Author Archives: rgangwisch

Nitrous Oxide Sedation

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Administration of Nitrous Oxide

Nitrous oxide (laughing gas) is an extremely helpful adjunct for dental treatment of the fearful patient. It was first discovered by Joseph Priestley in 1772, however, it was not until 1844 when Horace Wells used it as a medical anesthetic. Today, nitrous oxide is used in conjunction with local anesthetic when performing dental treatment on apprehensive patients. Nitrous oxide on its own cannot reliably anesthetize a patient profoundly enough for a patient not to feel a thing. Therefore, it must be used with novocaine to numb the area. Nitrous oxide is administered with pure oxygen and is breathed through a nasal hood. The machine that delivers the gas is a fail-safe machine which will turn off if the oxygen level falls below 35%. Nitrous oxide is not meant to put one to sleep, but merely relax. When given before the anesthetic injection, it can make that part of the procedure much more comfortable. It will put a patient in a state of mild euphoria and will alter the perception of sights, sounds, and time. It also has a mild amnesic effect leaving much less memory of the procedure. Another extremely nice feature of nitrous oxide is that the patient can be flushed with pure oxygen after the procedure and be totally lucid and able to drive home. Nitrous oxide can make a dental appointment a very pleasant experience.

Oral Sedation for Dentistry

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Fear of dental treatment is very common. Some times, good anesthetic technique, behavior modification, and nitrous oxide (laughing gas) may not be enough for someone who is very fearful. Oral sedation comes to the rescue. It is important to get a good night’s sleep before a dental appointment, but with dental phobics, that can be difficult to do.

Ativan 2mg Tablets

At our office, we use Ativan (lorazepam), a relatively long acting sedative. We prescribe two pills. One of those pills is taken before bedtime which helps a patient get a good night’s sleep. The other pill is taken an hour before the appointment. Since Ativan is very long acting, there will still be some blood level left from the initial dose, thus providing for an extremely relaxed state once the dental appointment begins. Conscious sedation is very safe because the patient still has their protective reflexes and is able to respond to commands readily. However, they are extremely relaxed to the point that the sights, sounds, and vibrations associated with dental treatment are minimized immensely. The concept of time is altered so that the appointment seems to fly by and there is also an amnesic effect so that the patient has very little memory of the procedure. Afterwards, the patient is delightfully drowsy and will go home and have a very restful nap.

Tips to Overcome One’s Fear of the Dentist

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There are many ways to overcome one’s fear of the dentist. First of all, don’t wait until the tooth hurts. It makes it more difficult for the dentist to get you numb. Plus the pain leading up to the appointment can be associated with the dental visit itself. The dental appointment itself is really nothing to be fearful of as long as good local anesthetic technique is used to numb the area. Try to get a good night’s sleep and avoid caffeinated drinks that could raise the anxiety level. For the novocaine injection, try to relax your muscles, especially your hands. Try this the next time you are in rush hour traffic and notice that your hands are tightly clasped to the steering wheel, consciously relax your grip and notice how the rest of your body will follow suit. Another trick is to find something on the ceiling to fixate on. We have televisions in our ceiling. This way patients can either watch cable TV or a serene aquarium movie to help keep their mind on things other than the injection. By flooding one’s brain with visual stimuli and concentrating on relaxing the hands, the anesthetic injection experience can be minimized greatly. Once the initial numbness has been achieved, further injections can be done relatively pain free. The remainder of the appointment should be a piece of cake and should be fear free.

Fear of the Dentist

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Fear of the dentist is a very common problem. It is not unusual for one to be somewhat apprehensive before one’s dental appointment, however, a higher level of anxiety can be a result of a real dental phobia. Dental phobia can cause a person to avoid dental treatment. Many dental phobias start with a bad experience at the dentist, especially as a child. In our office, we never do any potentially painful treatment without first numbing the area. Since we are a sedation practice, we see a high number of dental phobic patients. The common source of their dental fears came from an experience where their dentist kept drilling on their tooth even though the individual indicated that it hurt. Another common problem comes from the patient delaying treatment until they are in extreme pain. Not only is it extremely difficult to get someone numb in that situation, but also even if you can get the tooth numb, just the experience alone can be enough to cause the patient to avoid further dental treatment.

What is a Crown Buildup?

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A crown buildup is essentially a large filling that is used to replace enough missing tooth structure to retain a crown (or cap). Most teeth that require a crown (or cap) are broken down due to a large cavity or fractured cusp. Depending on the amount of missing tooth structure, there are times that there is not enough tooth remaining above the gums to allow a crown to grab hold of. Even though a crown is glued on, there must still be enough tooth structure present to provide a friction fit since the glue is not strong enough to bear the brunt of one’s bite.
Teeth that have undergone root canal treatment usually need crown buildups. This is because by the time the inner surface is removed to provide access to the root canal space and the outer surface is removed to provide space for the porcelain, there is not much tooth structure left to retain a crown.

Broken tooth with a buildup

There are different materials available for crown buildups: composite (tooth-colored filling material), amalgam, and glass ionomer. I prefer the glass ionomer because it leaches fluoride into the surrounding tooth structure. This makes the tooth more resistant to decay. This is an important feature since decay sneaking up under a crown can be its achilles heel. A crown that is placed on a properly constructed crown buildup should give a person decades of service.

Gum Line Fillings

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The gum line (cervical area) is a common location for fillings to be needed. They can be needed due to decay, toothbrush abrasion, erosion, or abfraction. Cavities along the gum line are totally preventable with good oral hygiene on a daily basis. Toothbrush abrasion is another preventable reason for needing cervical fillings. Chemical erosion can dissolve tooth structure. It is most common on any exposed dentin since dentin is significantly softer than enamel and the gum line is where most of the exposed dentin will be. Chemical erosion can come from acidic foods or reflux of stomach acids. Abfraction is thought to be caused by tooth flexure from biting and chewing forces. It is postulated that tiny particles of tooth structure fracture off at the cervical area eventually getting deep enough that it would need to be repaired. There are two types of materials used to restore cervical defects – composite and glass ionomer. Glass ionomer is most helpful in individuals with a high cavity rate. The glass ionomer will leach fluoride into the surrounding tooth structure making those areas more decay resistant. Unfortunately, glass ionomers are not very wear resistant and need to be replaced frequently. The other material that is used for gum line fillings is composite, the one that is normally used for tooth-colored fillings. Since the composite doesn’t leach fluoride, it tends to get small cavities around its edges and must be replaced frequently. The best thing to do is prevention by gentle tooth brushing along the gum line on a daily basis.

Pin Retained Fillings

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Three pins placed in tooth before adding filling material.

Many times, teeth can be so broken down due to extreme decay or fracture that there is not enough tooth structure available to hold a filling in place. In most of these cases, a crown (cap) would be indicated. However, certain situations may call for a change in plans. Things like inability to afford a crown, an unstable gum situation, waiting to see if a recent root canal will work, or any situation where the long term progression (outlook) is questionable are all possible reasons to go with just a filling. When there is not enough tooth structure to hold a filling, then pin retention is indicated. Pins are tiny threaded screws that are placed about ½ millimeter into dentin. A pilot hole ever so slightly smaller than the pin is drilled into the tooth, then the pin is screwed into place. An amalgam (metal) or composite (tooth-colored) filling is then placed over the top. The pin is only used for retaining the filling on the tooth. It does not reinforce like a rebar does with concrete. Pins have been known to cause microcracks in the dentin, however, I have not seen a fracture of the underlying tooth structure that was severe enough to lose the tooth that was caused by the pin alone.

Dental Posts

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Once root canal treatment has been performed then the tooth must be restored. Root canals are usually performed on teeth that are quite broken down and therefore must be built up to have enough tooth structure available to hold onto a crown. In order to retain the core buildup, many times a post must be placed inside the root canal. This is done by removing a portion of the root canal filling material (the part closest to the tip of the root is left to seal the end) and drilling out the proper size to accept the post (no need to worry about the drilling – remember there is no nerve in a root canal tooth). Then, the dentist chooses one of two types – a cast post and core or a prefabricated post. The cast post and core has advantages in that the core buildup is made as one piece with the post so there is no way for the two to separate. A disadvantage is that it must be fabricated outside of the mouth and therefore cannot be cemented on the same day, however, other provisions must be made to build up the tooth. Some prefabricated posts are metal and some of the newer ones are made of carbon fiber composite. The newer carbon fiber ones have a little bit of give to them and they look promising on possibly reducing root fractures in teeth with posts.

Periodontitis

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Periodontitis is a disease of the gums and causes a majority of the tooth loss in adults. The sad part is that over 90% of the cases are preventable. Periodontitis is caused by an interaction of bacteria which reside on the teeth and the body’s immune system. The bacteria adhere to the teeth by a sticky substance called dental plaque. The plaque protects the bacteria from antibodies in saliva, thus allowing the disease to progress. Simply by removing the dental plaque everyday would stop the disease dead in its tracks. Mild periodontitis is the first step past gingivitis, a reddening of the gums. It is marked by easily bleeding gums, especially when brushing the teeth. If good oral hygiene measures are initiated, many times the disease process can be reversed. Moderate periodontitis is accompanied by some bone loss. If caught at this time a procedure called scaling and root planing can be helpful in stopping the disease progression. From this point on, any bone damage is irreversible, so it is best to catch things as early as possible. Severe periodontitis is the point where the teeth will loosen and tooth loss can occur. These cases usually require surgery to give the sufferer access to all of the affected areas for the purposes of oral hygiene. Due to the irreversibility of the bone loss, it is always best to put the disease in check by daily home care and frequent professional checkups.

Root Canal Irrigants

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When a dentist does a root canal, he opens up the tooth to expose its inner contents and cleans out all remnants of the nerve and any necrotic tissue. Removing all organic deposits is tantamount in allowing for a good final seal. Any left over pieces of debris will contaminate the filling material and cause it to leak and fail prematurely. An irrigating solution is important to not only help flush debris from the canal during the cleaning process, but to also provide final disinfection of the canal before it is filled. Sodium hypochlorite, the main ingredient in common household bleach, makes an ideal irrigating solution. It will emulsify living tissue so that it can easily be flushed from the canals. This is especially important when working in canals that have lots of nooks and crannies for vital and non-vital tissues to hide. When an oxygenating agent is added it will bubble out hiding debris that cannot be mechanically removed with the thin files that the dentist uses to clean and shape the canals. It is important that the irrigant stay within the confines of the root canal space so as to not cause peripheral tissue damage. Once the irrigant has done its job, it is dried up with points of absorbent paper, but it still has the residual effect of disinfection before the root canals are filled.