, differentiation and apoptosis

Induction of intimal thickening

Vascular endothelial growth factor Regulation of angiogenesis

 

  1. Epidermal Growth factors (EGP)
  2. Regulation of cell proliferation, differentiation and survival.
  3. Insulin like growth factors IGF

Key regulators of cell metabolism and growth

Stimulates proliferation and differentiation functions in osteoblast. Mitogen for connective tissue cells and other cell types enhance the synthesis of collagen and structural proteins.

Regulation of angiogenesis and method of preparation of PRP:

  • Venous blood is drawn and mixed with anticoagulant to avoid platelet activation and degranulation.
  • The first soft spin centrifugation separates blood in 3 distinct layers:
  1. The red blood corpuscles constitute 55% of total volume form the bottom layer of the tube.
  2. The acellular plasma layer is mainly made up of fibrinogen and low in platelets called as Platelet-Poor Plasma (PPP) and constitutes 40% of total volume forms a top layer of the tube.
  3. Between the 2, an intermediate layer is where platelets concentrations are largely increased. It constitutes only 5% of total volume called as buffy coat. It will compose the major part of the future PRP, but at this stage, it is non separable completely.
  4. A sterile syringe is used to aspirate PPP, PRP and some red blood corpuscles, the remaining content is transferred to another tube which is anticoagulant less.
  5. This second tube will then undergo another centrifugation, purported to be longer and faster than the first (‘‘hard spin’’). This makes it possible to concentrate platelets at the bottom of the tube and subsequently to obtain once again 3 distinct layers some residual red blood corpuscles trapped at the bottom of the tube and at the top acellular plasma (PPP) consists of 80% of total volume and between these two a buffy layer called PRP.
  6. It becomes easy to collect the PRP at this stage. Major part of the PPP is discarded by using a syringe, just leaving some serum to place the platelet concentrate in suspension. The unit is then gently shaken to obtain a ready-to-use PRP. Note that the red blood corpuscles trapped at the bottom of the tube are also suspended by this last operation, which explains the rosy aspect of the final PRP.
  7. PRP is then mixed with bovine thrombin and calcium chloride at the time of application, with the help of a mixing syringe. Gelling of platelet concentrate will then quickly occur: Fibrinogen is also concentrated during the PRP preparation and its polymerisation will constitute a fibrin matrix with particularly interesting homeostatic and adhesive properties.

dentistrytoday

PRF preparation

PRF protocol is very simple compared to PRP. Venous blood is drawn without anticoagulant in 10 ml tubes which centrifuged immediately at 3000 rpm (approximately 400 g) for 10 minutes. Care in handling of blood and quick action is required.

dentistrytoday

Properties of PRF

  1. Contains intimate assembly of cytokines, glycanic chains, structural glycoproteins enmeshed between slowly polymerized fibrin network
  2. Considered as an immune node which stimulates defense mechanism
  3. Significant inflammatory response at surgical site after PRF placement due to cytokines enmeshed within the matrix

Application in Periodontics

  1. Treatment of Intrabony Defects – PRP alone or in combination with bone grafts, PRF alone or in combination with bone grafts have shown adequate regeneration than only open flap debridement
  2. Treatment of furcations involvement – PRP alone or in combination with bone grafts, PRF alone or in combination with bone grafts have shown bone regeneration in class 2 class 3 furcation cases
  3. Ridge augmentations
  4. Sinus perforation repair by using PRF membrane
  5. Gingival recession treatments
  6. Papilla reconstruction using PRF
  7. Socket preservation after extraction
  8. Enhance the healing at palatal wound after Free Gingival Graft.

Advantages of PRF over PRP

  1. No bovine thrombin or anticoagulant is used
  2. Single centrifuge cycle requires
  3. Easy handling
  4. Even act as a vehicle for tissue engineering

Conclusion:

PRPs are often considered as improved fibrin glues without consistency, however PRFs can be regarded as dense fibrin biomaterial with biomechanical properties. A dese fibrin clot can serve as a biological healing matrix. It supports cell migration and cytokine release. Expensive and complex procedures cannot always used in daily practice and many will disappear with time. Simple and free systems such as Choukroun’s PRF were developed by clinicians for clinicians and are anticipated to be major methods in the coming years. PRF have many advantages and prepared by chair side with less time, no complicated method of preparation, simple handling makes it a better choice in periodontal procedures.

References

  1. Dohan DM, Choukroun J, Diss A, et al. Platelet-rich fibrin (PRF): A second-generation platelet concen-trate. Part I: Technological concepts and evolution. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006; 101:e37-e44.
  2. Dohan DM , Rasmusson L and Albrektsson T Classification of platelet concentrates: from pure platelet-rich plasma (P-PRP) to leucocyte and platelet-rich fibrin(L-PRF). Trends in Biotechnology Vol.27 No.3

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DISCLAIMER : “Views expressed above are the author’s own.”

Top 10 reasons why dentist make excellent spouses!

Nov 21, 2018
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Top 10 reasons why dentist make excellent spouses!Top 10 reasons why dentist make excellent spouses!

Being a dentist, I always imagined myself marrying fellow professional. Somehow that was always my first criteria whenever it was discussed with my parents and family. Life however, had other plans for me. So now I think of it from a different perspective. My husband is very lucky to have married me! Very very lucky! All the more reason for me to write an article on dentists making excellent spouses. I’m sure there are many benefits of marrying a dentist but these are the ones that immediately came to mind.

1. Knowledge of Health Sciences

They learn Basic Health Science topics and Pharmacology in Dental School. Hence, apart from dental knowledge they have basic knowledge of the human body and quite good knowledge of tablets, medicines, supplements. Health related advice is obtainable free of cost at any time of the day. Even midnight! Minor health problems can be diagnosed and treated by them easily. Plus, your health-related queries can be solved in seconds.

2. Artistic Ability

Being a dentist makes them creative and artistic. Don’t be surprised to find your spouse single-handedly completing your kid’s Art Class assignments and models for Science Exhibitions. Their list of artistic adventures might even include re-decorating your home! Now that’s a lot of money saved on hiring an interior designer.

3. Patience and high on perseverance

Since they deal with all sorts of patients from all walks of life every day, they tend to become patient and kind with experience. The profession also brings out the best of their caring nature out. A caring and nurturing spouse in times of ill health makes recouping much sooner than usual.

4. Decent Income

Well, we can jabber as much as we want about money not being able to buy happiness. Blah blah… but come on! Money is important for survival, and dentists make decent money. There is never a long recession period in the health care industry.

5. They are smart

It isn’t easy passing out of Dental School. Their Dental Degree is not only a proof of their intelligence but also their tremendous hard work. Hardworking + Smart is a deadly awesome combination in a spouse. Don’t you think?

6. Free dental treatment

Walk away with a brand-new sparkling smile any time you wish! Mind you, dental procedures are really expensive! Free dental treatment throughout your life is a huge bonus. Trust me.

7. Good PR skills

Making patients aware about their oral health isn’t a child’s play. Soft skills are a necessary part of promoting dental health and treatment procedures. Their good PR skills makes them the most lovable person in the group and the highlight of any party.

8. Commitment

Dental school teaches them to be committed. This makes them very much committed to their long-term goals. You can be rest assured that all your combined goals will be achieved.

9. Time for socializing

As there are no emergencies in Dentistry, they have fixed working hours making them available for family time!

10. Loyalty & Trust

Some of the other qualities that dentists are known to possess include being trustworthy and loyal. It comes naturally to them. They are bound to be yours for life!

These are some of the perks of marrying a dentist. So those of you with dentist spouses, it is all set! Don’t forget to thank your lucky stars..

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DISCLAIMER : “Views expressed above are the author’s own.”

Airway concern in patients with special needs

Oct 23, 2018
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Airway concern in patients with special needsAirway concern in patients with special needs

ABC is essential steps used by medical professionals in differently abled persons. The protocol stands for airways, breathing and circulation. In the medical field, professionals manage any emergency by following ABC. Airway emergencies are a rising concern for clinicians among special need people. During dental treatment, they require medical, mental or psychological special consideration. Airway concerns can be viewed from preventive and operative aspects.

We define a special child or special case in a precise way considering certain rules for their conditions. As per American Academy of Paediatric Dentistry, a patient with the special need is defined as any physical, developmental, sensory, behavioural, cognitive and emotional impairment or limiting conditions that require medical management, healthcare intervention and/or use of specialised health services or programs”. Now the classification derived from this definition includes physical handicapping such as cerebral palsy, mental retardation, congenital defects such as cleft lip and palate, metabolic and various systemic disorders, immunological syndromes, convulsive disorders, autism, blindness, deafness, neoplasia, intrinsic and extrinsic handicapping along with medically compromised handicaps. Risks of airway obstruction get reduced maximally by the cooperation of mentally and intellectually sound patients. Whereas in cases of children with low threshold and minimal cooperation, the whole emphasis of practitioner is based on reducing iatrogenic causalities.

The protocols of management revolve around treatment planning while emphasising the airway concerns. Practitioners have designed the treatment plan based on cooperative behaviour of special needs people. They have to control the anxiousness of mentally sound patients to examine with advanced dental procedures, which includes designing, alterations of cavities and pulp therapies. Good experiences with doctors may boost up their confidence level.

The management and practitioners use a wide range of criteria to handle those patients. Physician uses their own hand for mouth opening rather than applying any kind of machines to make them feel comfortable. In the subsequent line of treatment, a newer technique has been introduced in dentistry by Dr Joe Frencken, named as “ART- Atraumatic Restorative Technique”, this technique is a successful model of treatment plan for patients with compromised cooperation. In this mode of treatment, no machinery or mechanical trauma is induced but instead, the cavities are limited to hand instruments and low metallic restorations, restorative materials like Glass Ionomer Cement and Composites are a part of this technique. In case of complex treatment, throat shields are an isolating material of choice with suction, provided cooperation is achieved.

Nature by its own way regulates the airway management by its construction of epiglottis and through the function of epiglottic fold, which involuntary acts as a barrier between the respiratory and deglutition pathway and by default closes upon wide opening of mouth. Certain times airway management not only matters during natural procedures but also majorly signifies itself during emergency management, which in case of any compromised patient is undertaken by the use of emergency drugs, adrenaline hitting the first in list. Adrenaline by nature is a vasoconstrictor which majorly helps in reducing laryngeal oedema and clearing the pathway for the airway. In the case of airway obstruction cases due to asthma, bronchodilators and sympathomimetics, such as salbutamol, salmeterol can be induced. Corticosteroids remain a question mark in patients with special need and are administered based on an overall assessment of the patient immunity system. The chemical way of approach remains only in case of emergency but can be used as preanesthetic medications and adjuvants to prevent any precipitation of medical complications.

The actual management of any patient with special need is a group effort of well experienced and knowledgeable doctors, who are ever ready to take up the risk assessment and risk management of any airway obstruction, but as a general practitioner we need to be clear with our ethics, first aid management and emergency drugs in our list. With the knowledge of these, also added to the priority list there has to be no hesitation in consultation with senior doctors, and regular therapists of the patient. A well explained medical history, confirmatory tests and informed consent always help to maintain a safe practice.

Concluding it with the warmth of the words spoken by Ms Tara McCallan A diagnosis can`t predict the extraordinary love you will have for your child” Any person with special needs requires love, guidance, encouragement, positive influence and a life teacher. We as practitioners can be the life teacher for many such patients who don’t fit into the boxes. Therefore, our approach to such people changes the way they look at us as a community and cooperation are inevitably achieved.

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DISCLAIMER : “Views expressed above are the author’s own.”

Sodium Hypochlorite Accident

Oct 16, 2018
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Sodium Hypochlorite IncidentSodium Hypochlorite Incident

Sodium hypochlorite goes in the periapex during irrigation when – Short roots open apex, Over instrumented apex straight roots.

USE OF FRONT VENTED NEEDLES

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Error in length determination.

How to identify or differentiate sodium hypochlorite accident from pulpal or periapical pain?

Sudden pain immediately after irrigation in an otherwise painless tooth.

Sudden oozing of blood from an otherwise cleaned canal swelling immediately after irrigation.

Colour changes in outer skin related to the tooth PRECAUTIONS:

ALWAYS USE A SIDE VENTED NEEDLE for irrigation

Keep the length of the irrigating needle 2mm short of working length inside the canal (correct length determination using apex locator important)

Do not push the irrigant with pressure (the needle should be loose in the canal, not locked) dispense the irrigant very slowly.

Focus on the irrigation.

How to manage a patient with sodium hypochlorite accident.

Reassure the patient and tell them the truth, “It is just medicine gone beyond your tooth. You will be fine soon.”

Immediately irrigate with abundant saline continuously.

Local anesthetic solution with adrenaline can be used as a first irrigant, if blood oozing from the canal.

If swelling present, give open dressing, recall after 12 hours, re-irrigate and give closed dressing advice corticosteroid at least for 3 days. (control inflammation)

Advise painkillers, if pain is terrible Tramadol may be prescribed.

Mild antibiotics are prescribed (sodium hypochlorite if goes, in large quantities, periapically may cause tissue necrosis making it susceptible to infection)

Advise ice pack application for a day; recall and reassure.

It may take 4 days to 3 weeks for complete recovery depending on severity. Prevention is always better than cure.

My patient immediately post sodium hypochlorite accident with upper left molar.

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DISCLAIMER : “Views expressed above are the author’s own.”

Are right angles, actually right?

Oct 6, 2018
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Are right angles, actually right?

One of my close friend Dr Mehta is an expert in the field. Keeping patient satisfaction being his only motto, he has established a very good practice in a short time. Dentistry is a laborious field which requires highly accurate preparations and a lot of hard work to establish a good practice. This includes sitting for a longer duration of time in a single position and working to achieve that highly skilful preparation which dentistry demands. Patients are highly satisfied with Dr Mehta’s treatment and friendly disposition, but Dr Mehta, in turn, is suffering from occupational problems, like back pain.

Unlike other fields, the problem encountered by a dentist is maintaining an ergonomic posture without compromising accessibility which is very difficult at times. The results being that majority of dentists suffer from lower back pain at one or the other time during their practice. Sitting for long durations of time alone has a detrimental effect on spine when compared to standing, but in a field like ours which demands sitting for longer periods throughout the day, what is the best way to sit?

Since the beginning of professional dentistry in eighteenth century, a lot of things have changed including instrumentations, concepts, techniques of working etc., one that however has remained same since the beginning of sit down dentistry is the posture of a dentist attending to patients. Most of us sit straight with all the major joint at right angle. T, this posture was considered to be proper until now, but their cent research suggests that it can cause detrimental effects on joints, discs and ligaments.

Problem:

Practising with all the major joints at right angle (Figure 1) for a longer period of time along with other contributing factors can lead to Cumulative Trauma Disorder (CTD).

CTD is defined as work-related pain or injury to the musculoskeletal system resulting from microtrauma which accumulates at rates faster than the body can repair.

dentalreach

Signs and symptoms:

  • Decrease strength and range of motion
  • Pain, stiffness, swelling or inflammation
  • Numbness or tingling in hands or feet
  • Shooting or stabbing pain in arms or legs

Solution:

Our posture should be such that it provides optimal working conditions along with physical comfort so that we as the dentist can perform the whole procedure accurately. For a posture to be balanced it does not necessarily require to be rigid.

To be classified under safe working posture there should be:

  • 0-20 degrees of neck flexion
  • Hip angle of 105 to 125 degrees
  • The seat of the operating stool should be slightly tilted forward to about 5-15 degrees.

dentalreach

Advantages:

  • Chairs with a tilting seat leading to hip angle of 105 degrees rather than 90 degrees helps maintain a low back curve, decreases disc pressure, enables closer positioning of patient and may help reduce low back pain.
  • It also minimizes strain on other spinal discs, muscles and ligaments while working.
  • An ergonomic posture will help reduce stress and eliminate many potential occupational associated injuries due overuse of certain muscles and bad posture.

Conclusion:

In order to render appropriate patient care, it is also necessary for a dentist to be mindful of their own health and well-being, by working in a comfortable posture guided by natural laws of human body anatomy.

To all my dental artists out there!!! Keep giving the world all your positive energies and pretty smiles but don’t get too busy to forget to take care of your own self.

Regards

Dr. Zainab Rangwala

References:

  1. Hedman T, Fernie G. mechanical response of lumbar spine to seated postural loads. Spine 1997;22(21):2571-4.
  2. Bethany Valachi (PT, MS, CEAS). Practice Dentistry Pain-Free.

PHOTOS: POSTUREDONTICS LLC.

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DISCLAIMER : “Views expressed above are the author’s own.”

You choose: Private or group practice?

Jun 21, 2018
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You choose: Private or group practice?You choose: Private or group practice?

You choose: Private or group practice?

The practice of dentistry is chosen based on an individual’s personality and goals. The dentistry practice in a group has the wide variety of conceptual configuration, different dentists and specialists. Whether you decide to practice in group or as an individual, there will be challenges, just that the types of challenges may differ. Dental practices consist of three basic types one is private solo practice, solo practice with facility sharing and group practice. The challenges faced by each practice has its own pros and cons depending on various factors.

Private practice

A private practice is a healthcare professional service usually by a medical physician or dentist, setting up practice by a practitioner who is independent of external policy control.

Private practice in dentistry

Advantages

  • They can provide and render services as required by the demand.
  • They have an option to increase or decrease the treatment modality fees.
  • They can locate their private practice where they decide.
  • Being own boss allows them flexibility to choose the number of hours they work.

Disadvantages

  • The overhead costs for staff, assistants, utilities and maintenance of equipment can’t be shared.
  • In the event of being unable to practice, they may not have a fallback plan for another source of income.

Note in a selection of place

  • Mindful decision because the place cannot be changed frequently.
  • Awareness of the number of dentists practicing in the vicinity.
  • Assessing the surrounding dental colleges in order to get support if required.
  • Assessment of demographics in the locality and surrounding areas.

Note in a selection of location

  • Choosing a busy area like a marketplace, heart of the city, streets which are on the main road may make it more popular and increase the chance of walkins.
  • A location near railway station and bus stand may make the clinic more accessible.
  • Areas of commercial trends especially office hours to support office goers.
  • Residential areas are also an option to cater to the elderly, retired individuals, housewives and children.
  • An important element to be considered which will resonate is to be safe for the doctors and patients.

Note in the selection of building

The clinic must preferably be on the ground floor, if it is in the higher floor, lifts, parking must be there for individuals to reach the clinic. There should also be security, good ventilation with proper electrical, sewage and drainage systems.

Ideas for setting up a dental clinic

First and foremost aspect is financial assistance, aware of the rate of interest and repayment terms and schedules, always buy dental products and equipment from best manufacturers. Always associate with good service network individuals, know the schemes, discounts, combo and promotional offers. Assess and know the guarantee and warranty for equipment and product.

Ideas for designing a dental clinic

Budget, manpower and space constraints, avoid dark colours with soft lighting environment which may soothe the body and mind. It is always better to take the support and service of the architect, interior designer and personal indemnity insurance with all statutory licenses and take initiative for the option of insurance coverage.

Management of dental clinic:

  • In the initial stage beginning and managing both are important.
  • Solo and group practice.
  • On-call specialists and cleaner.
  • Dental assistant, full-time receptionist.

Aspects and role of receptionist

The receptionist should be confident with pleasing personality and good looks. They must be trained to handle, manage patient appointments, maintain correct record keeping, scheduling the appointments. They must have the knowledge of computer skills like sending and receiving emails, collection of payments, maintain book of accounts, do payments to agencies on time and also stock maintenance.

 Aspects and role of Dental assistant

The role of dental assistant is to keep all the instruments ready for dental work. They must have adequate knowledge of handling equipment and instruments. They must be aware of dispensing materials and assist minor procedures like alginate mixing, developing of X-rays. The dental assistant service enhances productivity, reduces the stress of dentist and maintain sterilization protocols.

The responsibility of opening up a clinic 30 minutes prior to the first appointment and detail explanation must be given about investigations and diagnosis. It is better to inform the patient about the treatment cost and mode of payments. Association of the best laboratory technician and noting to take care of the time proper management and disposal of waste.

Strategies for marketing:

Educate patrons about the importance and value of dental health by creating more awareness with educational leaflets and posters.

There are two types of marketing:

External marketing

The initiative is taken to remain focused in the outward environment and activities are done in order to attract more patients such as free dental check-up campaign in schools and individuals working in private companies. Awareness about dental health is also done through lectures in social organisation, clubs, senior citizen groups and writing articles in magazines and newspapers. Free dental check-up programmes have been organised in a clinic and offered discount concessional treatments for specific target group.

 Internal Marketing

The action taken for marketing is within the dental setup which affects the current patients like making and creating brochures/informative booklets, videotapes of advanced trend treatment modalities such as implants, procedures of smile designing, teeth whitening, full aesthetic ceramic crown, surgical procedures, advanced RCT treatment procedures.

The successful programme must result in improved oral health habits among individuals who undergo and henceforth create a way for attracting many new patients. The overall effort is to make patient aware of the procedures and also can be helpful for individuals or others whom he or she can refer. The dental health emphasis is given mainly to comprehensive treatment. The effective way of marketing is when an existing patient is fully satisfied with the quality of treatment procedures undergone and recommends that to his family members, friends and acquaintances about that dentist. It is always best to treat each and every patient with commitment and dedication, and also being a practitioner better to enhance the dentistry skills by updating the advancing trends of the field.

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DISCLAIMER : “Views expressed above are the author’s own.”

Bleeding on punching in the nose … Thoughts on bleeding on probing

Jun 15, 2018
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Bleeding on punching in the nose ... Thoughts on bleeding on probingBleeding on punching in the nose ... Thoughts on bleeding on probing

Bleeding on probing is also known as bleeding gums or gingival bleeding. It is a term used by dentists and dental hygienists when referring to bleeding that is induced by gentle manipulation of tissues at the depth of the gingival sulcus. Bleeding on probing, abbreviated as ‘BOP’ is an objective, easily assessed and widely used criterion to diagnose gingival inflammation.

The two earliest signs of gingival inflammation are:

  • Increased gingival crevicular fluid production rate
  • Bleeding from gingival sulcus on gentle probing

Bleeding on probing appears as a change in colour or other visual signs of

inflammation. Gingival bleeding on probing indicates an inflammatory lesion

both in epithelium lining of the sulcus and in the connective tissue. The blood

comes from lamina propria after ulceration of the lining.

Peer-reviewed dental literature thoroughly establishes that bleeding on probingis a poor positive predictor of periodontal disease, but conversely, lack ofbleeding is a strong negative predictor. The clinical interpretation of thisresearch is that BOP presence may not indicate periodontal disease, the

continued absence of BOP is a strong predictor (approximately 98%) of

continued periodontal health.

Local Factors Associated With Bleedingon Probing

There are many possible causes of gingival bleeding. The main cause of gingival bleeding is the formation and accumulation of plaque around the teeth due to improper brushing and flossing of teeth. The hardened or calcified form of plaque and calculus provides an ideal surface for further plaqueformation. Contributing factors to plaque retention may lead to gingivitis and ultimately lead to gingival bleeding on probing. The contributing factors include caries, malpositioned teeth, mouth breathing, partial dentures, lack of attached gingiva and fixed orthodontic treatment.

Chronicand Recurrent Bleeding

Most common cause of gingival bleeding is gingival inflammation. Bleeding is chronic and provoked by mechanical trauma. Bleeding may occur from tooth brushing, toothpicks and food impaction. It may also occurby biting into solid food such as apples. Traumatic injuries such as laceration of gingiva by toothbrush bristles during aggressive tooth brushing or by sharp pieces of hard food can cause gingival bleeding even in the absence of gingival disease. Gingival burn from hot food and chemical increase the chances of gingival bleeding. Spontaneous bleeding or bleeding on slight provocation can occur in Acute Necrotizing Ulcerative Gingivitis (ANUG).

Histological evaluation has revealed that in early stages of gingivitis, cytokines are responsible for connective tissue breakdown. Matrix metalloproteinase also plays a vital role in tissue breakdown. Histopathologic alterations that result in abnormal gingival bleeding include dilatation & engorgement of the capillaries, & thinning or ulceration of the sulcular epithelium. After the vessels are damaged & ruptured interrelated mechanisms induce hemostasis. Vessel wall contract, blood flow diminishes, blood platelets adhere to the edges of tissue and a fibrous clot is formed, which contracts & results in approximation of edges of the injured area. Bleeding recurs when the area is irritated. In case of moderate or advanced periodontitis, the presence of bleeding on probing is a sign of active tissue destruction. 

Systemic Factors

Hemorrhagic disorders in which abnormal gingival bleeding is encountered include:

  • Vitamin C deficiency (scurvy): Interdental & marginal gingiva is bright red with swollen, smooth and shiny surface. In fully developed scurvy, gingiva becomes boggy, ulcerated and bleeds spontaneously.
  • Platelet disorders (thrombocytopenic purpura): There is an abnormal reduction in number of circulating blood platelets so patient develops focal haemorrhage into tissue & organs, including skin & mucous membrane.
  • Vitamin K deficiency: It is involved in prothrombin synthesis. It also regulates the level of factor VII, IX & X (proconvertin, christmas factor & stuart-prower factor, respectively). Hence, its deficiency leads to gingival bleeding.
  • Other coagulation defects:
    1. Haemophilia:It is characterized by prolonged coagulation time & haemorrhagic tendencies. Gingival haemorrhage in such cases may be massive & prolonged.
    2. Leukaemia:There is progressive overproduction of white blood cells which usually appear in circulating blood in an immature form. Oral manifestations are gingivitis, gingival hyperplasia, haemorrhage & ulceration of the mucosa.
    3. Christmas disease:It is also known as Haemophilia B, in which there is deficient level of coagulant factor IX (Christmas factor).
  • The effect of hormonal replacement therapy, oral contraceptives, pregnancy & the menstrual cycle are also reported to affect the gingival bleeding.
  • Diabetes:Marked inflammation noted in diabetic patients affects both epithelium & connective tissue which leads to destruction of reticulin fibers. The low immunity also makes them susceptible to opportunistic infections like candidiasis.
  • Medications: Anticonvulsants, antihypertensives & immunosuppressants are well known to cause gingival enlargement and increases the susceptibility of gingival bleeding.

Diagnosis

In order to determine the periodontal health of a patient, the sulcular depths of gingiva needs to be recorded followed by observation of any bleeding on probing. This is often accomplished with the use of a periodontal probe. A periodontal probe is a calibrated probe used to measure the depth and determine the configuration of a periodontal pocket. The insertion of probe to the bottom of the pocket elicits bleeding if the gingiva is inflamed & the pocket epithelium is atrophic or ulcerated. The probe is carefully introduced to the bottom of the pocket for bleeding test & gently moved laterally along the pocket wall. Sometimes bleeding appears immediately after removal of the probe; other times it may be delayed for few seconds. Therefore, recheck for bleeding on probing after 30 to 60 seconds.

An examination to rule out the systemic factors contributing to gingival bleeding helps to formulate the appropriate patient management protocol. Additional corresponding diagnosis tests to certain disease may be required. This includes oral glucose tolerance test for diabetes mellitus, blood studies, human gonadotrophin levels for pregnancy, radiologic imaging for teeth and jaw bones.

Alternatively, a dental floss may also be used to assess the gingival bleeding index. It is used as an initial evaluation of patient’s periodontal health especially to measure gingivitis. The number of bleeding sites is used to calculate the gingival bleeding score.

Many bleeding indices have been devised; some assess bleeding as simply present or absent, whereas others use grading in an attempt to assess severity of bleeding. The choice of which index to use depends on whether the purpose is an epidemiological survey, a clinical study, diagnosis and treatment. Bleeding may be elicited manually with toothpicks, dental floss and a periodontal probe. A controlled-force probe may be expensive and can cause less trauma and false-positive bleeding from healthy tissues.

There is evidence that smokers have less or delayed gingival bleeding when compared with non-smokers. Therefore smoking needs to be controlled to avoid gingival bleeding. Measurement of gingival bleeding tendency should be an integral part of a comprehensive oral examination. In clinical practice, the use of graded bleeding index is more likely to identify sites that are at risk of further destructive activity. Hence, bleeding indices are good tools for monitoring individual patients both for initial therapy and maintenance.

Bleeding point index

It is used for the evaluation of gingival inflammation. Retract the cheek & place the periodontal probe 1mm into the sulcus or pocket at the distal aspect of posterior tooth in the quadrant for recording the index. Carry the probe lightly across the length of sulcus to the mesial interproximal area on the facial aspect. Wait for 30 seconds & record the presence of bleeding on the distal, facial & mesial surface. Repeat the same for palatal surface. Percentage of the number of bleeding surfaces is calculated by dividing the number of surfaces that bled by the total number of tooth surfaces (4 per tooth) and multiplied by 100. A score of 10% or fewer bleeding points are considered good but 0 is ideal.

Sulcus Bleeding Index (SBI)

Developed by Muhlemann HR and Sen S in 1971. It is a modification of Papillary-Marginal Index of Muhlemann and Mazor ZS.

Scoring Criteria:

  • Score 0: Healthy looking papillary and marginal gingiva
  • Score 1: Healthy looking gingiva, bleeding on probing
  • Score 2: Bleeding on probing, change in colour, no edema
  • Score 3: Bleeding on probing, change in colour, slight edema
  • Score 4: Bleeding on probing, change in colour, obvious edema
  • Score 5: Spontaneous bleeding, change in colour, marked edema

Four gingival units are scored systematically for each tooth include labial, lingual marginal gingival (M units) and mesial, distal papillary gingival (P units). Scores for these units are added and divided by four to determine the sulcus bleeding index.

Gingival Bleeding Index (GBI)

In 1947, Carter and Barnes introduced Gingival Bleeding Index, which records the presence or absence of gingival inflammation. The mouth is divided into six segments and flossed in the following order: upper right, upper anterior, upper left, lower left, lower anterior and lower right. However, 30 seconds is allowed for re-inspection of each segment. Bleeding is recorded as present or absent. For each patient, a gingival bleeding score is obtained by noting the total units of bleeding. Gingival bleeding index by Ainamo & Bay (1975) is performed through gentle probing of gingival crevice’s orifice.

Papillary Bleeding Index

This index was introduced by Saxer and Muehlemann in 1975. A periodontal probe is inserted into the gingival sulcus at the base of the papilla on mesial aspect and then moved coronally to the papilla tip. This is repeated on the distal aspect of the papilla. The intensity of any bleeding is recorded as:

  • Score 0: No bleeding
  • Score 1: A single discreet bleeding point
  • Score 2: Several isolated bleeding points or a single line of blood appears
  • Score 3: The interdental triangle fills with blood shortly after probing
  • Score 4: Profuse bleeding occurs after probing, blood flows immediately into the marginal sulcus

Eastman Interdental Bleeding Index (EIB)

Caton & Polson developed this index in 1985. A wooden interdental cleaner is inserted between the teeth from the facial aspect, depressing the interdental tissues 1 to 2 mm. This is repeated four times and the presence or absence of bleeding within 15 seconds is recorded. Path of insertion should be parallel to occlusal surface. Insertion and removal of interdental cleaner are done four times and then moved on to next interproximal area.

Score = Number of bleeding areas/Total number of areas x 100

Treatment

  • Mechanical plaque removal
  • Corresponding treatments for diagnosed diseases must be given priority
  • Dentists may prescribe soft-bristle toothbrush for brushing
  • Flossing twice a day can prevent building up of plaque interdentally
  • Tobacco should be avoided as it may aggravate bleeding gums
  • Balanced healthy diet must be consumed

If there is persistent continuation of inflammation and bleeding, a prescription of antiplaque rinse would be useful.

Conclusion

BOP indicates the progression of attachment loss. If periodontal treatment is successful, bleeding on probing will cease. BOP is extremely important because it’s a wake-up call that gives the patient an opportunity to avoid a chronic and incurable disease. We have to heed signs and turn the patient around at this point for better health.

 References

  1. Charles R. Craig, Robert E. Stitzel (2004) In Modern Pharmacology with clinical applications (Edition 6). Lippincott Williams & Wilkins. p. 506.
  2. Carranza’s Clinical Periodontology, 9th edition, 2002. page 447
  3. Hayes EB, Gubler DJ. Pediatr Infect Dis J 1992; 11: 311- 317.
  4. Absence of bleeding on probing. An indicator of periodontal stability. J Clin Periodontol 1990 Nov; 17 (10):714-21.
  5. Newbrun E. Indices to measure gingival bleeding. J Periodontol 1996 Jun; 67 (6):555-61.

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DISCLAIMER : “Views expressed above are the author’s own.”

Are dentists contributing to an antibiotic overuse?

May 29, 2018
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Are dentists contributing to an antibiotic overuse?Are dentists contributing to an antibiotic overuse?

Before early 20th century, folk or traditional medicine was widely practiced all over the world to treat infections. The advent of antibiotic Penicillin in 1928 by Scottish Bacteriologist Sir Alexander Fleming revolutionized medical practice. He noticed inhibitory action of a stray mold on a plate culture of staphylococcus bacteria in his laboratory at St. Mary’s Hospital, London. The mold was a strain of Penicillium, P.notatum which gave its name to the famous drug Penicillin. The term antibiotic derives from Greek anti which means “against”+ biōtikos, “fit for life, lively”, which comes from biōsis, “way of life”, and that from bios, “life”. Antibiotics are a class of antimicrobial drugs used to treat and prevent bacterial infections.

Majority of the orofacial infections encountered in dental practice are of odontogenic origin. Most of the odontogenic infections are caused by aerobic and anaerobic bacteria. Viridans streptococci are the most frequently isolated bacteria among the aerobes, whereas Peptostreptococcus, Bacteroides and Prevotella are the most common bacterial species among anaerobes. Therefore, the use of antibiotics in dentistry for therapeutic as well as the prophylactic purpose is quite common. Amoxicillin which belongs to the Penicillin family is the first drug of choice to treat dental infections and to prevent other medical complications. But with 34% of Prevotella species resistant to amoxicillin, alternatives such as amoxicillin/clavulanate, clindamycin and metronidazole are also considered in dentistry.

Patients allergic to penicillin are treated with clindamycin which is the second drug followed by azithromycin and metronidazole. Azithromycin has enhanced pharmacokinetics in encountering the anaerobes involved in endodontic infections. Metronidazole is a synthetic antimicrobial agent, which is bactericidal and most effective against anaerobes. Ciprofloxacin is one of the common drugs used for endodontic infections due to its effective action against oral anaerobes, gram-positive aerobic organisms (Staphylococcus aureusEnterobacter species and Pseudomonas). The first generation cephalosporins like cefadroxil, cephradine provide a broad spectrum antibiotic when gram-positive organisms are suspected to be the causative factor of the infection. Cephalosporin is advisable for delayed-type allergic reactions to penicillin and when erythromycin cannot be used. It is indicated in endodontic practice as they exhibit good bone penetration. Tetracyclines are bacteriostatic antibiotics that may be used alone or in combination with surgical intervention in periodontal conditions.

As per The ICU Book, “The first rule of antibiotics is trying not to use them, and the second rule is trying not to use too many of them.” Antibiotic prescribing may be associated with unfavourable side effects ranging from gastrointestinal disturbances to fatal anaphylactic shock and development of resistance. Antibiotics should be prescribed at correct frequency, dose and duration so that minimal inhibitory concentration is exceeded, in order to prevent the side effects and selection of resistant bacteria. The ideal duration of antibiotic treatment is the shortest cycle capable of preventing both clinical and microbiological relapse. Repeated antibiotic prescriptions and prolonged courses of antibiotics destroy the commensal flora of oral cavity. In addition, longer durations up to 21 days may result in the selection of resistant strains and a reduction in the ability of the oral flora to resist the colonization by harmful microorganisms that are not normal residents, leading to superimposed infections by multi-resistant bacteria and yeasts. The alteration in GIT microflora also adversely affects gastrointestinal health.

Over the period of year’s misuse of antibiotics has led to Antibiotic Resistance (AR or ABR). Antibiotic resistance is the ability of a microorganism to withstand the effects of an antibiotic. It is a specific type of drug resistance. Antibiotic resistance evolves naturally via natural selection through random mutation, but it could also be engineered by applying an evolutionary stress on a population. In simple terms, there is emergence of bacterial strains that become resistant and continue to multiply even in the presence of therapeutic levels of antibiotic that it normally should have been susceptible to. Hence, they no longer respond to treatment with the most common antibiotics. The inappropriate use and overuse of antibiotics like penicillin and erythromycin have been associated with emerging antibiotic resistance since 1950s. We have entered an era where some bacterial species are resistant to the full range of antibiotics available with the methicillin-resistant Staphylococcus aureus. It is the most widely known example of extensive resistance.

Common forms of antibiotic misuse include excessive use of prophylactic antibiotics in travellers and failure to prescribe correct dosage of antibiotics on the basis of the patient’s weight and medical history. Other forms of misuse include failure to take entire prescribed course of the antibiotic, incorrect dosage and administration or failure to rest for sufficient recovery. Many antibiotics are frequently prescribed to treat symptoms or diseases that do not even respond to antibiotics or that are likely to resolve without treatment. Also, incorrect or suboptimal antibiotics are prescribed for certain bacterial infections.

Self-prescription of antibiotics is another example of misuse. A large chunk of the Indian population prefers going to a pharmacist rather than a doctor in order to self-prescribe antibiotics. These pharmacists inappropriately prescribe antibiotics even for viral infections such as common cold. The appropriate guidelines for prescribing antibiotics are not followed in most of the cases. The compulsory 3 to 7 day course for acute infections isn’t even mentioned to the patient. This leads to missed antibiotic dosages which contribute significantly to antibiotic resistance.

I personally witnessed an incident at a pharmacy right beside a hospital where a gentleman asked the pharmacist to prescribe a tablet for relieving cough & cold. The pharmacist politely asked him to take an appointment with the doctor in the hospital.The gentleman replied that he didn’t have time to consult a doctor. It made me wonder what made him to do so. Did he think that he would save time as well as few bucks which he would have had to spend as consultation? Also isn’t it obvious that he wouldn’t mind referring to a pharmacist again for a toothache, just to save money?

Is it a smart move? What about antibiotic misuse? Who is then responsible for the burden of Antimicrobial Resistance (AMR)? Are people even aware that it as an urgent threat to mankind? The increasing ineffectiveness of antimicrobial drugs to treat common and life-threatening infections would take a serious toll on healthcare. In developed countries, stringent rules and regulations do not allow patients to self-administer antibiotics without a doctor’s prescription. Is it high time that even we need to incorporate such rules in order to avoid indiscriminate use of antibiotics?

I’m sure as practising dentists; majority of you must have come across a lot of patients who just ask for tablets to relieve pain and infection. They have no interest whatsoever to get the tooth treated. To some extent, patient counselling does help to make them understand that pulp extirpation or tooth extraction is the treatment for the offending tooth. However, there is a group of treatment-averse patients who turn a deaf ear to our insistence.

In another scenario, lot of people must have experienced unscheduled emergency pain cases and walked into the clinic on a busy day leaving us with just 5-10 min to spare between other scheduled patients. The protocol would be to accurately diagnose the condition and do the needful accordingly. In spite of being aware that dental pain is primarily an inflammatory condition and usually best treated by clinical intervention supported with effective analgesia. But lack of time makes it more convenient for us to prescribe antibiotics and analgesics as we do not want a call from the patient late at night disturbing our peace and sleep.

Often, it happens that patients refer to the best dentist with acute pain symptoms. The dentists prescribe them with antibiotic and analgesic, the patients do not make subsequent appointments further for treatment of the offending tooth. After a week, when their pain shoots up. Severe pain again force them to refer to another dentist who again prescribes them with same routine antibiotics and analgesics. By chance, if the patient again fails to get treated and repeats this with third dentist, the susceptibility to opportunistic infections increase plus it leads to antibiotic resistance.

Can we afford to imagine a world without effective antibiotics? It is not just the responsibility of the medical practitioners but dental practitioners too to curb the menace of antibiotic abuse. Minimizing inappropriate antibiotic prescribing plays a key role in limiting the development of antibiotic-resistant bacteria. Since dentists prescribe approximately 7 to 10% of all primary care antibiotics, dental prescribing may contribute to antibiotic misuse. The National Center for Disease Control and Prevention estimate that approximately one-third of all outpatient antibiotic prescriptions are unnecessary. Antibiotics should be prescribed when there is severe infection spreading in the mouth. Unfortunately, lot of dentists routinely prescribe oral antibiotics in acute dental conditions. They are under the impression that over-antibiotics give better and unpleasant complications to patients.

Good knowledge of antibiotics is the need of the hour in prescribing for dental conditions. Recommendations to improve antibiotic prescribing practices are given below in an attempt to curb the increasing incidence of antibiotic resistance and other side effects of antibiotic abuse. Antibiotics should be prescribed only if it is clinically beneficial to the patient. Here are a few conditions commonly encountered in clinical practice that do not require an antibiotic prescription:

  1. Pulpitis: Inflammation is confined. Hence, it is not a true infection. Extirpation of inflamed pulp is the ideal treatment.
  2. Apical periodontitis: Infectious process has just reached adjacent periodontal tissues without any signs of systemic infection such as fever or facial swelling. Since there is pulpal necrosis involved there is no circulation. Effectiveness of antibiotic in such a situation is questionable as it is unlikely that the antibiotic would reach the bacteria in the necrotic pulp in therapeutic concentrations.
  3. Dentinal Hypersensitivity: Differentiate between pulpitis and dental hypersensitivity. Eliminate the cause such as sealing off open dentinal tubules by fillings or desensitizing toothpastes.
  4. Apthous ulcers: They are self-limiting. Symptomatic therapy such as hydration and topical analgesics is sufficient.
  5. Traumatic ulcers: Ulcers due to traumatic injuries, hot food items, chemical burns etc. heal within 10-14 days. Ulcers due to sharp cusps, ill-fitting dentures; sharp denture edges, Orthodontic wires etc. resolve after the trauma-inducing factor is removed. Provide symptomatic relief using topical analgesics.
  6. Viral infections like HSV-1 infections (Primary Herpetic Gingivostomatitis, Herpes labialis): Self- limiting, symptomatic therapy for associated fever and ulcers. Topical and oral antivirals, hydration, oral hygiene maintenance.
  7. Chronic Gingivitis: Resolves after removal of local irritant i.e. plaque via mechanical therapy.
  8. Chronic periodontal conditions: Resolves after removal of local irritant i.e. plaque & Calculus via mechanical therapy.
  9. Dry socket: Gentle irrigation and zinc oxide eugenol packs. NSAIDS for pain relief.
  10. Post-endodontic flare ups: Controlled prospective clinical trials have demonstrated that antibiotics are not beneficial in treating symptoms after root canal treatments.

Listed below are a few common conditions requiring antibiotics:

  1. Acute periapical abscess
  2. Infected periapical cyst
  3. Periodontal abscess
  4. Facial cellulitis which may or may not be associated with dysphagia
  5. Pericoronitis
  6. Acute Necrotizing ulcerative gingivitis: For cases of acute necrotizing ulcerative gingivitis requiring systemic antibiotic therapy in which penicillin is precluded, tetracyclines are most beneficial.
  7. Acute periodontal conditions where drainage and debridement is not possible and infection is spreading systemically
  8. Medically compromised patients, diabetics, organ transplant patients, HIV, Neutropenia, Chronic steroid usage, sickle cell anemia
  9. Oral infections accompanied by elevated body temperature, evidence of systemic spread like lymphadenopathy
  10. Bacterial sialadenitis
  11. Prophylactic antibiotics for Bacterial endocarditis
  12. Permanent Tooth avulsion

There is a clear need for the development of prescribing guidelines and educational initiatives to encourage the rational and appropriate use of antibiotics in dentistry. The concerned authorities in India need to start campaigns to create awareness among the dentists as well as general public regarding antibiotic misuse. Multifactorial interventions aimed at both dentists and patients can reduce inappropriate prescription of antibiotics. Knowledge about antibiotic selection, dosage duration of antibiotic therapy is a must. We as dentists must reinforce the phrase “Antibiotics don’t cure toothache” among patients. Therefore, antibiotics should never be considered as an alternative to dental intervention, but rather as an adjunct.

References:

  1. britannica.com
  2. Peng LF. Dental Infections in Emergency Medicine Medication. Medscape- Drugs & Diseases; 2018 Jan.
  3. Cope A, Francis N, Wood F, Mann MK, Chestnutt IG. Systemic antibiotics for symptomatic apical periodontitis and acute apical abscess in adults. Cochrane Database of Systematic Reviews 2014; 6.
  4. Marino PL (2007). Antimicrobial therapy. The ICU book. Hagerstown, MD: Lippincott Williams & Wilkins. p. 817.
  5. Larson E. Community factors in the development of antibiotic resistance. Annual Review of Public Health. 2007; 28 (1): 435–47.
  6. Hawkey PM. The growing burden of antimicrobial resistance. The Journal of Antimicrobial Chemotherapy. 2008; 62(1): i1–9.
  7. Bahl R, Sandhu S, Singh K, Sahai N, Gupta M. Odontogenic infections: Microbiology and management. Contemporary Clinical Dentistry. 2014; 5(3):307-311.
  8. dentalcare.com
  9. Ramu C, Padmanabhan T. Indications of antibiotic prophylaxis in dental practice- Review. Asian Pacific Journal of Tropical Biomedicine. 2012; 2(9):749-754.
  10. Dar-Odeh NS, Abu-Hammad OA, Al-Omiri MK, Khraisat AS, Shehabi AA. Antibiotic prescribing practices by dentists: a review. Therapeutics and Clinical Risk Management. 2010; 6:301-306.
  11. FC Peedikayil. Antibiotics: Use and misuse in pediatric dentistry. Journal of Indian Society of Pedodontics and Preventive Dentistry. October-December 2011; 29(4):282-287.

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DISCLAIMER : “Views expressed above are the author’s own.”