The art of suggestion: the use of hypnosis in dentistry

Hypnodontics, or the use of hypnosis in dentistry, is not widely used throughout the dental profession. Many patients seeking to use this therapy to help them access dental treatment are forced to seek treatment from non-clinically trained hypnotherapists. This article aims to explore what hypnosis is, its applications in dentistry and provide a brief insight into how these hypnotic concepts may be put to use in day-to-day dental practice.     

Ethical marketing in'aesthetic' ('esthetic') or'cosmetic dentistry'. Part 1

Prior to undertaking any elective,'cosmetic' dental procedures, it is vital for the treating dentist to discuss the merits and drawbacks of all viable options. It is important that the patient understands what the consequences and limitations of treatment are likely to be, and what the potential failures could entail later in his/her life. Informed consent should be obtained (preferably in writing) and the clinical notes and records should be clearly documented, with accurate and concise details provided of all the investigations carried out, and their findings, as well as including details of the various discussions that have taken place. Dentists need to be aware of the existence of heightened expectations in this group of patients and be cautious about accepting patients who have unrealistic 'cosmetic' expectations. Where possible, cosmetic or aesthetic dental treatment should be provided which is minimally destructive and, in the long-term, be in the 'best interests' of the patient. Important matters such as the gaining of informed consent and maintaining meticulous, contemporaneous dental records will also be emphasized. It is hoped that the article will provide clear definitions of some commonly used terms such as 'ethical marketing', 'ethics', and 'values', which are often used in association with the marketing, planning and undertaking of supposedly 'cosmetic' dental procedures. The important role of less invasive alternative treatment options will also be emphasized. Clinical Relevance: The aims of this article are to consider the common pitfalls that may arise when contemplating the marketing and provision of invasive,'cosmetic, dental restorations and to discuss how best to avoid a dento-legal claim where such treatment plans may not fulfil the patient's desired outcome.     

Medical and psychosocial risk factors in the dental treatment of the elderly

There is evidence to show that a 'new' type of elderly consumer of dental services is evolving with characteristics and expectations different from those of the 'old' elderly that dentists have had experience in treating. In providing care for the 'new' elderly the dentist must consider the many modifying factors which influence the type of treatment that an individual patient needs. These are the patient's lifespan, medical history, drug history, mental status, mobility, neuromuscular coordination, dental status, previous dental experience, the patient's or family's dental expectations as well as the economic status of the patient and the family. Before commencing treatment the dentist must also assess his/her own skills, the facilities in which he/she is working and the availability of equipment to carry out the dental procedures that may be required. Only when all of these considerations have been taken into account can rational dental care for an individual elderly person be planned and completed. The variation in what is rational is large. For one patient it may be no treatment at all and for another the most technologically sophisticated care dentistry can provide.     

Current practice in endodontics: 5. Obturation

The aim of this series of six articles is to improve the quality of endodontic treatment in general dental practice by considering what is currently being taught in dental schools. This article first considers the possible reasons for persisting symptoms following preparation of the root canals. It then reviews the many and varied methods of obturating the prepared root canal system that are available to the general dental practitioner. By considering the objectives of their treatment, and their own level of expertise, readers may decide that one or more new techniques may benefit their practice.     

Focused care of pediatric patients in the dental office.

No dental text can adequately prepare the practitioner with the necessary expertise to treat all presentations or office complications that may arise in the therapy of children. There are times when consultation with the child's parent and pediatrician may answer necessary treatment-related questions. Most chronic conditions do not prevent needed treatment interventions. Any acute illness or exacerbation of a chronic disease should be cleared by the primary care physician before commencing dental treatment. The mainstay of safe practice requires that the dentist to maintain a basic level of understanding of what constitutes an emergency and that office staff receive basic training and are adequately supplied with emergency equipment. Dentists are cautioned to consult their state board or dental society as well as their insurance carrier as to what constitutes necessary emergency equipment in the office and to what level they are responsible for providing emergency care to their patients. There is a great difference within the dental field just as there is with medical specialties. All practitioners, however, are liable for any acts of consignment, and although the intention is not to dissuade anyone from providing assistance in an emergency, supportive care and an immediate call of 911 to activate the local EMS are important. In addition, maintaining a familiarity with the local hospital and emergency department capabilities as well as travel time and distance is also important. Routine reviews and updates on life-saving interventions and resuscitations are good general practice and will save lives.     

Aspects of Malpractice in Prosthodontics

Crowns, fixed partial dentures, and removable dentures are the popular prosthetic dental restorations in current dental practice. Prosthodontic rehabilitation of the mouth, particularly in advanced and complex cases, requires careful planning, adequate clinical skills, and exacting technical standards. While a successful outcome is the ultimate goal for any prosthodontic treatment, complications, injuries, dissatisfaction, and/or failure may occur. When such events develop as a result of negligence or violation of standards of care, they are considered under the term of malpractice and may incur ethical and medico‐legal implications. This paper reviews and highlights some aspects of malpractice in prosthodontics. The current state of prosthodontic malpractice on a global level will also be evaluated. Standards of prosthodontic care, current literature of prosthodontic malpractice, where and how prosthodontic malpractice occurs, and recommendations for the future are presented. A thorough understanding of what is quality prosthodontic care and what disrupts this care can be a useful guard against professional litigation and may protect patients from poor quality of dental prosthetic care.     

Access to special care dentistry, part 5. Safety

This article considers the delivery of efficient and effective dental services for patients whose disability and/or medical condition may not be obvious and which consequently can present a hidden challenge in the dental setting. Knowing that the patient has a particular condition, what its features are and how it impacts on dental treatment and oral health, and modifying treatment accordingly can minimise the risk of complications. The taking of a careful medical history that asks the right questions in a manner that encourages disclosure is key to highlighting hidden hazards and this article offers guidance for treating those patients who have epilepsy, latex sensitivity, acquired or inherited bleeding disorders and patients taking oral or intravenous bisphosphonates.     

The medically compromised patient: Are dental implants a feasible option?

In healthy subjects, dental implants have evolved to be a common therapy to solve problems related to stability and retention of dentures as well as to replace failing teeth. Although dental implants are applied in medically compromised patients, it is often not well known whether this therapy is also feasible in these patients, whether the risk of implant failure and developing peri‐implantitis is increased, and what specific preventive measures, if any, have to be taken when applying dental implants in these patients. Generally speaking, as was the conclusion by the leading review of Diz, Scully, and Sanz on placement of dental implants in medically compromised patients (J Dent, 41, 2013, 195), in a few disorders implant survival may be lower, and the risk of a compromised peri‐implant health and its related complications be greater, but the degree of systemic disease control outweighs the nature of the disorder rather than the risk accompanying dental implant treatment. So, as dental implant treatment is accompanied by significant functional benefits and improved oral health‐related quality of life, dental implant therapy is a feasible treatment in almost any medically compromised patient when the required preventive measures are taken and follow‐up care is at a high level.     

The dental patient on oral anticoagulant medication: a literature review

Specific diseases and medications may considerably influence the delivery of oral care and the course of dental therapy. The purpose of this literature review is to examine the relationship between oral anticoagulant medication and dental treatment. Electronic and manual searches were conducted for clinical studies in the English literature for the years 1988-2010. The review process provided a total of 110 pertinent literature references, out of which 38 studies dealt with oral anticoagulants and dental treatment. Different treatment strategies relative to dental periprocedural anticoagulation regimens have been identified, and their accompanying thromboembolic and bleeding risks are being presented and discussed. Regarding to what extent a safe and successful dental treatment in patients on anticoagulant medication is feasible, the level of evidence is lacking. Until high-level data are provided, an individualised treatment approach after consultation with the physician of the patient is highly recommended.     

The use of amide local anesthetics in patients susceptible to malignant hyperthermia

The use of amide local anesthetics in dental patients presumed to be susceptible to malignant hyperthermia (MH) is controversial. A literature review of 17 recent dental publications and their reference citations revealed that the recommendation to avoid local anesthetics of the amide type in dental treatment of MH-susceptible (MHS) patients is based on in vitro muscle investigations, unpublished communications, and a single case report suggestive of MH. Therefore, a survey of members of the Malignant Hyperthermia Association of the United States designed to determine what, if any, MH-like reactions have occurred in patients with MHS receiving dental treatment was conducted. Of a total of 307 MHS respondents, 36 (12%) reported adverse reactions to dental care. Only one respondent, however, reported symptoms suspicious of MH (fever, muscle pain) in which the administration of amide local anesthetics appeared to be closely linked. Fifty-six (18%) of the respondents have had difficulty obtaining routine dental care since being identified as MHS; this includes 27 who have been refused dental treatment or have had to undergo operative procedures without the benefit of local anesthesia. These results support the conclusions that amide local anesthetics may be administered to MHS patients without significant risk and that currently the diagnosis of MH susceptibility can adversely affect the quality of dental care.     

Current practice in endodontics

The aim of this series of six articles is to improve the quality of endodontic treatment in general dental practice by considering what is currently being taught in dental schools. This first article considers the rationale behind endodontic treatment, what we are aiming to achieve and why. It looks at the dental and medico-legal issues which dictate the standards of our practice, and sets out the programme for the series.     

The articulator: a diagnostic instrument

The success of dental restorations depends on how we view the existing occlusion. Clinicians may be confounded with what aspects of the occlusion will contribute to the success of a restoration. This information can be reviewed with the dental laboratory when it is stored in a dental articulator in the form of dental casts with simulated movements.     

Drugs for pain management in dentistry

Pain is one of the most common reasons patients seek dental treatment. It may be due to many different diseases/conditions or it may occur after treatment. Dentists must be able to diagnose the source of pain and have strategies for its management. The '3-D' principle — diagnosis, dental treatment and drugs — should be used to manage pain. The first, and most important, step is to diagnose the condition causing the pain and identify what caused that condition. Appropriate dental treatment should then be undertaken to remove the cause of the condition as this usually provides rapid resolution of the symptoms. Drugs should only be used as an adjunct to the dental treatment. Most painful problems that require analgesics will be due to inflammation. Pain management drugs include non-narcotic analgesics (e.g., non-steroidal anti-inflammatory drugs, paracetamol, etc) or opioids (i.e., narcotics). Non-steroidal anti-inflammatory drugs (NSAIDs) provide excellent pain relief due to their anti-inflammatory and analgesic action. The most common NSAIDs are aspirin and ibuprofen. Paracetamol gives very effective analgesia but has little anti-inflammatory action. The opioids are powerful analgesics but have significant side effects and therefore they should be reserved for severe pain only. The most commonly-used opioid is codeine, usually in combination with paracetamol. Corticosteroids can also be used for managing inflammation but their use in dentistry is limited to a few very specific situations.     

The management of hypodontia: present and future

Developmental absence of teeth (hypodontia) is associated with characteristic morphological changes in the teeth, alveolar volume deficiencies, and skeletal jaw mal-relationships. Management may be complex, involving several dental specialties, ideally working as a close-knit team. Improved diagnostic and treatment technologies continue to evolve, ever widening the management opportunities for these patients. This paper reviews current treatment methods and looks to what the future may hold. Clinical Relevance: Specialist teams with access to traditional and evolving diagnostic and treatment technologies are best able to manage patients with complex treatment needs such as some of those presenting with hypodontia.     

Drugs for pain management in dentistry

Pain is one of the most common reasons patients seek dental treatment. It may be due to many different diseases/conditions or it may occur after treatment. Dentists must be able to diagnose the source of pain and have strategies for its management. The ‘3‐D’ principle — diagnosis, dental treatment and drugs — should be used to manage pain. The first, and most important, step is to diagnose the condition causing the pain and identify what caused that condition. Appropriate dental treatment should then be undertaken to remove the cause of the condition as this usually provides rapid resolution of the symptoms. Drugs should only be used as an adjunct to the dental treatment. Most painful problems that require analgesics will be due to inflammation. Pain management drugs include non‐narcotic analgesics (e.g., non‐steroidal anti‐inflammatory drugs, paracetamol, etc) or opioids (i.e., narcotics). Non‐steroidal anti‐inflammatory drugs (NSAIDs) provide excellent pain relief due to their anti‐inflammatory and analgesic action. The most common NSAIDs are aspirin and ibuprofen. Paracetamol gives very effective analgesia but has little anti‐inflammatory action. The opioids are powerful analgesics but have significant side effects and therefore they should be reserved for severe pain only. The most commonly‐used opioid is codeine, usually in combination with paracetamol. Corticosteroids can also be used for managing inflammation but their use in dentistry is limited to a few very specific situations.     

Dental treatment: utilization, motivation and prevention. A behavioural study of why people seek dental care

Fears of over-production of dentists in South Africa may be unfounded as less than 30 per cent of the population attend for preventive dental treatment (PDT). This study was undertaken to ascertain what motivates a person to seek PDT. The sample population consisted of 107 members of the Vanderbijlpark Medical Benefit Fund. Data gathered from questionnaires led to the following results. A belief in the benefits to be derived from dental treatment when combined with a belief in the seriousness of the consequences of dental disease, as well as when these two variables are combined with a belief in one's own susceptibility to dental disease, all significantly influence making a preventive dental visit (PDV). To promote acceptance of PDT efforts should be directed towards three areas: firstly information must be propagated to show people that they will be severely handicapped by the loss of their natural teeth and that dentures are a poor substitute. Secondly, the benefit of dental treatment should be pointed out, with the emphasis that fillings do last and, therefore, are not a waste of money. Thirdly, the fatalistic attitude which exists towards dental decay and tooth loss should be changed so that people realize that they can keep their teeth all their life. Due to the heterogeneity of the population the needs, demands and attitudes of each socio-economic and ethnic group should be ascertained before promoting any preventive programme.     

The dental patient with asthma. An update and oral health considerations

OVERVIEW: Asthma is a serious global health problem that has steadily increased in prevalence during the past two decades. New classification and treatment guidelines have been published, and dental providers need to be aware of these changes. LITERATURE REVIEWED: The authors searched textbooks and MEDLINE, looking for the most updated medical information on asthma, as well as for previous publications on treatment of asthmatic patients in a dental setting. RESULTS: More than 9,000 articles on asthma were published in English between 1997 and 2000. From 1960 until 2000, approximately 40 articles specifically addressed asthma and dental care. The authors reviewed more than 300 articles from the medical literature and all articles after 1980 that directly focused on oral health issues for importance and relevance. CONCLUSIONS: Recent information regarding the etiology, pathogenesis and treatment of asthma had not been adequately addressed in the dental literature. Dental care of asthmatic patients may necessitate considerations beyond what has previously been published in the dental literature. CLINICAL IMPLICATIONS: In the treatment of asthma, as with treatment of most medical conditions, oral health care providers play a role that is important in terms of both the patient's overall health and the systemic condition's effect on oral health. This article provides dentists with a timely update on asthma and the relationship between asthma and oral health, and it offers suggestions for safe and appropriate dental care.     

Requirement-driven dental education and the patient's right to informed consent

In dental education, students spend much of their time treating patients' oral health care needs. Many dental schools still require students to complete a specified number of treatments of various kinds before they can graduate. It often happens that students need to do a particular treatment in order to complete school requirements, when this treatment is not what the patient truly needs, or is not the only treatment indicated for the patient's condition. Consequently, students will be tempted to talk the patient into accepting the procedure. Likewise, educational requirements may tempt the student to postpone certain treatments or forgo non-credit-bearing interventions altogether. We argue that this conflict of interest is inevitable (even though the educational system adopted by the school may mitigate the problem) and analogous to that found in therapeutical experimentation. Hence, we advocate the same ethical solution as has long been adopted for conflicts arising in biomedical experimentation: informed consent.     

Changing patient needs and their impact on clinical education

Dental records of 1,800 clinic patients were examined in nine U.S. dental schools. The objective of the study was to identify what changes, if any, occurred over the five-year period between 1978 and 1982 in dental clinic patient treatment needs. Patients were found to be older at the time of entry into the clinical system and they required less operative treatment, fewer opposing full dentures, and less fixed bridgework. Increases in single full dentures and partial dentures were recorded. No changes were observed in endodontics, periodontics, or oral surgery treatment needs. These findings present a potentially serious problem in affected areas that may lead to a decline in the availability of sufficient experiences for the clinical training of dentists.