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A request from a colleague to observe my practice for procedures and protocol, administration, maintenance and management is what has initiated this series.

The complex world of dentistry today, whether private, corporate or institutional, poses a challenge to the budding dentist as well as to the seasoned one. The climate has changed and so has the way we need to practice our profession.

Famdent is undoubtedly the most widely read and appreciated dental journal that reaches out across the country to educate and bring together dentists in the pursuit of one simple goal – a better quality of service to patients and better opportunity for dentists via education and sharing of information.

It is through these pages I want to reach out to the profession with snippets of information of value to you. I have, in my decades of practice, found some solutions to the great many questions out there. Some, I have learned the hard way, others the patients themselves have shown me. This page will be a random mix of this evolved experience which I hope will make for some interesting reading.

There are several aspects that we deal with every day. The set-up, the reception, the assisting staff, the team and the equipment. Add to that our speaking skills, our clinical skills, lab support, hygiene standards and maintenance. And to top it all the overwhelming presence of the Internet ruling our lives.

Where do we begin? At the dental chair, of course! Chairs are getting more and more expensive with technological advances and are inevitably costlier. Therefore, you will see chairs ranging from a lakh of rupees to twenty lakhs!

Where do we draw the line? Is it only a matter of budget?

What do we really want from a chair?

I am sure you will agree that ‘trouble-free’ will be the first word and ‘convenience’ the second. Most chairs today fall broadly into hydraulic or electrical types. While both work well, the hydraulic one may develop oil leaks and sometimes have a jerking movement as it goes into a selected position especially when descending. Many chairs boast of multiple chair positions. Ironically, we use just a few of them. We just end up paying for what we never use. It is like the fancy car with automatic everything. Do we need it?

Here is a list of what works practically in my clinic:

• A chair that is not bulky and cumbersome and rust proof
• The spittoon should be ceramic and the spittoon cover over the drain hole for which a spare is readily available
• The seat should not be moulded. If it is so, it will be impossible to re-upholster after some years. We change the chair upholstery every 3 years.
• A reservoir bottle for letting in controlled clean water into the unit, connected to an external compressor to provide high vacuum. Air Venturi systems are not powerful enough and are useful at best for a saliva ejector.
• The nurse’s side should have the high vacuum, the saliva ejector, the 3- way syringe and the light cure unit.
• The operators side should have the 3- way syringe as well.
• The ultrasonic scaler, two hi-torque hand-pieces and an air motor fixed with the contra-angle and straight hand-pieces is ideal.
• The faucet for rinsing should be easily accessible and managed by the patient and the nurse. Control from the operator’s side is not necessary.
• A shadow-less lamp is required that throws sufficient light and is easy to clean. Some newer LED lights cast a blue glow that is most disturbing.
• The foot control should be able to perform chair movements both from the console and the foot control. A push type of control is easier than a step on and press type.
• Operators stool and assistant stool is necessary to facilitate 4 handed dentistry.

Most chairs today are ergonomically designed with an adjustable head rest but none of them are comfortable and give very poor neck support. The patient ends up extending his neck which can be very tiring. I have solved the problem by making a small bolster that is tied around the headrest. A car seat neck pillow also serves very well. Try it…you should see the grateful relieved look on your patients face when you provide this support.

Once a patient sits on the chair it doesn’t matter what model it is. It matters to us, the dentist and the assistant. Choose wisely, not too cheap, not too expensive. Focus on sturdy, functional and efficient after sales service. We protect our chairs with a stitched piece of plastic at the foot end of the chair so that a patient can keep his footwear on and still not damage the chair. The headrest is covered with a shower cap to avoid oil and dye stains. Children are treated on a disposable chair cover that covers the chair entirely.

A maintenance regime includes wipe down of the chair, spittoon and tubing cleaning after every patient and at the end of the day.

A dental chair is a big investment. Let us choose wisely, maintain it well, and it will last for decades.

Now you see it, now you don’t. And it does not come from your favorite perfume. That fine mist that surrounds all of us as we work, day after day in our practices. Aerosols.

These are a suspension of fine solid particles or liquid droplets in air or another gas. They may be natural such as fog or mist or anthropogenic which are particulate air pollutants.

In dentistry, aerosols are everywhere. They are produced from handpieces, three-way syringes and other high-speed instruments. An aerosol cloud of particulate matter and fluid is often clearly visible during dental procedures such as scaling, tooth preparation and polishing. It is important to realize that these aerosols are contaminated with bacteria and blood from the treatment site. These represent a potential source for disease transmission.

The smaller particles of an aerosol have the potential to penetrate and lodge in the lungs and are thought to carry the greatest potential for transmitting infections. Splatter is defined as particles larger than 50microns in diameter. These are airborne only briefly until they contact a surface or fall to the ground. It is the particles less than 50 microns that can stay airborne and enter respiratory passages. Saliva is contaminated with bacteria and viruses. Our focus on aerosols have been sharpened due to the pandemic.

During a procedure, we are covered by aerosol mist on the face, hands and clothes most of the time as well as on two thirds of the mask we wear.

We need to use effective respiratory protection to help combat against infectious diseases such as Influenza, Measles, Corona Virus and its variants to name a few.

The CDC guidelines of May 2021 that states that fully vaccinated people no longer need to wear a mask does not apply to our line of work in health care.

One virus is apparently receding while the Omicron is gaining ground as it is very infectious. All mutant forms are potentially capable of disrupting normal life in so many ways. It is necessary not to let our guard down. The same infection control methods need to be adhered to as well as ventilation in operatories, limiting and spacing patients and placement.

Masks continue to be our best defense. They are measured based on their performance matrix such as

1. Particle Filter Efficiency
2. Bacterial Filter Efficiency
3. Fluid Resistance
4. Breathability -The measure of the mask’s resistance to airflow.
5. Inflammability.

For dentists, Fluid Resistance is of the most importance.

The mask types that we are familiar with are as follows:

1. Face Mask: Used by the general public not meant for medical purposes.
2. Procedure Masks: These have loops instead of ties and are used in many practices.
3. Surgical Masks: These are loose-fitting masks that cover the nose and mouth to provide a physical barrier to particulate materials and fluids. They have ties to enable a tighter closer fit and are worn over surgical hair coverings. They are considered medical devices with a filtration rate of around 80%. They are designed to protect only in one direction that is, from inside out. These do not ensure a good hermetic seal and allow particles to enter around the edges.
4. Respirators: Also called FFRs (Face Filtering Respirators) are classified according to their filtering facepiece (FFP). These could be FFP1, FFP2, and FFP3 with a particle filtration capacity of .3 microns of 80%, 95%, and 99% respectively.

Respiratory masks provide protection in two directions. They can filter both incoming and outgoing air and are resistant to liquid spray or blood splatter. These masks allow adjustments to provide a hermetic seal on contact with the skin.

In conclusion we need to use medical grade N95 respirators without valves.

The use of N95 or FFP2 respirators is part of PPE for dental use during patient care. For a longer useful life for Respirators an outer surgical mask is added. Masks were there and in use by dentists long before the pandemic. They will continue to be there long after.

They are a way of life, a protection, and a true friend of the dentist indeed!

Administering local anaesthesia to a patient is a science and an art. The “science” lies in understanding the different types of anaesthetics available, their composition, their action, and their application.

The “art” is to choose wisely and master the one procedure that precedes clinical dentistry which could make or break your practice.

How do patients judge the skills of their dentist? What gives them confidence?

Their experience, how they feel and most often from the way they get an injection.

Equally, studies have shown that when a painful response to an injection is elicited, the dentist undergoes a great deal of stress. We have seen some of us break into a sweat!

What we need to know:

• Current products
• The physiology of pain
• Patient’s fears
• Proper selection and proven technique
• 80% of patients have a dread of the needle.

It is advisable to avoid making them wait for a long time before the procedure as this will only increase their anxiety. Prior to starting, a review of history and current medication could prove useful. It is necessary to use a topical anaesthetic before injection. These are available in gel, liquid, ointment or pressurized forms. The most common ones are those containing benzocaine or lidocaine.
Gels are used for effective pain relief and to alleviate pain at the point of injection of the local anaesthetic.

To apply the topical:

Retract the tissue, identify the area and wipe dry with gauze to remove saliva. Carry the gel on a cotton bud and rub for 30- 60 seconds. Inject local anaesthetic within 2 minutes, all the time keeping the tissue away from the site and then wash off the gel.

The needle should ideally be a triple bevel design for minimal tear to the tissue. The scalpel bevel is also a good choice.

Injecting Information:

1. Inject in a straight line
2. Do not bend the needle as there is a risk of breakage.
3. Smaller gauges break easily. 25-27 gauge needles are ideal for infiltrations or nerve blocks.
4. Do not bury the needle to the hub.
5. Inject slowly, with good control. The rapid injection causes ballooning and stretching of the tissue, causing pain.
6. Pay attention to the direction of the needle. For example, an infiltration for the upper anterior teeth could end up with a swollen lip or a numb nose. A misdirected mandibular block can also benumb the ear lobes.

During the procedure use ‘The Gate Control’ theory to distract the patient.

The Gate Control theory asserts that a non- painful input (pressure/vibration) closes the nerve gates to a painful input (needle prick) which prevents the pain sensation from travelling to the central nervous system.

Tapping the shoulder or stretching the cheek or jiggling lip tissue are methods commonly used.

For palatal injections, topical anaesthesia does not work so well due to thick, immovable tissue. Always infiltrate on the buccal side first and then move to the palatal. A sliver of ice can be applied to briefly numb the area, or the back end of a mouth mirror could be used to compress the mucosa and the needle inserted alongside the instrument slowly.

When dealing with an infected site:

1. Ideally, wait for the active infection and accompanying swelling and pain to subside with covering antibiotics and then perform the procedure.
2. Try infiltrating directly into the periodontal ligament, intraosseously and around the crest surrounding a periodontally compromised mobile tooth needing extraction.
3. Select a more protein-bound anaesthetic with a less acidic pKa value (this value indicates the strength of the acid). Articaine, with a pKa value of 7.8 can work effectively.
4. The STA Wand or any computerised local anaesthesia injection system is worth considering, as it provides visual and audio feedback. It can effectively anaesthetise a section or a single tooth with minimal discomfort using an intraligamentary technique.