Volume 2 Issue 2 Spring 2018

A Letter from Dr. Couzens

Finally, Spring has begun to settle on Kentucky. The days are longer, the hyacinths and daffodils and even the hydrangeas are beginning to make their appearances. The cardinals, and jays, are chattering as they announce each morning’s beginning. It is a time of transition and being in the transition business we celebrate the break with the cold and the promise of the days to come. We invite you to visit with us in this time of change. Call for an initial appointment to discuss your smile and your overall dental health. It’s the perfect time for new beginnings.
Susan Couzens, DMD
 

Multi-Tasking with Gina Lane

Gina Lane has been a part of the Couzens Dental team for six-and-a-half years. Initially, she began work as the scheduling coordinator for the practice. Since then her responsibilities have broadened to include insurance, financial arrangements, cost estimating as well as scheduling. “This practice is personable and friendly, mostly because there is a genuine concern about the patient from the time they enter until they leave. The care even extends beyond office hours with Dr. Couzens willing to take patient calls late into the evening and weekends as well as weekdays,” says Gina. The mother of a 19-year-old daughter, now a freshman at Eastern Kentucky University, Gina says she finds herself multi-tasking to give every patient full attention. “From the first call, we want to find out about the patient, what are his or her likes and what have been their previous dental experiences. We want patients to feel like they’re part of a family,” she says. “I guess you could say I love my job,” Gina says.
 

Anesthesia Wand Reduces Dental Anxiety Painlessly

If you’ve ever had needle phobia, you might like to learn about a new technology referred to as an “anesthesia wand,” which is a computer-controlled dental-injection tool. In fact, some people feel it is more of a “magic” wand because it doesn’t look like a typical injection and it works even better by making the entire process virtually painless.

Here’s How it Works:
Your anesthesia will be delivered through a syringe-free wand or pen-like device that is connected to a computer. Before the tiny needle attached to the wand is inserted, the computer delivers a small amount of anesthetic so that the insertion site starts going numb before the needle enters the skin.

Once the needle is in place, the computer delivers an accurate, consistent amount of anesthesia so that you remain comfortable — typically below the threshold of pain. The computer’s microprocessor automatically adjusts the injection pressure for different tissue densities, maintaining a constant, comfortable flow of anesthesia. This is important because the culprit with most injection anxiety is discomfort from anesthetic being injected too quickly, not from the needle entering the skin.

What Are Some Advantages of Using an Anesthesia Wand?
• One of the most important advantages is that it doesn’t look threatening, as it eliminates the initial anxiety upon seeing a syringe.
• It can be used in conjunction with other conscious sedation methods (i.e. nitrous oxide) for a more comfortable treatment.
• It provides painless injections for all routine dental treatments including root canals, crowns, fillings, and cleanings.
• With the wand, you will receive a more consistent and comfortable injection, especially in more sensitive areas such as the front of your mouth or in your palate (roof of your mouth) where tissue is less elastic.
• Due to the wand’s penlike grasp, it is easier to handle, rotate, and accurately glide the wand into precise, hard-to-reach places to deliver anesthetics.
• Last but not least, many people who previously experienced a fear of injections are able to overcome their fear after the first use. This provides them with a better, less stressful dental experience.
Source: Downtown Parker Dental, Parker, CO
 

Sedation Dentistry:

Can You Really Relax in the Dentist’s Chair?

Does the thought of having your teeth cleaned make your entire body tense with fear? Would you rather endure the agony of a toothache than step foot in a dentist’s office? You’re not alone. A lot of people are so phobic about going to the dentist that they prefer not to have any treatment.

For people who avoid dentists like the plague, sedation dentistry may take away some of their anxiety. Sedation can be used for everything from invasive procedures to a simple tooth cleaning. How it’s used depends on the severity of the fear.

What is Sedation Dentistry?
Sedation dentistry uses medication to help patients relax during dental procedures. It’s sometimes referred to as “sleep dentistry,” although that’s not entirely accurate. Patients are usually awake with the exception of those who are under general anesthesia.

• Minimal sedation -- you are awake but relaxed.
• Moderate sedation (formerly called “conscious sedation”) -- you may slur your words when speaking and not remember much of the procedure.
• Deep sedation -- you are on the edge of consciousness but can still be awakened.
• General anesthesia -- you are completely unconscious.

What Types of Sedation are Used in Dentistry?
The following types of sedation are used in dentistry:

Inhaled Minimal Sedation
You breathe nitrous oxide -- otherwise known as “laughing gas” -- combined with oxygen through a mask that’s placed over your nose. The gas helps you relax. Your dentist can control the amount of sedation you receive, and the gas tends to wear off quickly. This is the only form of sedation where you may be able to drive yourself home after the procedure.

Oral Sedation
Depending on the total dose given, oral sedation can range from minimal to moderate. For minimal sedation, you take a pill. Typically, the pill is Halcion, which is a member of the same drug family as Valium, and it’s usually taken about an hour before the procedure. The pill will make you drowsy, although you’ll still be awake. A larger dose may be given to produce moderate sedation. This is the type of anesthesia most commonly associated with sedation dentistry. Some people become groggy enough from moderate oral sedation to actually fall asleep during the procedure. They usually can, though, be awakened with a gentle shake.

IV Moderate Sedation
You receive the sedative drug through a vein, so it goes to work more quickly. This method allows the dentist to continually adjust the level of sedation.

Deep Sedation and General Anesthesia
You will get medications that will make you either almost unconscious or totally unconscious -- deeply asleep -- during the procedure. While you are under general anesthesia, you cannot easily be awakened until the effects of the anesthesia wear off or are reversed with medication.

• Regardless of which type of sedation you receive, you’ll also typically need a local anesthetic – numbing medication at the site where the dentist is working in the mouth -- to relieve pain if the procedure causes any discomfort.

Who Can Have Sedation at the Dentist’s?
Sedation is most appropriate for people with a real fear or anxiety that is preventing them from going to the dentist.

Sedation Dentistry May Also be Appropriate for People Who:
• have a low pain threshold
• can’t sit still in the dentist’s chair
• have very sensitive teeth
• have a bad gag reflex
• need a large amount of dental work completed

Sometimes, children are given sedation if they are terrified of going to the dentist or refuse to cooperate during the visit. Nitrous oxide tends to be safe in children, and just about any dentist can administer it. A smaller percentage of pediatric dentists are trained to give children oral sedation. Oral sedation can be safe when kept within the recommended dose for the child’s age and weight.
Can Any Dentist Perform Sedation?
Most dentists can administer minimal sedation (such as nitrous oxide or pills). An increasing number of dentists can give moderate sedation. However, only a small percentage of dentists who have completed the Commission on Dental Accreditation (CODA) program in deep sedation and general anesthesia can use these more complex techniques. These dentists are typically oral and maxillofacial surgeons and dentist anesthesiologists. Some dentists use a dentist anesthesiologist, who is specially trained to give all levels of sedation and anesthesia to both children and adults.

Each state’s dental board carefully regulates the use of sedation techniques. Many states require dentists to hold permits in order to perform sedation.

How Safe is Sedation Dentistry?
There is always a risk in getting anesthesia. It is usually safe, though, when given by experienced dentists. However, certain people, such as those who are obese or who have obstructive sleep apnea, should talk to their doctor before having sedation. That’s because they are more likely to develop complications from the anesthesia. It’s important to make sure that your dentist is trained and qualified to administer the type of sedation you will be
receiving. To be a smart patient, you should make sure the following things are done:

• Before the procedure, your dentist should go over your medical history. Your dentist should also determine whether you are an appropriate candidate for sedation and ask about any medications you’re currently taking.
• You should ask what dose of the sedative is appropriate for your age and health. You should also ask whether it is within the dose recommended by the FDA.
• It’s important to find out how much training the dentist has and how many procedures he or she has performed using sedation. The more procedures the dentist has performed, the better.
• You should receive a form detailing the risks of the procedure. Go over it carefully with your dentist. Ask questions if you’re unclear on any of the wording.
• The dentist should monitor your vital signs during the procedure following the American Dental Association’s guidelines. The dentist should also have oxygen -- artificial ventilation -- and drugs that reverse the effects of sedation on hand in case you need them

WebMD Medical Reference Reviewed by Michael Friedman, DDS on January 15, 2018

The Role of the Dental Professional in the Diagnosis and Treatment of Sleep-Disordered Breathing
John B, a 47-year-old male and longtime patient, was in for his annual dental checkup. John had great teeth—maybe a little too good, as he had accumulated an extra 50 pounds over the past decade and now at 5'10" weighed 250 pounds with an 18-inch neck and a 46-inch girth.

As the dentist walked into the room, John was recumbent in the dental chair. Quickly perusing the patient's past dental records, the dentist heard a raucous freight train.
John was fast asleep at 9 AM, snoring loudly enough to shake the building. The dentist shook him awake and asked about his snoring, which he said was now every night. He had been banished from his marital bed to the guest bedroom. He often awoke choking and gasping for
air and was now so sleepy during the day he could no longer drive without falling asleep. He was hypertensive and poorly controlled on 3 drugs. His oral exam showed marked uvular edema and a Grade III Mallampati (a grading system to determine difficulty of intubation in
anesthesia patients - III is high on the scale and indicates significant blockage). His teeth were, of course, fine. The dentist told John he had sleep apnea and needed a sleep test and treatment for this serious medical condition.

Sleep-Disordered Breathing
Sleep-disordered breathing (SDB) is a morbid, mortal illness affecting 10% of children, 24% of adult males, and 9% of adult females. The co-morbidities of sleep-disordered breathing are hypertension, obesity, diabetes, heart failure, atrial fibrillation, heart attack, stroke, asthma, and gastroesophageal reflux disease. Sleep-disordered breathing is also associated with a 7-fold increase in the incidence of motor vehicle accidents; linked to accidents at work and home; and implicated in failed personal relationships and the general bedroom disharmony caused by rancorous snoring. The pathogenesis of sleep-disordered breathing is that oral cavity and oropharyngeal musculature loses its normal, awake, dynamic tone during sleep. The tongue falls posteriorly into the oropharynx. The airway is narrowed and ultimately obstructed. The interruption of breathing results in cerebral arousal, hypoxia, and elevated blood pressure. The obstruction and arousal stimulate the autonomic nervous system, a condition known as sympathetic neural stimulation. In normal sleepers, blood pressure falls during sleep. In SDB sleepers, it rises.

During oropharyngeal airway obstruction, the soft palate and uvula are sucked back into the oropharynx. The turbulent airflow around the uvula results in uvular palatal vibration. This generates the low-frequency sound commonly known as snoring, the primary symptom of sleep-disordered breathing. As the obstruction worsens, the patient and the bed partner may notice apneic episodes, in which the patient wakes up choking or gasping for air. As the disease progresses and the patient ages, daytime sleepiness becomes evident. Patients fall asleep not only in the dental chair but at work, in front of the television, at the movie theater, and often, tragically, behind the steering wheel.

One of the most common physical findings in sleep-disordered breathing is uvular edema. As dentists carefully inspect the patient's oral cavity at each visit, a close look at the uvula will show evidence of SDB-related edema. Edema of the uvula is not a normal finding; therefore, any uvular edema is abnormal and strongly suggestive of snoring and SDB. Given that 24% of adult males and 9% of adult females snore, uvular edema can be expected in 10% to 20% of adults. The uvula can be easily seen by gently depressing the tongue with a tongue blade. The dental mirror can also be used to examine the uvula by depressing the tongue and viewing the uvula on the mirror's surface.


The Dentist’s Role in SDB
The dental profession should play a role in the diagnosis and treatment of sleep-disordered breathing in numerous ways. SDB is associated with a narrowed palatal arch and a foreshortened mandible. Early orthodontics to expand the palate and maxilla and to elongate the mandible by pulling the teeth anteriorly is an important recommendation to prevent adult SDB. This may speak against premolar extractions for orthodontic reasons. Those patients with snoring and anatomic abnormalities should be evaluated for SDB. Patients can be referred to a sleep specialist, or the interested dentist can perform this evaluation. A sleep test is required. The current home sleep test technology is excellent. If a dentist is interested in sleep-disordered breathing, he or she may consider the use of a screener device. While not yet reimbursable, these sleep machines are relatively inexpensive, and many patients are concerned enough about their snoring and SDB that they will pay for the test.

Conclusion
Sleep-disordered breathing is a prevalent, morbid, mortal condition. Given that all adult patients should be seen at least once a year by the dental profession, and given that the dental profession has developed expertise in conditions involving not only the teeth but also those of the surrounding tissues, the dental professional should routinely screen for SDB. Those with particular interest may consider sleep testing, oral appliance therapy, and appropriate referral to colleagues in orthodontics, maxillofacial surgery, otolaryngology, and sleep medicine.

Source: Dentistry Today
References
Young T, Palta M, Dempsey J, et al. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med.
1993;328(17):1230-1235.
Davidson TM. The great leap forward: the anatomic basis for the acquisition of speech and obstructive sleep apnea. Sleep Med.
2003;4(3):185-194.
Somers VK, Dyken ME, Clary MP, Abboud FM. Sympathetic neural mechanisms in obstructive sleep apnea. J Clin Invest.
1995;96(4):1897-1904.

Dr. Davidson is professor of head and neck surgery and associate dean of continuing medical education at the University of California, San Diego. He is also the head and neck surgery section chief at the VA Medical Center, San Diego. The director of clinical operations for the UCSD Sleep Medicine Clinic, Dr. Davidson is well-known for his contributions in the evolutionary anatomy of sleep-disordered breathing and the use of multichannel home sleep testing. He can be reached at (858) 822-4229 or tdavidson@ucsd.edu.



Anxiolysis in General Dental Practice
In this age of anxiety, pain control and sedation have become important aspects of dental care. It is now becoming more common for general practitioners to provide in-office sedation for routine dental procedures. A segment of the population that would otherwise not seek care because of fear or anxiety is now receiving treatment. The use of sedation for dental care has become a topic of intense interest, and many states are re-writing their regulations to require a special permit to provide this service.

There has been much debate concerning different levels of sedation, and what is appropriate for the dental office. Anxiolysis and conscious sedation are well suited for oral medications, and depending on state regulations, may be safely and effectively administered in the dental office.

The definition of anxiolysis is simply, “a reduction in anxiety.” More precisely stated, “…a drug-induced state in which patients respond appropriately to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.” In the spectrum of sedation, anxiolysis is the lightest level of sedation. For the purpose of many state regulatory agencies, anxiolysis involves the use of a single anxiolytic drug (per day, not including nitrous oxide), in a single dose, prescribed before a patient’s appointment, and administered prior to the beginning of the dental appointment.

If anxiety is part of your visit to the dentist, ask Dr. Couzens about anxiety-reducing medications before your next dental procedure.

Source: Dentistry Today