The Business of Dentistry: Patient Appointments and Scheduling

Transcription

1 The Business of Dentistry: Patient Appointments and Scheduling Natalie Kaweckyj, LDARF, CDA, CDPMA, COMSA, CPFDA, MADAA, BA; Wendy Frye, CDA, RDA, MADAA; Lynda Hilling, CDA, MADAA; Lisa Lovering, MADAA; Linette Schmitt, CDA, RDA, MADAA; Wilhemina Leeuw, MS, CDA Continuing Education Units: 3 hours Online Course: Disclaimer: Participants must always be aware of the hazards of using limited knowledge in integrating new techniques or procedures into their practice. Only sound evidence-based dentistry should be used in patient therapy. This appointment management course focuses on the many procedures and appointments offered by today s dental offices. The business assistant must have a basic working knowledge of these procedures and therefore maintain an efficient office scheduling system. Conflict of Interest Disclosure Statement The authors report no conflicts of interest associated with this work. ADAA his course is part of the home-study library of the American Dental Assistants Association. To learn more about the ADAA, please visit ADA CERP The Procter & Gamble Company is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at: 1

2 Approved PACE Program Provider The Procter & Gamble Company is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing education programs of this program provider are accepted by AGD for Fellowship, Mastership, and Membership Maintenance Credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 8/1/2013 to 7/31/2017. Provider ID# Overview Dentistry is a business as well as a health care service profession. It is essential to provide treatment for patients in a caring manner, but it is also necessary to maintain maximum efficiency and production in order to ensure a successful practice. The administrative assistant plays a key role in the smooth operation of any dental practice, from managing accounts, appointments, and inventory to ensuring vital communication between team members and with the patients of the practice. The knowledgeable business assistant not only helps to increase office production, but also assists the dental team in the smooth running of day-today operations. This appointment management course focuses on the many procedures and appointments offered by today s dental offices. The business assistant must have a basic working knowledge of these procedures and therefore maintain an efficient office scheduling system. Learning Objectives Upon completion of this course, the dental professional should be able to: Differentiate between preventative and therapeutic hygiene procedures. Explain the advantages and disadvantages of amalgam versus composite resin in restorative materials. Explain what a CEREC restoration is and list its advantages and disadvantages. Describe the two types of sealant materials. Understand the benefits of sealant placement in children. Explain what limitations insurance companies may pose on sealant placement. Discuss the difference between a sealant and a posterior preventative restoration. Differentiate between fixed and removable prosthodontics. Discuss when ceramic crowns may be contraindicated. Define the term porcelain veneer. Explain the differences between a Maryland bridge and a traditional three-unit bridge. Contrast the differences between ceramic, porcelain fused-to-metal, and gold crowns. Identify the various types of removable prostheses. Explain what types of procedures each of the dental specialties perform. Differentiate between a traditional denture and an immediate denture. Explain some advantages and disadvantages of implants. Define three types of extractions. Describe a common side effect of bleaching. Define an abscess. Describe when endodontic treatment is necessary. Understand when various types of images are used during a radiographic procedure. Give three examples of equivalent exposure to x-ray radiation. Explain ways in which the community is protected from unnecessary radiation exposure. Differentiate between disinfection and sterilization. Understand the need for infection control procedures and how they impact scheduling. State the levels of Maslow s Hierarchy of Needs. Identify the considerations of special needs of patients for scheduling. Understand how to schedule appointments to assure smooth patient flow, to maximize productivity, and to make effective use of practice time. Demonstrate how to create, maintain and use a scheduling template with preferred units of time for each commonly performed procedure: new patient visits, crown and bridge work, medical conditions, etc. 2

3 Describe how to schedule appointments, gather necessary information, and confirm appointments. Discuss how to establish an appointment series for a patient for specific procedures allowing sufficient laboratory working time between visits and allowing proper chair time at each visit. Explain how to manage changed appointments including broken and cancelled appointments. Explain how to use a call list to fill open schedule times. Describe how to create a daily schedule to be posted in treatment areas. Explain how to assemble records needed for each patient visit. Course Contents Glossary Clinical Considerations Pre-treatment Procedures Preventative Procedures Hygiene Procedures Pit and Fissure Sealants Preventative Resin Restoration Restorative Procedures Amalgam Materials Composite Materials Fixed Prosthodontics Inlays Onlays Crowns Bridges Removable Prosthodontics Partial Dentures Provisional Appliance Complete Dentures Immediate Dentures Surgical Procedures Dental Implants Extractions Bleaching Procedures Endodontic Procedures Orthodontic Procedures Post-Operative Instructions Radiography Technique Types of Film Types of Receptors Duplication of Radiographic Images Patient Concerns about Radiation Infection Control Prevention of Cross-contamination General Patient Management Patient Types Medical Emergencies Common Medical Emergencies in the Dental Practice Syncope (Fainting) Hyperventilation Pregnancy Asthma Attack Allergic Reaction Anaphylactic Reaction Angina Pectoris Acute Myocardial Infarction (MI) Cerebrovascular Accident (CVA) Hyperglycemia (Diabetic Coma) Hypoglycemia (Insulin Shock) Seizures Adrenal Crisis (Acute Adrenal Insufficiency) Appointment Control Telephone Protocol Appointment Scheduling Scheduling Guidelines Conclusion Course Test Preview References About the Authors Glossary abscess Localized collection of pus; two types - endodontic and periodontic. abutment Tooth, root, or implant used for the retention and support of a fixed or removable prosthesis. acrylic Synthetic resin material used in various restorative materials, prostheses, and assorted appliances. acute Characterized by sudden onset, sharp or severe pain, and of short duration. adverse reaction Unintended reaction to a medication or product. allergic reaction Sensitivity to a foreign substance known as an allergen in the body resulting in a variety of symptoms from itchiness and hives to airway obstruction. 3

4 alloy Mixture of metals. alveolitis Inflammation and/or infection of the alveolar bone; commonly referred to as a dry socket. analgesia Decreased or absent sensation of pain following the administration of anesthesia or a medication. analgesic Drug that relieves pain. anaphylactic shock Severe and sometimes fatal reaction to a foreign object (allergen) in the body. anesthesia Temporary loss of feeling due to an administered substance. angina pectoris Pain or pressure around the heart caused by a lack of oxygen, often due to heavy exertion. angioedema Giant hives as a result of an allergic reaction. arch Pertaining to the upper (maxillary) or lower (mandibular) jaw. armamentarium Instruments or tools needed to do a specific task. articulation The contact relationship of the maxillary and mandibular teeth as they move simultaneously. appointment matrix (or appointment framework) Is the schedule for each provider, broken down into 10, 15 or 20-minute increments. asymptomatic Presenting without symptoms. atherosclerosis Hardening of the arteries. bacterial endocarditis Infection of the lining of the heart. bracket Small, metal or acrylic piece that is bonded to the tooth to hold wires in orthodontic procedures. bradycardia Slow heartbeat. CAD/CAM Computer-aided design and computer-aided manufacturing. caries Infectious disease caused by bacteria in dental plaque that destroys tooth structures; also known as tooth decay or dental cavities. carious lesion Area of decay on a tooth. cavity Hole or decay lesion in a tooth. cement Dental material that can be used to hold items together, or to protect the tooth. cephalometric radiographic image Extraoral radiograph of the head; used in orthodontic and prosthodontic dentistry to show a profile of the patient s head. cerebral embolism A floating blood clot that lodges in a cerebral artery that can lead to stroke. cerebral hemorrhage Rupture in a cerebral artery that can lead to stroke. cerebral infarction Decreased blood flow to a cerebral artery as a result of atherosclerosis that can lead to stroke. cerebral thrombosis Obstruction of a cerebral artery as a result of a clot that forms in the artery that can lead to stroke. cricotracheotomy Incision of the trachea through the cricoid cartilage. chronic Drawn out and lasting over a long period of time; not acute. composite Resin restorative material used for tooth-colored restorations. conscious sedation Sedative technique used to calm nervous anxiety without the loss of consciousness. convulsions Uncontrolled muscular contractions of the body. coronal polishing Removal of plaque and extrinsic stains from the surfaces of the teeth that are above the gingiva. 4

5 debridement Removal of debris with hand instruments or mechanical devices. debris Accumulation of excess or foreign material attached to a surface. dental public health A special area of dentistry that organizes and runs dental programs in school systems or underserved areas of communities. denture Removable prosthesis that replaces two or more teeth in an arch. disinfection Process of killing pathogens (germs) by physical or chemical means; does not destroy spores and resistant viruses. edema swelling edentulous Without teeth. elective A choice; not mandatory or required. endodontics Branch of dentistry that diagnoses and treats diseases of the human dental pulp. epilepsy Condition characterized by convulsions due to disordered cerebral functions. epileptic cry Sounds made during an epileptic seizure as a result of the sudden contraction of the respiratory muscles forcing air out of the mouth. erythema Redness or inflammation of the skin. extraction Surgical removal of a tooth or teeth. fissure Groove or natural depression on the surface of a tooth. general anesthesia Anesthesia that involves the loss of consciousness. gingiva The mucous membrane tissue that surrounds the teeth. gingivitis Inflammation of gingival tissues; also known as Type I periodontal disease. HIPAA The Health Insurance Portability and Accountability Act. hyperglycemia Abnormally high blood sugar. hypertension High blood pressure. hyperventilation Abnormally rapid and deep breathing resulting in decreased levels of carbon dioxide. hypoglycemia Abnormally low blood sugar. hypotension Low blood pressure. idiosyncratic reaction Unusual or unpredictable drug response that may be genetically related. immediate denture A denture inserted immediately following extractions. impaction Remaining unerupted in the alveolar bone beyond the time the tooth should be erupted. implant Device inserted into the alveolar bone to anchor a prosthetic device. incipient caries Beginning caries that has not yet broken through the enamel into the dentin. intramuscular Injection within a muscle. intravenous Injection within a blood vessel. intrinsic stains Stains that are within the enamel or dentin; cannot be removed by polishing. local anesthesia Anesthesia that is limited to one place. localized Confined to one area of the body. malocclusion Any deviation from normal occlusion; may involve one tooth, several teeth, or an entire arch. myocardial infarction Heart attack. occlusal equilibration Removal of all occlusal interferences on the teeth. occlusion The contact between the maxillary and mandibular teeth in any functional relationship. 5

6 OPIM Other Potentially Infectious Materials; pose a hazard to dental team. oral and maxillofacial surgery Specialty within dentistry that diagnoses and treat conditions of the mouth, head, and neck regions. orthodontics Specialty within dentistry that corrects malocclusion skeletal-facial conditions. orthostatic hypotension Abnormally low blood pressure upon assuming a sitting or standing position after being in a supine position; also called postural hypotension. pediatric dentistry (a.k.a. pedodontics) Dental specialty; treats children beginning at the newborn stage through adolescence. periodontics Dental specialty which encompasses the prevention, diagnosis and treatment of the supporting and surrounding tissues of the teeth or their substitutes and the maintenance of the health, function and esthetics of these structures and tissues. periodontitis Inflammation of the periodontium that extends beyond the gingiva, and includes the formation of periodontal pockets and bone loss. periodontium Tissues that surround and support the teeth; includes the gingiva, alveolar mucosa, cementum, periodontal ligament, and alveolar bone. plaque Soft, sticky deposit on teeth that contains bacteria and bacterial products. pontic Artificial tooth that replaces a missing natural tooth. prime time Specific time of day that is most often sought after by patients for their appointments, typically the first and last appointment of the day and any appointments over the noon hour. productivity Amount of income generated, minus expenses, per unit of time. prophylaxis, Antibiotic administration of antibiotics to an uninfected patient to prevent bacterial endocarditis. prophylaxis, dental Professional cleaning and polishing of the teeth. prosthodontics Branch of dentistry pertaining to the restoration and maintenance of oral functions, comfort, appearance and health of the patient by the restoration of natural teeth and/or the replacement of missing teeth and the adjacent oral and maxillofacial tissues with artificial substitutes. pumice Ground volcanic ash that is used for polishing. radiolucent Producing dark images on a film because a large amount of radiation interacts with the film; refers to the structures that are easily penetrated by x-rays such as the pulp, bone and foramina. radiopaque Producing light images on a film because only a small amount of radiation interacts with the film; refers to the structures that absorb radiation such as the amalgam, and gutta percha. rampant caries Widespread tooth decay throughout the dentition. recurrent caries Decay occurring beneath the margin of an existing restoration. root planing Smoothing of the root surface with instruments done by the dentist or dental hygienist. scaling Removal of plaque and calculus from the crown and root surfaces of the teeth done by the dentist or dental hygienist. sealant Resin material that is used to fill pits and fissures to protect against caries. sinus rhythm Normal heart rhythm. sterilization Process of destroying all living microorganisms. syncope fainting translucent Ability to transmit light but diffuse an image. 6

7 units of time Increments of time a schedule is broken down into, typically 10, 15 and 20 minute increments. urticaria Hives as a result of an allergic reaction. veneer Thin layer of tooth-colored material (composite or porcelain) that is bonded or cemented to the facial surface of a prepared tooth. Clinical Considerations Although the administrative team will not be responsible for patient care directly, it is important to know basic information about different treatment procedures in case a patient asks questions during scheduling, when making financial arrangements, or speaking on the telephone. Clinical information should only be dispensed with the knowledge and approval of the practice. Pre-treatment Procedures Before beginning any dental treatment, the patient s health history must be reviewed by the patient and dental team members involved. Should the patient require pre-medication before dental prophylaxis or restoration, the dental and physician offices must agree on the protocol and decide who will prescribe the medication(s). Confirmation must be documented in the patient record that the patient followed the medically approved protocol. The dental team often consults with a patient s physician or specialist to ensure necessary procedures are followed. If the procedure has not been followed, the patient should be required to reschedule the appointment. Anti-anxiety agents are available for patients who are extremely fearful. Several oral medications exist in pill and liquid forms and can be administered before treatment begins. When these medications are combined with dental treatment, the patient must be advised not to drive to the office, but make arrangements for alternate transportation. Preventative Procedures Preventative procedures are performed in the dental practice to prevent dental caries and destruction of natural tooth structure. Hygiene Procedures The most common preventative procedures are hygiene procedures. These procedures are typically performed by the dental hygienist. However, under certain conditions, they may be performed by the dentist. Preventative hygiene procedures Modern dentistry is all about prevention. Dental patients should not only be taught good home care techniques such as brushing and flossing, but they should also receive instructions on other periodontal aids, such as interproximal brushes or irrigation, that are appropriate for each patient s oral situation. There are many different dental products that can help patients maintain their oral health. A dental professional should utilize those products and tailor them to each patient s specific needs. Therapeutic hygiene procedures Some therapeutic hygiene procedures can include scaling and root planing. Scaling involves the complete removal of plaque and calculus from the teeth. Root planing is the process of planing, or shaving, the root surface with a dental instrument to make it smooth, thus preventing the accumulation of plaque and calculus. Antimicrobial mouth rinses and antibiotics are sometimes used in conjunction with scaling and root planing. Chlorhexidine is a commonly used antimicrobial mouth rinse. In some cases, the patient may also be prescribed a systemic antibiotic. Another method consists of inserting fibers impregnated with the antibiotic tetracycline into the gingival sulcus. If periodontal pockets are deeper than 4-5 mm and are not resolved with the above procedures, periodontal surgical procedures can be performed to help the patient keep these areas clean. The key to dental care is making sure the patient has good patient dental education and home care instructions, which will result in faster healing and proper maintenance of the oral cavity. Pit and Fissure Sealants Pit and fissure sealants are a clear or shaded resin material that is placed in the deep grooves and pits of a tooth surface. Some molars and premolars have deep pits and fissures on the 7

8 occlusal surfaces and buccal or lingual pits that are virtually impossible for a patient to keep clean, thus making these areas more susceptible to caries formation. Fluoride can be beneficial for the smooth surfaces of the teeth, while pit and fissure sealants can provide protection deep in the pits and grooves. There are two main types of sealants: lightcured sealants, which polymerize when they are exposed to a curing light; and self-cured sealants, which consist of a base and a catalyst that are mixed together. Sealants can come in different colors such as clear, opaque, or tinted. Sealants can be placed on any premolar or molar that does not have an existing restoration or decay on the intended surface. Advantages of sealants include sealing of deep pits and grooves so decay cannot penetrate those areas as readily. Sealants can provide excellent caries protection for children through the cavity prone years to prevent decay in molars and premolars that are just erupting. Disadvantages of sealants are that some insurance coverage may be limited by age or type of tooth and the insurance coverage varies from policy to policy. (For more information on Pit and Fissure Sealants, refer to the ADAA course The Use of Pit and Fissure Sealants in Preventive Dentistry.) Preventative Resin Restoration A preventative resin restoration (PRR) is placed in the occlusal or biting surface of a tooth. Premolars and molars may have such deep grooves that even sealant material cannot flow into them. A dentist may check the grooves of the teeth with an explorer, and sometimes the grooves can be slightly sticky. The dentist will then use a special preventative resin bur, and clean out or open up those deeper areas. Then a resin can be placed in this minor preparation. A flowable resin or a putty type resin can be used in larger areas, as well as sealant materials that are bonded in the tooth. One of the advantages with PRRs is that tooth structure can be preserved, as only a small amount is needed be removed to place the restoration. On most occasions, a patient does not require a local anesthetic before the treatment is performed. A disadvantage of PRR is that insurance coverage can vary for adults and children depending on the dental insurance plan. Restorative Procedures Restorative procedures are treatment procedures that restore the tooth to optimum health. Typically, this involves a restoration. A patient may have several options in the restoration of his/ her tooth. For some individuals, it is a matter of personal preference of a particular material, while for others it may be what the dental plan will pay or the cost itself that dictates which procedures and materials will be used. The following is a brief summary of each of the procedures and materials, along with advantages and disadvantages of the material/treatment option. Amalgam Materials Amalgam Materials The first reported use of amalgam as a restorative material dates back to 659 AD in China. Amalgam is a substance that combines two or more different metals, usually silver, copper, zinc, and tin to form an alloy. This alloy is combined with mercury to make dental amalgam. Various groups have tried to have amalgam banned because of the toxicity of mercury in certain situations. Studies continue to show amalgam as a safe, affordable, durable, restorative material, backed by the American Dental Association and governmental agencies. Amalgam is still a common material used for dental restorations today. Advantages of amalgam include its durability and long lasting restorations, ease of use in hard to reach areas, or in areas where isolation of fluids is Figure 1. Amalgam Restoration 8

9 a problem. It is time efficient, which is important when children are uncooperative. Disadvantages of amalgam include its color, concerns about mercury content, and the possible need for the removal of healthy tooth structure for mechanical retention. (For more information on mercury refer to the ADAA course Mercury in Dentistry - The Facts.) Composite Materials Composite Materials Composite materials, similar to amalgam, can be used in restorations to replace missing tooth structure. There are many different types of composite materials on the market today, with varied durability, shade selection and delivery systems. Advantages of composite include that the tooth colored restorations are more pleasing to the patient and the wide variety of shades allows for creating optimum esthetics. Composite restorations are bonded to the tooth, which can help with better retention of the restoration. Disadvantages of composite restorations include the cost of placement, insurance restrictions on replacement, and at times, patient sensitivity. Fixed Prosthodontics Prosthodontics is the dental specialty that pertains to the replacement of missing teeth and tissues. A fixed prosthesis is one that is fabricated outside the mouth and then is permanently cemented in the oral cavity. Examples of fixed prostheses include: inlays, onlays, crowns, veneers, bridges, cantilever or Maryland bridges, implants, and fixed partial or full dentures. A crown is a single unit or two single unit crowns fused together. A bridge is a prosthesis that replaces one or more missing teeth. to last longer without fracturing from biting and chewing forces. Disadvantages include the color, the fact that patients have to come back for an additional procedure while the laboratory makes the restoration; and that many insurance plans will downgrade the treatment fee to an amalgam fee. Porcelain materials used for inlays are made of a glass-silica substrate, closely matched to the patient s tooth color. Advantages of porcelain include: tooth colored restorations that are esthetically pleasing and bonded to the tooth for better retention. If using CEREC, the main advantage is a one-appointment procedure. Disadvantages of porcelain include its fragility when compared to other materials, and the two-appointment procedure technique. For some individuals, insurance reimbursement may be lowered if the tooth could have been restored with a less expensive material. Onlays An onlay is a fixed prosthesis that is a conservative approach to restoring a tooth instead of placing a full crown. An onlay is placed when an inlay design is not adequate to restore the function of a tooth. Onlays are made from gold or porcelain and cover the occlusal surface as well as one or more cusps of the tooth. Advantages of gold onlays include: smoother margins of the restoration with a tighter seal against the tooth. Gold onlays can last longer than porcelain onlays due to less fracturing from biting and chewing forces. Disadvantages of gold onlays include: the color of the restoration, and a two-appointment procedure. Many insurance Inlays An inlay is a type of fixed prosthesis that is a conservative approach to restoring a tooth. An inlay is placed inside the coronal portion of the tooth and may involve one or both of the proximal surfaces. Inlays can be made from gold or porcelain. Gold inlays are cemented with dental cement, while porcelain inlays are generally bonded into place with an adhesive. Advantages of a gold inlay include: smoother margins of the restoration; a tighter seal between the tooth and restoration allowing the restoration Figure 2. Example of Gold Inlay and Gold Onlay 9

10 plans will downgrade the treatment fee or deny coverage all together. Advantages of porcelain onlays include: a tooth colored restoration that is esthetically pleasing and bonded to the tooth for better retention. Disadvantages of porcelain onlays: they can fracture more easily from biting and chewing forces and two appointments are required. For some individuals, insurance reimbursement may be lowered or denied. When insurance is involved, pre-authorization is always a wise choice. Crowns A crown is a single unit or two single unit crowns fused together. Crowns can be made of a gold metal alloy, porcelain or a combination of the two. Appointments for crowns include preparation and impressions in the dental office. Fabrication of the crown is usually completed at an off-site dental laboratory. When scheduling this type of procedure, two procedures are necessary: the first appointment is for preparation of the tooth and taking necessary impressions and the second for delivery of the completed crown and cementation. There must be enough time between appointments for the lab to make the crown and return it to the office. Ceramic crowns Ceramic porcelain is used to fabricate an all porcelain crown. Different types are available at various dental laboratories. An advantage of an all-ceramic crown is that shades can be custom matched to a patient s tooth. The ceramic porcelain can match the natural shades of anterior teeth and mimic translucency in the incisal portions of teeth, due to the absence of metal in the crown. Light reflections are more natural in all porcelain restorations. Due to the lack of a metal substrate, the greatest disadvantage is a greater risk of fracture, especially in anterior teeth. A patient may be asked to go to the laboratory for a custom shade (extra time and effort would be needed from the patient). The crown is bonded into place, and therefore may be a longer procedure for the patient. Porcelain fused-to-metal crown (PFM) is a crown that uses a metal substructure with a porcelain overlay. Porcelain is used because Figure 3. Porcelain Fused to Metal Crown it is tooth-colored and provides an esthetically pleasing restoration. Porcelain is not as strong as metal, so it is often fused to a metal base for strength, especially when used in the posterior region of the oral cavity. When a significant amount of tooth has been lost to decay or a large restoration, the cusps can weaken with daily chewing. An advantage to a full coverage PFM is that it can completely cover the tooth with porcelain and have a metal substructure. This provides strength and protection for the remaining natural tooth structure. With proper home care, a patient s PFM may last for many years. Cementation can take less time by using cements rather than light cured bonding resin cements. A disadvantage is the risk of fracturing the porcelain overlay with heavy bites. Additionally, as the patient ages and recession of the gingiva comes into play, the metal margin of the crown may become visible. Last, there is also a risk of allergies to certain metals contained in the metal substructure of the crown. Porcelain veneers A dental laminate or veneer is made from porcelain. A preparation is made on the facial surface of an anterior tooth. A thin layer or sheet of porcelain is fabricated at the laboratory, and the laminate is bonded into place. One advantage is that patients with misaligned teeth who do not want to have orthodontic treatment can sometimes have veneers placed to straighten out their smile line. Patients with tetracycline staining can use veneers to improve the shade and look of their teeth. Bonding cements that are used in conjunction with veneers can warm up or cool down a shade to maximize 10

11 a good shade match. Patients can achieve a whiter and /or straighter smile with minimal tooth structure loss, in comparison to having a full crown. Disadvantages include a risk for fractures and the veneers may need to be replaced or repaired more often. Also, there may be no insurance coverage for porcelain veneers. CEREC An innovation in fabricating inlays, onlays, and crowns involving CAD/CAM technology. An advantage of the CEREC restoration is that it only requires a single dental appointment. A CEREC restoration is a porcelain inlay, onlay, or crown that is generated from a computer image of the tooth and an in-house milling machine. Once the prepared tooth has received a digital impression and image, the information is sent to a milling machine, which takes the information and mills a block of porcelain to the desired specifications of the restoration. Disadvantages of CEREC crowns include the possibility of easier fracture, as there is no metal substructure under the porcelain, especially in posterior areas where more force is generated when chewing and sensitivity in some individuals. Color choices for crowns are also limited and often the insurance reimbursement is downgraded. Bridges A bridge is a fixed prosthesis that replaces one or more missing teeth and is permanently attached to one, two, or more teeth. Maryland Bridge A Maryland bridge is a conservative approach most often used when a patient has a missing tooth where the adjacent teeth have had little or no restoration. The bridge can be placed in the anterior or posterior segments of the mouth. This restoration includes a pontic that is connected to thin wing-like retainers that are placed on the lingual surfaces of the adjacent teeth. Cantilever Bridge this is another conservative bridge that has only one abutment tooth and one pontic. This bridge can be used in areas where there will be little stress or no traumatic occlusion. An advantage to these types of bridges would be their preparation requires little or no reduction of tooth structure and they are cemented in place by Figure 4. Veneers using resin bonding to assisting in their retention. A disadvantage is because of retention issues, biting pressure, and stress areas, these bridges may have to be re-cemented or redone more often. Porcelain Bridge Ceramic porcelain is used to fabricate all porcelain bridges. This bridge is created for ultimate esthetics. Advantages are that porcelain crown/bridge shades can be custom matched to a patient s tooth; porcelain can bring out more natural shades of anterior teeth and mimic translucency in the incisal portions of teeth, due to the absence of metal in the crown. Disadvantages are that there may be a strength concern with an all porcelain bridge, depending on the length of the bridge, since there is no metal substructure to support extra forces from the bridge. There is a greater risk of fracture, especially in anterior teeth, with all porcelain bridges; and patients may be asked to go to the laboratory for a custom shade, requiring extra time and effort. Also, since the crown is bonded into place, the result is a lengthier procedure time for the patient. Porcelain Fuse-to-Metal Bridge (PFM) A PFM bridge is fabricated with a metal substructure with porcelain baked on the outside. Porcelain is used because it is tooth-colored and provides an esthetically pleasing restoration. Porcelain is not as strong as metal, so it is often fused to a metal base for strength, especially in the posterior region of the oral cavity. Advantages of a PFM bridge include that the patient has the choice of having a fixed restoration vs. a removable prosthetic. This bridge provides more chewing strength in an area where teeth 11

12 Figure 5. Gold Bridge are missing. One of the biggest disadvantages of a PFM bridge is that porcelain can fracture under a heavy bite. The replacement of missing teeth requires the preparation of teeth that may be structurally sound. With every tooth that is replaced, the cost increased. Each false tooth, known as a pontic, is counted as a crown unit. As the patient ages and recession of the gingiva comes into play, the metal margin of the abutments may become visible. There is also a risk of allergies to certain metals contained in the metal substructure of the crown. Gold Bridge is similar to a PFM bridge, except that the bridge is made out of gold combined with other metals for strength. Advantages are that the margins are smoother and can be fabricated to be thinner, so the restoration has a better seal against the tooth and the margins are kinder to the gingival tissue. Gold bridges can last longer due to no risk of fracturing from biting and chewing forces as seen in porcelain and porcelain fused to metal restorations, prolonging the life of the restoration. For the patient, the cost of gold versus porcelain fused to metal restorations is the same. The primary disadvantage of gold is the color. Removable Prosthodontics Removable prosthodontics are included in the prosthodontics specialty, although many general practitioners provide the service. Removable prostheses include various types of partial dentures and complete dentures. Partial Dentures A partial denture replaces one or more missing teeth and can be prepared in many different Figure 6. Removable Partial Denture styles. The most common type is a clasp retainer style. Partial dentures can require semi-precision or precision attachments for retention of the appliance in the oral cavity. A partial denture can be fabricated from all acrylic, or more commonly, a cast framework of palladium with acrylic or porcelain teeth added. Most clasps on a partial denture are metal or part of the cast framework, but some dental laboratories are using strong plastics for clasps as well. A unilateral partial is a removable prosthesis that replaces missing teeth on one side of the mouth. A bar and clasp or clasps are made to extend to the opposite side of the oral cavity for stability of the partial. A bilateral partial is a removable prosthesis that replaces missing teeth on both sides of the mouth. A bar and/or clasps are set on the remaining teeth to add stability to the appliance. Advantages of partial dentures are teeth can be replaced in areas where bridges are not feasible. Partial dentures can replace chewing ability in areas of tooth loss, but often to a lesser efficiency than natural teeth. Disadvantages are that partial dentures are a removable prosthesis, and a patient may dislike removing them for daily cleaning. Partial dentures may become loose over time, and can cause sore areas on tissue from rubbing. Substantial weight gain or loss will affect the fit of the prosthesis. For patients will poor oral hygiene habits, the clasps surrounding teeth can trap food debris and areas can decay. Unilateral partials are not very stable and may affect eating and speaking for some patients. Clasps can break or bend, and the acrylic can break if dropped. Provisional Appliance Provisional appliances are provisional partial dentures, commonly known, as a flipper that is 12

13 used to replace a missing tooth or teeth during the healing phase of treatment. When multiple teeth are removed, bone and gingival areas need additional time to heal. A flipper can supply the patient with esthetics, help with tooth function in those areas, and keep the remaining teeth in position until they are ready for more permanent cast prosthesis. Complete Dentures A complete denture, also known as a full denture, can be made from acrylic but can include metal for reinforcement in the palatal area. A complete denture replaces all of the missing teeth in an arch. Patients can function with one or both arches replaced by complete dentures. Advantages are that complete dentures replace all of the missing teeth and structures when needed. Dentures can help patients chew more easily, although chewing efficiency is only 20% of the natural dentition. One disadvantage is that the lower dentures are sometimes difficult to keep in place, and can wear away the lower ridge of bone over time, causing more difficulties with chewing and denture stability. Also, patients may have difficulty chewing some foods, as well as speaking clearly and will need to learn to adapt. Dentures can cause sore areas and can make it painful for patients to eat and talk. It is important that dentures be removed daily for a period of time to allow tissue to rest. The appliance must be carefully cleaned, as dropping it can cause it to break. Immediate Dentures It is common practice to remove some of the posterior teeth prior to taking an impression for an immediate denture. This allows the tissue to heal without forcing the patient to go totally edentulous until the appliance is fabricated. These dentures are made from acrylic but can include metal for reinforcement in the palatal area. Immediate dentures are promptly inserted in the patient s mouth after the extraction of any remaining teeth. A soft tissue conditioner is placed inside the portion of the appliance that rests on the tissue. It acts as a cushion and aids in healing. Advantages are that a patient can have a denture placed immediately after extractions, allowing the denture to assist in keeping food and other debris out of the surgical areas and guiding the tissue to heal in the shape of the denture during healing. Disadvantages: the denture can become loose or ill fitting after bone and tissue heal from the extraction areas. The need for frequent return visits to the dental office for replacement of the tissue liners can be a constraint on the patient s time. Insurance coverage sometimes dictates when a patient can have an immediate denture relined. Most often it is six months. A patient may have more sore spots as the extraction sites are healing and the underlying bone is changing. A patient may need multiple visits to relieve those areas. An immediate denture usually needs to be remade after a period of time for a more comfortable fit. Again, insurance coverage may dictate the frequency of remakes. Immediate dentures tend to be costlier than regular dentures because of the relining materials and visits. Surgical Procedures There are many types of surgical procedures available in dentistry. Many general practitioners enjoy the challenge of surgical procedures. However, many refer to an oral surgeon for more complicated cases. Some of the more common procedures are listed below: Dental Implants An implant is a metal cylinder acting as a root form that is placed into the bone of the mouth to replace missing teeth. It is made from titanium, and is surgically embedded into the bone and it will actually fuse to the bone through a process called osseointegration. An oral surgeon usually places the implant, and the general dentist will place the final restoration, a crown, bridge or denture. Advantages of implants are that they are beneficial in replacing teeth in areas where teeth on either side of it have no previous restorations, especially anterior teeth where one tooth is missing. They can be successful in adding retention to lower dentures where the mandibular ridge has been worn and the denture has no stability. Disadvantages: cost can be a factor for most patients, as insurance companies most often do not provide coverage. Also, the implant process can vary in time depending on the area, type of implant, the patient s oral hygiene and healing time. Extractions An extraction is a removal of a tooth. Teeth can be removed under local anesthesia, or general 13

14 anesthesia. Rarely does a patient undergo the procedure without some type of anesthesia. Extractions can be classified as simple, complicated, or impacted. A simple extraction typically involves a partially or fully erupted tooth, with little or no difficulty in removing the tooth. Complicated extractions can begin as simple extractions, but can evolve into something more intricate during the procedure. Examples of complication may result from root tips breaking off, a sinus perforation, or excessive bone removal. Impacted extractions involve the uncovering of the unerupted tooth and often involve cutting away some bone and tissue. The patient usually leaves the appointment with sutures, which may or may not need to be removed within a short period of time. As with any type of dental treatment, the extent of discomfort and time required for healing will vary from patient to patient. A common consequence for some mandibular extractions is a dry-socket (loss of a clot). This condition occurs 3-5 days after treatment. This is a painful condition where the patient will need to return to the practice to have the extraction site flushed with a saline solution and packed with a dressing material that encourages new clot formation. Bleaching Procedures Bleaching can be effective for lightening teeth that have become dark or discolored as a result of stains from foods or beverages, oral habits, aging, fluorosis, or tetracycline. Teeth that have undergone endodontic treatment can also become dark, and bleaching can be effective for these nonvital teeth as well. Bleaching is done either in the dental practice or at home, or a combination of the two may be utilized. Before bleaching begins, the current shade of the patient s teeth is recorded, and photographs may be taken. The advantages of bleaching procedures include a whiter and brighter smile, which can boost selfesteem of a patient and can lead to other dental procedures that may make their smiles more esthetic. Disadvantages: Bleaching procedures can cause sensitivity, although it is short term in duration. Results are not guaranteed, and certain food may stain teeth over time; a patient may have to do additional bleaching at home and/or in the dental practice. The patient is instructed to refrain from eating certain foods directly after bleaching to maintain bleaching results for a longer duration. Note: The American Dental Association does not endorse bleaching by an unlicensed dentist. Endodontic Procedures When a tooth presents symptoms that indicate that the nerve inside the tooth is dying, the root canal inside the tooth must be treated with root canal therapy (RCT). These symptoms may include a sensitivity that lingers to cold, hot, or biting pressure. A tooth can also become infected and can have an abscess or fistula on the gingiva below the tooth. It may or may not be evident on a radiographic image; a dentist will perform tests to determine if the tooth is still vital. This is just one of many endodontic treatment procedures performed in dentistry. The advantage to a root canal treatment is that it can provide a patient with pain relief. If a tooth is broken down severely, an RCT can aid in the placement of pins or a post to help strengthen the tooth while it is being rebuilt. RCTs can save teeth that may otherwise be doomed. Disadvantages: RCTs can sometimes increase the risk for fractured teeth because once the nerve is removed; the tooth becomes brittle and more fragile, necessitating the placement of a crown on the tooth. Sometimes a tooth that has had RCT may need to have further treatment done due to infections, fractures, or additional canals not seen on the initial radiographic image. Orthodontic Procedures While many general practitioners refer these cases, several offices may also engage in minor orthodontic therapies. After cases have been presented, the office will schedule several timely appointments to restore a patient to proper occlusion. Treatment plans can include the use of brackets and wires, retainers, and appliances that reshape the oral cavity and realign the dental arches. Proper and timely scheduling is a key factor in orthodontic treatment and a working knowledge of anticipated procedures is critical. Time must be available in the schedule for orthodontic patients who require bracket 14

15 Figure 7. Example of Orthodontic Treatment re-bonding or other minor dilemmas that if not treated in a timely manner, may lengthen the overall treatment schedule. Post-Operative Instructions Upon completion of any dental treatment in the office, time must be reserved to offer postoperative instructions and explanations. These instructions often include information on how to care for the patient or restoration during the next hours and days after treatment. Also included in the instructions should be information about possible duration of anesthesia, eating and rinsing instructions, extended follow-up care, and additional appointments in the future. When the patient is a minor, the instructions should be given to a parent or guardian. Cautions should include watching that the child does not bite lips, cheeks or his/her tongue while the mouth is numb, and also reiterating concerns about brushing, flossing, and the importance of fluoride. Radiography Radiography involves both the administrative and clinical team. Some basic information about radiology is necessary to order supplies, pull radiographic images for insurance processing, or answer a patient s questions. Technique Dental offices currently have a choice in obtaining the radiographic images of their patients. The office can choose to use a film-based technique, or choose to use image receptors or sensors that create a digital image which requires computer processing. As in film-based radiography, digital imaging requires x-ray interaction with a receptor, latent image processer and image viewer. The Figure 8. Types of Film receptors (direct or indirect sensors) used in digital imaging are faster, and more sensitive thus requiring less radiation than film. The energy received by the receptor must be converted to digital data before it becomes usable. Types of Film There are several types of film used in dentistry today. Intraoral films are categorized according to size of the film packet, using numbers 0, 1, 2, 3 and 4. The size of the film packet corresponds to the number (Figure 8). Size 0 film the smallest periapical film, generally used for pediatric dental cases. Size 1 film used for narrow anterior periapical views. Size 2 film adult periapical views and bite wing views. Size 2 film is sometimes called the universal size. This is because it can be used for every film needed in an adult full mouth series, almost any periapical film, and also can be used as an occlusal film in a child patient or in an adult patient with a very small mouth. Size 3 film for extended bite wings views that cover more teeth in one exposure. When a size 3 film is used for bitewing radiographs, only 2 bitewings, one on each side of the patient s mouth are necessary, rather than the 4 bitewings exposed with size 2 film. Occasionally a supplemental size 2 film is necessary to open contacts between molars. Size 4 film used for occlusal views. It is the adult occlusal film. It can be used to evaluate the palate and mandibular symphysis, utilizing either a maxillary or mandibular occlusal technique. Panoramic film an extraoral film used in some practices in place of a complete series (Figure 9). 15

16 existing images may be improved by use of film duplication techniques. While this procedure does not require an appointment, it does require staff time. Should a duplicated image or images be necessary, time must be allowed in the schedule to complete this procedure. Figure 9. Panoramic Film Normally, it is best to attempt to use the largest intraoral film that can fit within the area being examined, in order to obtain a view of the entire anatomical area of interest. Very few patients consider periapical film to be comfortable, however, with an experienced operator the procedure should take relatively little time and placement of the film packet is usually endured during the exposure time needed. Films are placed vertically in the mouth for anterior periapicals and placed horizontally for posterior periapical and bitewing views. Bitewings may be positioned either horizontally or vertically, depending on the patient s level of crestal bone. Types of Receptors Digital receptors come in two basic formats; rigid wired, or wireless, sensors or phosphor plates. Rigid digital receptors are categorized as direct sensors. Photostimulable phosphor plates (PSP), also known as storage phosphor plates (SPP), are another types. PSP are categorized as indirect digital sensors as they require a scanning process to digitize the image. PSP are flexible, wireless receptors similar in size and thickness to film. Phosphor plates are available in the same sizes as intraoral film including 0, 1, 2, 3 and 4. Duplication of Radiographic Images Recently, it has become indispensable to be able to duplicate existing radiographic images for various reasons, such as: to provide verification for dental insurance carriers, for second opinions of dental care, for medical/legal uses, etc. The capability to duplicate an existing image may also prevent the need for a repeat film on a patient, therefore reducing his or her overall exposure to ionizing radiation. At times the quality of Patient Concerns about Radiation Often patients like to know the risks involved with the dose of radiation they are receiving or going to be receiving. Generally, to convey dosages or exposures in numerical terms is insignificant to most patients. An alternative to stating dosages in terms of numbers is a comparative dose that would be received from other events, to which the patient might better relate. If a full mouth radiographic series (FMX) were exposed on an individual, he or she would receive a dose of radiation similar to that received if he or she: Lived at sea level for 65 days characteristic for most of the US Flew 5 hours in an airplane at a 30,000-foot elevation Lived in Denver for 30 days (higher elevation) The dose of radiation received from an FMX is NOT equivalent to a day at the beach in the sun! Ionizing radiation is around us all the time. Everyone in the world receives some amount of ionizing radiation just from living on this planet. Every day we are exposed to radiation from radon in the soil, cosmic rays from outer space, radioactive substances found in building materials, and from radioactive substances found within our own bodies. A key for patient compliance is to relate the importance of prescribed dental radiographic images. Their benefits far outweigh the negative effects when used properly for diagnostic and preventative purposes. Infection Control The administrative team in the dental practice may have very little to do with reprocessing of dental instruments. Infrequently, an assistant who is cross-trained may be called upon to help out with the processing of instruments. Frequently, however, patients will ask questions of both the clinical and administrative team about 16

17 the process of cleaning the instrument for the next patient. This section briefly covers the basics of infection control in dentistry. Personal health and safety is crucial in every dental practice. The well being of healthcare providers, administrators, patients and society is very important, especially when these areas are in constant change with new products, technology and processes. With all of these new and improved options, dentistry is bombarded on a regular basis by governmental agencies and professional associations who regularly release new rules, regulations and recommendations to make the practice of dentistry safer to all parties involved. Dental practices are required to comply with certain requirements, but the methods involved often seem complex, time consuming and relatively expensive. However, there really is no alternative to an effective workplace health and safety program. Each dental practice must make the commitment to establish and maintain a safe work and treatment environment for the dental team and their patients alike. Prevention of Cross-contamination Protocols to comply with infection control procedures do affect the daily schedule. The clinical areas of the dental practice have specific protocols for setting up and tearing down treatment rooms. In healthcare, there is no room for shortcuts. Many offices use barriers to assist in the prevention of cross-contamination. The degree to which an office uses barriers can also vary greatly. Some practices will cover everything in sight, while others will barrier the items used in the immediate area of treatment that is difficult to disinfect. Another means of preventing crosscontamination is the use of disposable items. Cleaning Before anything can be disinfected or sterilized it must be cleaned. There are two basic methods of mechanical cleaning used in dentistry today. The first method is by ultrasonic cleaner, which consists of a chamber that instruments are placed into. A solution of water and detergent clean instruments as the unit creates sonic waves that produce cavitations, the mechanical means of cleaning instruments. Instruments are usually in this cleaner for approximately 10 minutes. The second mechanical cleaning method is the use of instrument washers, which clean more efficiently and effectively than hand scrubbing. Customarily used in central sterilization services of hospitals and dental schools, these devices are relatively new to the dental industry. Hand cleaning is not recommended; if hand cleaning must be used, the operator should use a long handled brush. The instrument should be placed under water and scrubbed away from the operator. After such cleaning procedures are completed, additional time is added for sterilization and instrument cool down. Procedures must be timed so that proper protocols are continually followed and that enough instruments and set ups are available for every procedure scheduled each day. Disinfection For years, dental offices have relied on chemical germicides to decontaminate surfaces and equipment in the treatment areas that are not removable for sterilization. Disinfection differs from sterilization in its lack of spore killing activity. Disinfectants are not capable of achieving sterilization, and heat sterilization is always the preferable method for sterilization of instruments used in the patient s mouth, or those contaminated with body fluids. The protocol in the treatment areas involve a spraywipe-spray technique that takes time to complete between each patient. The operatory must remain untouched for approximately 10 minutes before the room can be set up again for the next treatment. Sterilization Sterilization removes all pathogens and is the process used to make certain that instruments and devices that come into contact with the patient s oral tissues are free from contamination from a previous contact. General Patient Management Dentistry is both a health care system and a business. In order to have a successful and thriving dental practice, the dental team must understand the patients they serve. Patient Types Each dental staff member should have an understanding of the basic drives involved in motivating their patients. Unless the entire dental 17

18 needs on a specified income. The dental team must make an effort to determine the patient s needs, realize the patient s potential conflict, and consider presenting an alternative treatment plan so the patient has some treatment and/or financial options. Figure 10. Maslow s Hierarchy of Needs team can understand these drives, they will become discouraged after numerous attempts fail to motivate their patients to value top-notch dentistry. Patient Needs The well-known works of the humanistic psychologist, Abraham H. Maslow, can be applied to the dental patient. Maslow s Hierarchy of Needs (Figure 10) explains how an individual s needs motivate behavior. Maslow identified five basic levels of needs ranging from basic biological needs to complex social/ psychological drives with the most fulfilling of needs at the top. Individuals may move back and forth from one level of need to another depending on the circumstances at any given time. The ability to gain consent for treatment and make appointments accordingly directly affect the daily schedule. To relate Maslow s hierarchy to dentistry, the dental team must get to know their patients. Before the dental team can motivate a patient to accept a certain type of dental treatment, it must be understood where the patient is on the hierarchy of needs. Setting up financial arrangements for a dental patient often exposes a conflict of needs. The patient must make certain that basic needs of food, housing, and clothing are met, and yet there may be a desire to meet social needs by improving appearance with some form of dental treatment. A conflict arises in the decision making process when the patient is confronted with the dilemma of how to satisfy all of these Special Needs Accommodations may be necessary in order to treat patients with special needs. At times, the caregiver may need to be in the treatment area while treatment is ongoing, to help assist the patient down the hall, or assist the hearing or visually impaired patient with communication. Special adjustments may be needed in the scheduling of certain patients, providing for extra time or specific times during the day. Accommodations to the treatment schedule may include options of anesthesia. While some patients require no, little, or standard amounts and types of anesthesia, others patients may request more profound methods. Some patients, including those with extreme anxiety or small children, may be prescribed a sedative medication. Conscious sedation methods can be introduced to patients in the form of oral medication, inhalation ( laughing gas ), or with proper training, the dentist can use intravenous or intramuscular methods. If a patient requests or requires these methods, the schedule should reflect extra time to accommodate the procedure. Medical Emergencies Medical emergencies do happen in the dental office. It is essential that the entire dental team, clinical and administrative, be prepared to handle any emergency should one occur. There are several factors that may increase the incidence of a medical emergency occurring in a dental practice. They include: A pregnant patient An increase in the use of prescription drugs An increase in the use of nonprescription drugs and herbal supplements that may interact with certain dental procedures or medications used A higher incidence in recreational drug use An increase in outpatient care allowing many patients to be treated in the dental office who would not otherwise normally be seen for care Increased stress on medically compromised patients when longer dental appointments are scheduled 18

19 And a substantial increase in the number of patients over the age of 65 years seeking continuing dental care If a medical emergency occurs within a practice, it generally occurs during and after the delivery of local anesthesia. Stressful procedures that cause anxiety to the patient, even before the appointment, include the extraction of teeth and endodontic therapy. A patient s anxiety level may be very high during these procedures; pain control may be difficult, resulting in a greater risk for a medical crisis. If the patient has been in the supine position for an extended period of time, he/she may become light headed while scheduling the next appointment. The entire dental team must always be prepared for any predicament, large or small, particularly at these times. Immediate response is required of all personnel during an emergency, and preparation allows for an appropriate response. It is usually the dental practice administrator s responsibility to post and update emergency telephone numbers. A listing of important numbers is normally posted near every phone in the practice area with specific numbers such as 911 being programmed on speed dial. Common Medical Emergencies in the Dental Practice The following section pertains to the most common medical emergencies seen in dentistry today. Treatment considerations for both treatment areas and administrative areas are given as the administrative staff may be called upon to assist in treatment areas. It is important to know the patients, and check their health history when scheduling appointments. Being prepared for possible emergencies and scheduling the treatments accordingly will negate possible emergencies and scheduling delays. Syncope (Fainting) Syncope is the loss of consciousness caused by decreased blood flow to the brain. It is the most common medical emergency in the dental office. There are many reasons why a patient may faint in the dental office. Psychological factors include, but are not limited to: stress, anxiety, trepidation, and pain, while physical factors include exhaustion, hunger, and remaining in one position for a long period of time. For most patients, there are warning signs that one is ready to faint. Table 1 compares the signs and symptoms of pre-syncope with those of syncope. To treat syncope: Stop dental treatment and remove any objects from patient s mouth. Place patient in a supine position with the feet slightly elevated; if pregnant, place patient on her side and loosen any tight clothing around the neck. Establish/maintain open airway, administer oxygen and monitor vital signs. Use ammonia capsule under the nose. Once consciousness is regained, keep patient calm and comfortable and do not move until fully recovered with vital signs at baseline readings; record all information in patient s record. Syncope frequently occurs in the reception area of dental practices. Similar treatment measures would be taken in the reception area once another team member notified the doctor of the occurrence. Hyperventilation Hyperventilation is an increase in the rate or depth of breathing resulting in a decrease in carbon dioxide levels in the blood. This condition is most commonly caused by anxiety and often occurs prior to syncope. To stop hyperventilation: Stop dental treatment, remove any objects from the patient s mouth and place patient in an upright position; loosen tight clothing around the neck. Calm the patient, and explain what is happening; have the patient take deep, slow breaths. Never administer oxygen to a patient who is hyperventilating. Record all information in patient s record. Hyperventilation frequently occurs in the reception area of dental practices while the patient is waiting to be called back for dental treatment. Similar treatment measures would be taken in the reception area once another team member notified the doctor of the occurrence. 19

20 Table 1. Comparison of the Signs and Symptoms of Pre-syncope with Syncope Table 2. Signs and Symptoms of Hyperventilation Pregnancy Several common things that take place during pregnancy can pose difficulty for a female dental patient. Through 40 weeks of a full-term pregnancy, her body adapts to the baby and works harder. Vital signs may show variations from her previous office visits. An elevation in blood pressure is common but must be monitored. Other cardiovascular issues may arise: anemia, edema of the ankles, and shortness of breath are common but usually don t need any special alterations of dental treatment. As a baby grows, it pushes its mother s stomach and diaphragm upward and her intestines decrease in motility. She may have an increased gag reflex that could cause problems for any procedure. Some women may have problems with gastroesophageal reflux and constipation. Morning sickness is common and may cause permanent damage to the tooth enamel. The patient should rinse her mouth with water after vomiting rather than causing further damage with toothbrush abrasion. Throughout pregnancy, hormones fluctuate. The development of pregnancy gingivitis and gingival granulomas is believed to be caused by these changes in hormones. Pregnancy may lead to development or worsening of several oral problems such as erosion, and tooth mobility. Asthma Attack An asthma attack is a respiratory disorder in which the airways in the lungs become narrow, causing difficulty in breathing. There are many causes that can trigger an attack: exposure to allergens such as dust, pollen, animals, and certain foods; an upper respiratory or bronchial infection and anxiety or emotional upset. To treat an asthma attack: Stop dental treatment and remove all objects from patient s mouth. 20