Previously I blogged about oral sedation and talked about some medications. In this blog however, I will talk more about general benefits of oral sedation and its application in dentistry.

If dentist apply oral sedation in his office ,he can:

1. Increase the quality of his procedures
2. Increase the quantity of treatments
3. Have more accepted treatment plans
4. Decrease stress for the patient 

Patients who can benefit from oral sedation are so many however I will mention some of them ;

• Complex big cases patients
• Those who are allergic to Anesthesia
• Phobic,Anxious and Fearful patients
• Sever Gag reflex patients
• Post operative sensitive patients

It is documented that 30 to 50% of patients avoid the dentist due to fear.


Spectrum of sedation has 3 phases

1. Minimal sedation
2. Moderate sedation
3. Deep sedation

Dentists should sedate patients in their office within the minimal and moderate levels only. Deep sedation attempts should be avoided unless the dentist has gone
through special residency training and got special licence.

Let us mention some of the most popular oral sedatives dentists can use:

Generic                       Trade
Diazepam                     Valium
Zalepon                         Sonata
Triazolam                      Halcion
Hydroxyzine                   Atarax or Vistaril
Lorazepam                      Ativan
Nitrous Oxide                 Laughing gas


In every dental office using oral sedatives, Romazicon (flumazenil) 10ml injection 1mg/10ml or 0.1mg/ml should be available to reverse the effect of bezos in case of over sedation(overdose).

Protocols: Usually pill can be taken one to two hours before procedure. If pill will be taken home, somebody should accompany the patient and he should be informed.
A dose at night can be given as well one day before the appointment depending on the case.

Valium(Diazepam) is usually given at bedtime . Dose depends on some factors like age, BMI, history and other medications.

• If age >or = to 65,then the dose ranges from 0 to 2.5mg 
• If BMI >or= to 30,then the dose ranges from 5 to 10mg

The more obese the patient is the higher the dose that can be given

Patients taking CNS depressants or other serious medications should be treated carefully. You should avoid prescribing Valium to all patients with the same dosage. Please seek  consultation from experts before prescribing any medicine
in critical medical cases.

If you use oral sedatives in your office, it is recommended to track and monitor vital sign during the whole treatment appointment.Pulse oximeter blood pressure unite is necessary in this regard.  

T-scan computerized occlusal analysis system

T-Scan^® III

computerized occlusal analysis

The only clinical diagnostic device available that senses and analyzes occlusal contact forces to quantify whether a patient's bite is balanced

Dentistry is in the right digital direction

New Version of Logicon Caries Detector Software

Carestream Dental announces the availability of Logicon Caries Detector Software version 5.0.22.4. Logicon Software is a computer-aided detection tool that helps dentists identify and treat more interproximal caries at an early stage for improved patient care.
New for Logicon Software is the addition of a PreScan feature that further automates caries detection and improves practice efficiency. With a single click, practitioners can use the PreScan feature to automatically scan all interproximal surfaces in a bitewing radiograph and immediately display the results, instead of having to scan one interproximal surface at a time. Dentists then have access to an index of the results that correlate to each interproximal surface.

Where are we now regrading the treatment of periodontitis?

Through the past decades, it was common to treat periodontitis,periodontal pockets and bone loss, through the use of two modalities:
1) scaling and root planning
2) flaps and osseous remodeling

It was evident that the upper two modalities were unpredictable regrading the regenration of bone,fibers and the attachment around the teeth. Although scaling and root planning eliminate the bacteria from around the teeth, the long epithelium tissue would grow in around the tooth before the bone can make its regeneration,thus preventing the bone and surrounding tissue from rebuilding back around the teeth.

Nowadys, a third modality has been introduced to the bouquet;the LANAP


The LANAP (Laser Assisted New Attachment Procedure) allows removal of the inflamed epithelium,cleaves bond between calculus and root surface and kills biofilm.Thus scaling and root planning becomes effective. The final pass with the LANAP laser stimulates osseous regenration and leads to the formation of a fibronectin clot.

According to John chrispens DDS,the Laser for use in the LANAP procedure is the Nd:YAG and namely the periolase MVP-7.2.
The patient is asked not to brush in the area for one week post LANAP therapy.
Each laser works within a specific wavelength. Nd:YAG absorbes within the  range of heme(darker colors),therefore penetrates into the tissue. 
The Diode laser uses heat,therefore burns the tissue and penetrates only a short distance into the gingival sulcus before causing damage to the tissues. The CO2 and Er:YAG are absorbed by H2O, which is at the surface of oral tissues and do not penetrate into the gingival sulcus. Therfore, they have little effect on the biofilm in areas greater than 2mm subgingivally. The goal of the LANAP is not biofilm control but regenration.

Some periodontists contradict this formula. They suggest a membrane to stop epithelial cells from growing down into the socket and give bone and fibroblasts a chance to grow up.They say the laser will de-epithelialize  the pocket but the epithelium will still grow back.




The LANAP protocol:
A) Perio probe indicates excesssive pocket depth
B) Laser radiation vaporizes bacteria, diseased tissue, pathologic proteins, and alerts the practioner to the presence of tartar.
C) Ultrasonic scaler and special hand instruments are  used to remove root surface accretions.
D) Laser is used to form a gel-clot containing stem cells from bone and Periodontal ligaments.
E) Reattachment of rete ridges to clean root surface, with a stable fibrin clot at the gingival crest to create a closed system.
F) occlusal trauma adjusted
G) New attachment is regenerated

Please welcome with me MR. Opalescence PF....

I use Pola Day 9.5 % of Hydrogen Peroxide from SDI for my home whitening protocol. Today I am adding opalescence PF 35% of carbamide peroxide to the game. Opalescence PF contains potassium Nitrate, a desensitizing agent that has shown to decrease sensitivity to its minimal range.It acts more like an analgesic or anesthetic by keeping the nerve from re-polarizing after it has depolarized into the pain cycle.  This whitening system also contains fluoride that primarily acts as a tubular blocker, plugging the holes in dentin and slowing down the fluid flow that causes the sensitivity. 

Please welcome with me MR. Opalescence PF....

Please welcome with me Mr. Opalescence PF........ 

Periodontal disease & the heart disease; what is the link?

Periodontal disease is a risk factor for heart disease. Periodontal pathogens found in periodontitis have been found in the endothelial lining of patients with heart disease in carotid artery surgery. It was also found that DNA from periodontal pathogens have been found in cardiac tissue.
During inflammatory process,Patients predisposed to produce inflammatory mediators such as C-reactive protein, tumor necrosis factor and interleukins when the body is challenged in some way. Sometimes a patient genetically predisposed to a certain inflammatory reaction. For example in periodontal disease one may respond with high levels of C-reactive protein, which are the same inflammatory mediators seen in cardiovascular disease.
In conclusion , up to this date we can say that periodontal disease is a risk factor for heart disease but not necessarily a causing factor to this illness. More researches have to be done.

Super white teeth, here how you get it.............

 Office chairside tooth whitening

• If you are a smoker, do not smoke for 48 hours.
• Stay away from highly colored foods (red sauce, blueberries, etc.) and beverages (coffee, tea, etc.) for 48 hours.
• Mild sensitivity to hot or cold liquids may occur.  This usually passes within 1-2 days.  If sensitivity is severe or persists, contact us.
• If you experience gum sensitivity do not brush the afflicted area while brushing your teeth.
• Immediate whitening results can be quite dramatic due to minor dehydration of your teeth.  It is normal for the color to tone down somewhat after treatment when your teeth rehydrate to a natural white tone.
• Long term results vary from patient to patient.  This can depend on the original shade of your teeth and include habits such as smoking or drinking colored beverages (red wine, coffee, tea, etc.)
• “Touch-up” treatments may be needed every 6-12 months to retain color.  You can ask us about different “touch-up” options such as home whitening protocol.
• Existing fillings, crowns, bonding, etc. will not whiten.  Therefore, these may need to be changed in order to match your new smile.
• If your family or friends notice your new smile, let them know that  whitening can help improve their smile too!

If you have any question?

email: dental.spa@hotmail.com

Follow me on twitter !

http://twitter.com/chayahdentalspa

 

Follow me on facebook !

http://facebook.com/dental.spa1

Fusion presenting as gemination;rare case report

Gemination is a developmental anomaly of form ,which is recognized as an attempt by single tooth germ to divide resulting in a large tooth with a bifid crown &usually a common root and root canal in which the teeth count is normal when the anomalous tooth is counted.

Fusion is recognized as union of two separate tooth buds during odontogenesis,therefore one fewer tooth than normal in the dentition if the affected tooth is counted as one.

Case report: An 11 years old boy appeared in my clinic for examination. During intra oral diagnostics, tooth # 8 was not erupted yet. Clinically, it was revealed an abnormal maxillary temporary incisor retained in the mouth;two crowns joined togther. A provisional diagnosis  of gemination was given since the teeth count is normal. Radiographically, two fused  crowns with seperate roots and root canals were seen,along with a supernumerary tooth preventing the central incisor from erupting. A diagnosis of two temporary anomalous teeth fused together conjoined with a peg shaped anomalous supernumerary tooth embedded between the central permanent incisor and the temporary milk tooth.

A decision was made to surgically  extract the temporary tooth along  with the impacted peg shaped supernumerary tooth to give a way to the central permanent incisor to erupt.

**N.B. Normally,Maxillary central incisors begin to erupt at the age of 6. In this case the eruption of maxillary permanent right central incisor was delayed.

Chewing Gum, Aye or Nay..!

Caries is the most common chronic infectious disease in the World. We should do everything to prevent or at least decrease its spread. Sugar increases blood pressure,bad cholesterol and risk of heart disease. On top of that, sugary food adhere to teeth and stimulate plaque growth.
Xylitol is a five carbon sugar alcohol compound. Sugar alcohols are neither sugar nor alcohol. Xylitol is not an artificial sweetener as well. Xylitol is a naturally sugar compound which can be derived from  vegetables and plants. Xylitol has all the benefits of sugar without its many drawbacks.
Bacteria can use the six carbon monosachcharide such as glucose or fructose as food source to produce plaque on teeth which leads to decay but cant use xylitol for this same purpose.

Xylitol has been added to chewing gums as a sweetener instead of sugar.For this reason, it is very important to know all its advantages. Now to get back to our main subject about chewing gums. Chewing gums are very effective in preventing teeth decay for the following reasons:

1. It increases saliva flow up to 10 times.Saliva helps to wash away food debris and plaque.
2. Chewing gum mechanically washes away food debris and food trapped on deep areas of back teeth.
3. The increased saliva flow increases remineralization process. What the plaque acids take out, the extra saliva puts back.
4. Dry mouth is common for people who take medications such as antidepressants and anti-histamines. More saliva production helps those patients from dry mouth side effect.
5. Chewing gum  improves memory and increases concentration. We all remember the legend Micheal Jordan and how he used to chew gum during his NBA games. 
6. Chewing gum helps those who want to quit smoking. 

How to use the chewing gum?

Chew gum immediately after each meal for 20 minutes.When you eat sugary meals, the PH level in your mouth drops rapidly and remains low for some time.The chewing action stimulates far more saliva,which rapidly brings the PH levels back up to its normal limit.

N.B. Be sure to chew  chewing gum with xylitol.Other sweeteners such as mannitol,aspartame or sorbitol can be used by bacteria in the mouth as food sources and they can lead to causing decay. So be sure whenever you buy any product with sugar substitute,that xylitol is the main and only ingredient.

Fluoride treatment

Fluoride treatment can reduce caries in children and adults.
There are many Types of fluoride treatments, we will take about topical method.
Topical fluoride application includes either sodium fluoride NaF or Acidulated phosphate fluoride APF.
Sodium fluoride comes in a solution, gel or foam forms of 2 % . It is also available in varnish of 5 % . Acidulated phosphate fluoride comes in a solution, gel or foam of 1.23%.
APF is the preferred topical application over NaF, however it is avoided when patient has cosmetic restorations as it may cause some pitting.

Fluoride application techniques:
1- paint-on-method: not for gel or foam forms to avoid fluoride ingestion.
2- tray technique for gel or foam forms; 2 ml for children & 5 ml for adults.
In both techniques, dry teeth before & after with 2*2 gauze.
No drinking or eating for 30 min after procedure.

3- fluoride varnish application: safe and durable. Most effective technique to use on children.

Optimal level of fluoride in drinking water is 0.7mg/ L .

Ingestion of extra fluoride is toxic.
Certainly lethal dose in adults is 5 to 10 grams of sodium fluoride taken at one time. It is between 0.5-1g in children depending on size and weight.
Signs of toxicity begin to appear after 30 min of ingestion.
Emergency treatment : induce vomiting by stimulating back of throat or by Ipecac syrup.
Giving calcium binding agent such as milk.

Drying root canals

While I was drying root canal yesterday for tooth number 4, I noticed a very important thing. Regardless of how copious you try to irrigate the canal with disinfectant, small tissue tags can still resist the force of irrigation.
Very important tip: always while you are drying the canal with paper points at your last step, put three or four paper points together into the canal until they fit tight, then twist them all together against the canal walls. This way, you mechanically remove any tiny small tag holding still on the inner walls.If you find any tags trapped on the paper points, repeat irrigation and drying, before filling the canal with GP.

Sutures -everything you should know

Suture material that retains long term strength for up to 14 days and resorbs in 21 to 28 days is polyglycolic acid (PGA )

Conversely suture to be placed intraorally where tissue heals quickly ; surgical gut or the new rapidly resorbable PGA suture material (PGA -FA) is used.



Degradation of absorbable , biological origin sutures such as surgical gut ( plain & chromic gut) are digested by intra oral enzymes .

Gut suture is from animal protein
Which resorbs in 1 to 2 days. If coated with chromic compound, it extends 7 to 10 days.

Fast absorbing PGA FA suture is made from synthetic polymers and dissolves in 7 to 10 days. It should be used when gut suture is contraindicated .

Thread sutures range in diameter from 0 to 10

The higher the number, the thinner and more delicate the thread.


5-0 diameter is used in plastic perio surgery
4- 0 diameter is used for other perio flaps.

3-0 diameter used in implant surgeries when mattress suturing technique is used. 4-0 is used when interrupted or continuos techniques are used.


Silk is a classical suture used in dentistry . It's nonresorbable inexpensive multifilament material. Dentist should remove it in a week. It's down side is pulling bacteria into the wound site. In this case nonresorbable sutures such as nylon, polyester, polyethylene, polypropylene or expanded polytetrafluoroethylene (e-PTFE) are a better choice.


Polyester sutures are made of multifilaments braided in a single strand. This suture is coated with absorbable compound that makes the knot untie if not secured well by the dentist

e-PTFE is better in this regard . It is nonresorbable monofilament that has high tensile strength but a little more expensive than polyester.

The 3/8and 1/2 are the most used suture needles in dentistry .


The 3/8 passes easily from buccal to lingual in one motion

The 1/2 circle needle is used in more restricted areas such as maxillary molar area and anterior incisal areas.


Generally in dentistry the 3/8 reverse cutting needle with 3-0 or 4-0 thread diameter and the 1/2 reverse cutting needle with the thinner more delicate 5-0 or 6-0 thread diameter are most commonly used.

How to manage moderate to sever pain after third molar extraction?

NSIADS such as Ibuprofen or Naproxen could be given immediately before the surgery and continued for 2 to 5 days. A combination of NSAID with Acetaminophen can even give a better analgesic effect.

Opiods such as (vicodin or percodan) are the hallmark drugs used to manage sever pain after third molar extractions; however their side effects are limiting their use. 





Alternative to opoids is ketorolac tromethamine such as sprix. This nonopoid NSAID is equivalent in strength to the opoid drugs without their side effects. 

Oral Conscious sedation

"Happy pills"! Have you heard about it?? You may or may not. But let me tell you a little about it.

Medically these drugs are named Benzodiazepines or Benzos as they like to  call them in the United  States. These are Anti- Anxiety pills and prescribed for the treatment of anxiety,insomnia, agitation,seizures & muscle spasms.
What is important to me and what I will be talking about is their use in dentistry.
Many people love to have beautiful smiles........who doesn't? but there is a small little problem that comes with it which is that they still feel anxious going to the dentist. Now, do you want a nice white smile without going through the anxiety and stress that come with it??  Oh yeah , you definitely do.
Here is the solution and it is very simple. Benzo pills are excellent to use and implement before dental appointments.
There are several dental sedative protocols that can give many patients the chance to go through their  dental treatments without feeling anxious or stressed.
Even if you don't feel stressed going to your dental appointment, you can still benefit from benzo pills and feel more calm and relaxed during the procedure.

Let us talk about some of these drugs:


Valium: this is the trade name of the drug. The generic is diazepam . Valium  has been in the market since the 1960's.It has long duration of effectiveness.It stays in your body for like 20-100 hours until it goes out totally.Dose ranges from 5-10mg.
This drug is used for insomnia in first place but it has its role in dentistry and I will come back to this later.

Halcion: this is the trade name of triazolam. This drug is very popular in the United States.It is used commonly before dental appointments; very safe drug. The popularity of this drug comes from its amnesic properties (memory loss).So after finishing your dental appointment, you  can barely remember anything.This drug is used for short appointments ranging from 1to 2 hours.The drug's half life (duration of staying in your body) is 1.5-5 hours. It can be mixed with Vistaril; an anti-histamine drug to get more extended effect.

Ativan:This is the trade name of the generic lorazepam. It is used to treat anxiety in first place. It has high level of amnesic effect.You barely remember anything after your dental treatment. Dosage ranges from 2 to 3 mg. It kicks in after about one hour.Duration of action is 6 to 8 hours and it stays up to 14 hours in your body.

Versed: The generic is midazolam.It is a short acting benzo drug.Excellent  for short appointments.It still has the same level of effectiveness as other benzos. Half life is about 1 to 3 hours. Lasts for as little as 1 hour.  Kicks in after 10 to 20 minutes. Excellent to use in dentistry. Dormicum is the alternative brand known in Lebanon .

There are two other drugs that have anti-anxiety effect without being benzos. These drugs are Vistaril and Sonata.

Vistaril: The generic is hydroxyzine; it is an antihistamine drug .It has anti-anxiety effect without amnesic properties. Can be mixed with benzo drug. Duration of action is 3-6 hours. Half life time is 3-7 hours.

Sonata is the trade name for Zaleplon. Used for insomnia. Duration of effectiveness is 1 to 2 hours. It quickly gets out of your body in an hour or two.

It is very important to mention that all benzo drugs are only given by prescription meaning that you can not get them from the pharmacy as an OTC(over-the counter) drugs.

Now you should know that you can not take benzo drug with other CNS depressants.You should not drink alcohol while taking benzo pills as well.

 Going back to Valium. The best protocol for oral sedation  to be used in dentistry  is as follows: Valium( diazepam) can be given to patients the night before the appointment while Triazolam can be given one hour before the treatment.
This is the best protocol for benzo drugs when used before dental appointments.
Valium is not always necessary to take the night before. Most of the time, it is more than enough to take one pill of triazolam one hour before the treatment.

UV toothbrush sanitizers

Everyone has a tooth brush at home....
But do you know ?
1- A single toothbrush can accumulate millions of bacteria
2- Putting your toothbrush  in the warm/ moist environment  of the average bathroom translate those bacteria into harmful ones.


Now what is the solution??
VIOlight system(emitting Ultra Violet light device) eliminates up to 99.9% of bacteria that thrive on your toothbrush. That's millions of microscopic bugs that can cause flu, colds and other illnesses, zapped in minutes!

Easy as Brush, Store and Sanitize


VIOlight uses a germicidal UV bulb — the same technology used in hospitals — to kill germs. A blue-violet glow lets you know the sanitizer is working. The entire process takes minutes. When finished, the bulb automatically shuts off and your toothbrush is fresh, clean, and protected for the next time you brush! 

VIOlight Toothbrush Sanitizer Information Report

Did You Know...?

• A number of studies suggest that oral heath is associated with general health. Advanced gum disease has been linked to heart disease, diabetes, premature delivery in pregnant women, and stroke.
  
• Researchers have found more than 10,000,000 bacteria living on a single toothbrush.
  
• Tooth decay is caused by bacteria that can survive on toothbrushes.
  
• Viruses that cause colds, flu, and fever blisters can survive for many days on toothbrushes.
  
• Droplets produced by flushing toilets can harbor bacteria and viruses that can remain airborne long enough to settle on surfaces. Thus, a person could acquire an infection from an aerosol produced by a toilet.

The Problem

USA Today Health Review for April 27, 2000 reported: "The most serious threat to your everyday health may be hanging in plain sight in your bathroom."

Influenza (the flu) virus, herpes simplex I, streptococci, staphylococci, yeasts, and the bacteria that cause gum disease, cavities, and even diarrheal illness can survive --some even thrive-- in high numbers on toothbrushes.

Some researchers have even found biofilm - colonies of breeding bacteria - on toothbrushes, and numbers as high as 100,000,000 microorganisms have been recovered from individual brushes.

Because most people keep their toothbrushes in the bathroom, bacteria from the mouth isn't the only contaminant. Flushing propels germs from the toilet into the air, where they can land on toothbrushes. Toothbrushes are usually stored together, so contact between family members' toothbrushes can spread germs from one brush to another.

Bacteria, molds, and fungi love moist environments, like the bathroom. They also do well in the dark, so the medicine cabinet provides an ideal environment for germs to survive and even multiply.

Toothbrushes become infected some time between one week and one month after initial use. The ADA and most dentists recommend changing toothbrushes only every three to four months.

Some sources report that most American are likely to change their toothbrushes only twice a year. The Solution Ultraviolet (UV) light is a proven germicide.

It kills fungi like yeasts and molds; disease-causing bacteria like strep, salmonella, and E. coli; and even some hearty viruses like influenza and hepatitis.

The Proof

Numerous studies have shown ultraviolet light to be effective in killing germs on toothbrushes.

UV toothbrush sanitizers have been reported to kill of bacteria, yeasts, and viruses.

A study* performed on the VIOlight Toothbrush Sanitizer by Dr. Philip Tierno, Jr., PhD, Director Clinical Microbiology and Immunology, Associate Professor, Departments of Microbiology and Pathology, New York University Medical Center, found that the VIOlight eliminated up to 99.9% of bacteria tested on toothbrushes.

Another study* by Bureau Veritas, a global independent testing laboratory, also found that the VIOlight Toothbrush Sanitizer eliminated up to 99.9% of germs tested on toothbrushes.

How Many Germs Are Living on Your Toothbrush? 

Power tooth brush Vs manual tooth brush

Power toothbrush and that is for many reasons:


- The Cochrane review confirmed that oscillating-rotating technology is more effective at reducing plaque and gingivitis than a manual toothbrush.
-Power toothbrush reduces up to 2 times more plaque than a manual toothbrush.
-Power toothbrush is more gentle on the gum and teeth. Patients are proven to brush nearly three times harder with a manual toothbrush than with a power toothbrush.
-Most manual toothbrushes will need to be replaced within 3 months of usage.Electric toothbrushes head last a lot longer than regular ones.


Toothbrush care:

1. Thoroughly rinse the toothbrush with running water.
2. Do not share your toothbrush with others.
3. Store in an upright position and air dry. Putting  toothbrush in cases or covering the bristles creates a moist environment that can promote the growth of bacteria.
4. Replace the head of electric toothbrush every 4 or 6 months or when the bristles become frayed or splayed .

http://www.facebook.com/media/set/?set=a.301436463206177.96712.100000194777512&type=1&l=23fb4f0b0f