Life-Threatening Emergencies In The Dental Office

Dr. Rich Herman, Chair, ADA Culture of Safety in Dentistry Workgroup | ddsrph@aol.com

A safe dental office will have in place a plan of action for when a life-threatening emergency occurs. An emergency, whether medical or dental, can present at any time; successfully handling it requires a plan of action that the entire staff understands and has practiced. After all, it may be the dentist having the emergency! Emergency policies must be developed specific to the size and type of dental practice. What is appropriate for a small general practice is entirely different than that of a large clinic, which is yet again different from what would be expected in an oral surgery practice. Regardless of the type of practice, the goal of an emergency plan is to manage the patient until help arrives. This comes down to maintaining an oxygen supply to heart and brain (thus managing the airway), breathing and circulation. The small or solo practice may have a simple policy of two basic steps: 1. Calling 911 2. Instituting Basic Life Support (BLS) procedures to support oxygenation culminating in the use of an automated external defibrillator (AED). In this situation, the entire staff must have current CPR training, which now includes the use of an AED. There should be a staff member (and backup) designated to call 911 stat. An oral surgeon’s office or a practice that utilizes sedation or general anesthesia should have access to more resuscitation equipment and be able to provide more advanced care. In both settings, only repeated practice can result in calm, clear communication and effective addressing of the emergency. The takeaway: Have a basic plan and practice that plan!

ABOUT THE AUTHOR: Dr. Casamassimo is an ADA member, a member of the ADA’s Establishing a Culture of Safety in Dentistry Workgroup, a general dentist (DDS) and former chair of the ADA’s Council on Advocacy for Access and Prevention

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BOTULINUM TOXIN: WHY AND HOW TO INTEGRATE IT INTO YOUR PRACTICE

By: Tracy S. Blessing, DMD

Dentistry isn’t changing. It has changed. Forty years ago, amalgam fillings were the norm and patients weren’t concerned with achieving white teeth via bleaching. Twenty years later, composite bonding and teeth whitening options became “on trend” and now they are the new standard. Even just ten years ago, porcelain-fused-to-metal was still the predominant crown material of choice. In recent years, incredible advances in the digital and dental material worlds have shifted doctor and patient demands to all-ceramic options—another new standard. Dentistry is constantly evolving to address both cosmetic and functional issues. These advancements expand our scope of practice, in turn improving the quality of care we’re able to offer and improving our patients’ quality of life. Botulinum toxin was originally developed in the 1970s to treat strabismus (crossed eyes) but has subsequently been used to address a growing number of different functional and aesthetic problems. It is quickly becoming a part of the modern dental practice due to its tremendous ability to help patients cosmetically and functionally. What has been a new trend will soon become a standard as patients increasingly turn to their dental providers for these treatments. My journey with facial injectables (botulinum toxin and dermal fillers) began ten years ago when I decided to expand my scope of practice outside of the mouth and learn about these treatment modalities. I refreshed my knowledge of facial anatomy, studied appropriate literature, and finally shadowed expert injectors. Soon afterwards, I introduced facial injectables into our dental practice. Aesthetically, I utilize botulinum toxin in both the upper and lower face to rebalance specific muscles in order to reduce skin wrinkles or to subtly improve the positioning of the overlying soft tissue. Goals of upper face treatment include reducing crow’s feet around the eyes, vertical frown lines between the eyebrows, horizontal “worry” lines on the forehead, and lifting or sometimes “arching” the eyebrows. In the lower face, carefully placed Botulinum toxin can make dramatic changes to the frame of a patient’s smile. Injection in specific lower lip muscles can reverse downturned oral commissures and reduce the appearance of a resting frown. Additionally, the dynamic nature of the orbicularis oris muscle inevitably leaves its mark in the overlying skin in the form of stubborn vertical lip lines or perioral rhytids (wrinkles). Using small, targeted injections of botulinum toxin can calm the hyperdynamic muscle resulting in a smoother, softer, and more youthful lip and smile. Finally, the appearance of a “gummy smile” can be minimized or eliminated using targeted treatment with botulinum toxin to the lip elevators. Functionally, botulinum toxin adds tremendous value to our practice in helping patients suffering from TMD with a muscular component. While botulinum toxin is no substitute for a well-adjusted occlusal guard, many patients are noncompliant or simply unable to break the “clench” habit even with this therapy. Botulinum toxin injected into the masseter and/or temporalis muscles reduces these muscles’ strength and size, appropriately weakening their bite force and reducing clenching and grinding. Patients report less tension in their jaw, fewer headaches and a noticeably slimmer appearance in the contour of their face.

Facial injectables now account for roughly 60% of my practice and is one of those procedures that I enjoy seeing on my schedule. Over time, I have progressed to addressing patients’ total facial aesthetic and functional issues using a combination of botulinum toxin and dermal fillers. Each patient’s case is unique and requires careful thought, planning and creativity with a delicate touch, which challenges and stimulates me while also fulfilling my artistic inclinations. I have found that these patients want to be in my chair and want the treatments; a nice feeling that is not always

Botulinum toxin gummy smile - before and after

common in everyday dentistry. Treatments take anywhere from 10 to 30 minutes and produce quick results (1-4 days with botulinum toxin and almost immediately with dermal fillers). That same “wow” effect you get when your patient sees their new smile for the first time is the same “wow” effect you get each time you hand a patient the mirror after an injectables session — a wonderfully rewarding experience. The patients receive near instant gratification and they appreciate being able to “pop in” for a treatment that offers such great and fast results, which also helps fill holes in our schedule.

In our practice, staff esprit de corps is boosted because of facial injectables; they often want these procedures done on them and are eager to share their enthusiasm and results with patients. Throughout the year, our staff helps set up and run injectable parties and promotional events, which generates a buzz in the practice and helps to recruit more patients. Our practice growth has directly benefitted from adding injectable procedures — patients that come in initially for facial aesthetic treatments often end up becoming our dental patients and vice versa. This synergy of dental and facial cosmetic procedures allows us to be more comprehensive in our treatment planning and enables us to offer “Total Facial Aesthetics” to our patients. As our patients become increasingly aware of the aesthetic value of dentistry, we dentists have the opportunity to branch out beyond just the teeth. If you are looking for a new dynamic that will challenge you and allow you to offer more to your patients, then facial injectables might be right for your practice. Approached conservatively, these treatments are safe, minimally invasive, and most of all, fun for you and the patients. Aside from your investment in proper training, there are no big ticket items you need to purchase to get started — just a few basic supplies including insulin needles, alcohol swabs, and marking pencils.

ABOUT THE AUTHOR: Tracy S. Blessing, DMD graduated from Tufts University School of Dental Medicine in 2010 and completed a residency program in New York City the following year. She is currently Associate Director of the University of Oklahoma College of Dentistry’s Advanced Education in General Dentistry (AEGD) program. She maintains private practices in Oklahoma City and Miami Beach, FL. She is also the founder of Aesthetic Interface, a training and consulting company dedicated to facial injectables in dentistry. Through her company, Blessing provides seminars, certification courses, original marketing and consulting services in the use of botulinum toxin and dermal filler to offer patients a new concept of "Total Facial Aesthetics."

If you have a case your study club would like to submit for publication please contact Dr. Mary Hamburg, ODA Journal Editor, at editor@okda.org.