Dental Phobia – Dental Fear lecture part 1 of 2

Hi everybody. My name is Dr. Jeffrey Dorfman. We are in The Center for Special Dentistry in New York City. We are discussing dental phobia – dental fear or dental anxiety. There are a whole host of names to describe people who really don’t like to go to the dentist. There are several objectives. We are going to talk about what is dental phobia and understand dental phobic patients. We are going to talk about how to reach those kinds of people, and how to actually get a dental phobic patient into a dental chair and to commit to treatment. Dental Phobia is described as an intense or unreasonable fear of Dentistry. People can fear a specific part of dentistry. For example, they can be afraid of the injections. Some people can be afraid of the noise. Some people can be afraid of the pain. Some people can be afraid of all of the above, whereas in contrast, someone who has dental anxiety is just nervous about Dentistry. Now, what I can say is dental anxiety and dental phobia is on various degrees of a spectrum and can sometimes appear as similar things.

I have treated patients in the past who have had some horrendous problems in the past with dentists. For example, I treated a patient whom World War II, was actually in occupied France and her well-intentioned neighbors whom tried performing dentistry and removing bad teeth with pliers while holding down her arms and legs. That woman had a reason to fear dentistry.

I’ve taken care of other people with extraordinary circumstances. One was a female teenage who was in a different country and raped in a dental chair by a dentist. We do treat people who have had that kind of an extraordinary experience in dentistry. But generally, dental phobia, dental fear and dental anxiety is describing a continuum of people who just really don’t like dentistry. I can tell you, I for one, don’t like having dentistry performed on myself either. So, it’s a question of coming into terms with that and recognizing that, and how to make someone dislike it less so that they can get the treatment that they need.

Here, this slide is talking about how common it is. It is talking about how there could be nine to fifteen percent of people in the American population who suffer from dental anxiety or dental fear. This different British study from the British Dental Health Foundation said 36 percent of people didn’t see a dentist because of fear. I actually could suggest that perhaps in addition to dental anxiety or dental fear, I talked to a lot of my patients that it’s not unusual for people to have what they would consider dental anxiety, dental phobia, dental fear. I’ll use those terms interchangeably but it’s not uncommon for people to have that feeling and sometimes they may just be the victim of sequential bad dentistry by one or more dentists. We’re going to get back to that and I could say that if someone has gone to one or more dentists and have had a series of dental procedures ultimately fail and become painful, then one could actually say that their dental anxiety is quite rational. And then, the treatment that’s most important is actually providing them with good dentistry.

The ADA, American Dental Association, does actually have guidelines on how to treat dental anxiety and part of it is with pain control. They do discuss that there are various physical, chemical and psychological modalities to the prevention of treatment for people who suffer from that. I actually was fortunate to study at the University of Pennsylvania Undergrad. I studied biochemistry and I stayed there for dental school but while I was as an undergraduate, I was fortunate to study with Martin Seligman who is a social psychologist who actually has published extensively on depression and learned helplessness. He associated a lot of people who suffered depression, felt helpless about situations. Brilliant guy, I did research with him way back then and I actually adopted a lot of what he taught me way back then, in dental practice and applied it not to people who were depressed in dentistry, but people who were actually anxious. What he taught me over 35 years ago, is the way you would help someone who was clinically depressed is with baby steps and creating achievable minor goals and keep on increasing those goals. So, along those lines, it is not unusual that the kinds of people that will come into this practice. We may tend to see the more of the extremes for dental phobia and they may be so, to such an extent, that a spouse may actually come in for the first visit without the patient and they may be in fact interviewing me and I may be interviewing them to discuss is it appropriate for them to bring their spouse in here first. It may not be unusual if that person comes in, some people may actually sit in my private office on my couch for one or more visits, before we even bring them into a treatment room. That is not unusual here, and we’ll talk more about that also.

There is a dental, one or more, anxiety scales that you can reap. I believe it is a 20 scale you can answer a five part questionnaire or 20 part questions with five different grades within each question to assess how anxious or afraid someone is in dentistry. I’ve been practicing 32 years and never used the scale though I think it could be very worthwhile for people academically and learning to judge people who suffer from anxiety. I can pass through my waiting room and see a patient out there and from 15-20 feet away, I can think to myself that patient is suffering from either mild, moderate, or severe dental anxiety. I can actually address that very quickly, since I’m on the subject, if I’m walking through the waiting room, and I see a patient like that, one of the first things that I’ll do is actually greet them in a very friendly, calm manner. Sometimes, I can just see them going “ah”. Sometimes, I’ll even joke about it because humor is one method that I use to make people feel comfortable in our practice. In our practice, CSD, we do have a large team of 16 dentists and specialists who offer all kinds of multi-specialty dental care. But regardless, we also have an MD anesthesiologist on staff. For some of the lower level cases of dental anxiety, we’re able to provide patients with laughing gas, which is technically nitrous oxide to make people comfortable. Separate from that, we may give them valium pills that they can take the night before and morning of, to take the edge off. Sometimes that with nitrous oxide is enough to make people comfortable. Sometimes people like having a drink of alcohol and there have been times people might be more comfortable having a drink or two before a dental procedure as opposed to something like taking valium that may be more alien to them or nitrous oxide. The point is, if I follow on Martin Seligman’s teachings, and I do recommend you read some of his work, I like to give people choices and I like to give them control over the environment so that they have less to fear. Getting back to the MD anesthesiologist — by being able to offer them the extremes of dental anesthesia, pain control, nitrous oxide pills, whether it’s an alcoholic drink, or being able to have an IV conscious sedation with an MD anesthesiologist – the fact that we’re able to offer all of those treatment modalities in our office can give people comfort because sometimes just having the choice can make someone feel better, even if they don’t need to escalate. For example, see an MD anesthesiologist and knowing they have that choice and that it’s their decision gives them comfort.

This is a picture of our entry of our waiting room. It’s not the latest and high-tech. It doesn’t look like a rocket- ship with bells and whistles that many young dentists may ascribe to, but the intention of the layout is actually no barriers that we do not have high desks and high counter tops. It’s very comfortable. It’s very common walking into medical and dental practices to see almost walls separating the office from the patient entering, that they are high and they could be rather sterile looking, that could be sliding windows, there can be doors. The intention of the layout is just with antique furniture, low desks, where chairs can be part of the environment in the waiting room. It’s the intention to be inviting, friendly, non-threatening, the non-barriers and that’s from the beginning. Separately from that, staff is friendly, talkative. As some of you may already know in our practice, all the administrative staff, the front desk staff, office manager, as well back office administrative staff, everyone in this practice doing that type of work are pre-dental students who apply and are chosen to actually join our practice typically for one or two years after college and before dental school. So we have a lot of our administrative staff who are very hyper-motivated, friendly, pre-dental students who are just happy to be in the office. There is a very positive energy that people, I think, can feel that very quickly. They can feel it on the phone, they can feel it when they walk in, they can certainly feel it with our specialists, and our other dentists and myself.

And also an important part is I can tell you that, I can recall being at one particular medical office visit a number of years ago and I can remember being in the waiting room and the physician that I was waiting to see, in a small private practice, walked out to the front. And I will never forget that he looked at me to see me in his waiting room and then immediately looked down at the front desk and walked back and never said a word. I’ll never forget what a bad, opening feeling it left me and that’s the kind of thing that I would suggest to all of you young dentists, middle aged dentists, and older dentists and dental students and pre-dental students – it’s all about the relationship. You want to treat your office like your home and if someone’s in your home, you’re going to greet them. As I said earlier, if I see a new patient or any patient in my waiting room, I greet them. I introduce myself if they don’t know me. If they’re an established patient, I’ll give them a handshake or a hug or both, and it’s warm and affectionate. If it’s genuine, people recognize it and it gives them a level of comfort.

All right, so here we’re talking about some of the things we do in our practice, some of the techniques to make people comfortable. One, first and most important actually is pain control with really gentle dental anesthesia and you can actually walk the walk, talk the talk, but if you really haven’t mastered how to provide Novocaine, a shot, the injection gently, then you’re going to have a problem. So we can talk about that, and I may briefly address how I give Novocaine which may be different than a lot of other people, believe it is actually. Firstly, a lot of dentists will use the long needles for mandibular block injections. Sorry for getting too technical. And there are longer needles. Because of that, they are a wider needle and they are more uncomfortable for the initial penetration. I suggest the mandibular block injections, and then even if you ultimately want to end up providing anesthesia with the longer wider gauge needle, you first start with the shorter narrow gauge needle to begin your initial anesthesia application of the Novocaine. The reason is, it is much more comfortable for the patient and then you give them time. After they’ve had time to get numb from that initial injection, then if you need to go to a heavier gauge, you can actually go to it and it should cause little to no pain. Separately, there are other parts of the body where they are much more sensitive than others, in the mouth technically. For injection, one area is the palate. An injection in the palate can be for an oral surgical procedure or root canal or a gum surgery. Those palatal injections are very painful. The way I teach how to perform to provide that injection is actually to anesthetize in the cheek side or a buccal side of a tooth. After that area gets numb, and then I recommend starting the injection from the buccal and penetrating through the papilla while applying more Novocaine, until it gets to the palatal surface. By doing that you can actually provide a vast amount of palatal injections with little or no pain. Similarly, another area that injection is quite painful is under the nose in this area, the upper front teeth. That’s another very painful area. The way I teach to provide that Novocaine, the anesthetic, is to start a little further back where it is less painful and let the anesthesia kick in for a few minutes and gradually move forward with the series of very short injections in those areas so you can get to the front with little or no pain.

I’ll digress for a moment on this. Since I mentioned that I am talking about injections, in some detail right now, time is a slide later on. This is where I talk about how much time we allow for Novocaine to kick in. But, it is my understanding that many offices work on the clock in terms of getting patients into and out of the dental chair. In this practice, we perform very low volume, high-end dentistry. The clock is not ticking to get a patient out of the chair in 14, 30 or whatever amount of time, or however minutes it takes. So, for that reason we have the luxury that if someone needs 10 or 15 minutes to get numb before we begin a procedure, they have all the time they need to get comfortable. Regarding appropriate pain medication after office visits, if there is any procedures that we think that can endure any kind of pain afterwards, whether it’s a particularly deep restoration or a surgical procedure, we always want to make sure that our patients have enough post-op pain medication, typically prescription. If they have an emergency, they have something to get through one or two nights. We do this so they don’t have pain. Certainly with the opioid crisis going on in the United States and around the world, there are changes in the medications that we may prescribe. But it is worthwhile for whenever your patients may have pain, to make sure they have a proper amount of pain medication. Should they need it in the middle of the night when you are not available to take care of them?

Next, we will talk about dental anxiety reduction with behavioral therapy. We tend to fear the unknown, whereas, us, dentists are used to coming into our offices are more familiar with what we do every day. Most patients walking in are not familiar, and so because of that, everything is kind of like kindergarten. It’s look, see and do. So I take a lot of time explaining my diagnosis with patients. I explain the rationale for a diagnosis. I photo-document ad nauseam for what our patients need to see. We use digital cameras – intraoral cameras. I’ve been using them for over 20 years. Everything that we’re going to do, I will photograph. When we’re performing procedures, we will photo document. At the end we will do post-op pictures and when a procedure is completed, we will actually sit back for those patients who are willing to see the pictures. We will go through detail. It can be 4 pictures or it can be 24 pictures. Probably a mean of 8 pictures per tooth of the kind of work we are doing. As people begin to understand, they’re still not going to necessarily love dentistry. I don’t have that high in aspiration. The issue is to get them to the point where they fear it less and are not as anxious so at least they can get the dentistry performed that they need. We talked about nitrous oxide and sedation, so this is actually worthwhile to cover realistic treatment plans, time-action calendars based upon individual patient needs. I tend, like I tend to photo document ad nauseam, to write very detailed treatment plans. I think that if we will be working on one tooth, performing full mouth reconstruction, if it’s on natural teeth, implants, or any combination, people have a right to understand what you intend to do, why you intend to do it, what the benefits are, the recommendations, what your alternatives to your recommendations, how long it will take, what it will cost, what it will look like before, during and after, what it will feel like before, during and after. I tend to go over that stuff in very significant detail and if you have an intention of focusing and helping people who are afraid of dentistry, those things are important to do.

Now it’s also worthwhile to note that in our practice, the Center for Special Dentistry, we also take care of people who are not afraid. We take care of people who are not anxious, who are not scared, and just want to come in for superlative dentistry. We behave the same way with everyone, in terms of giving them all the information they need and making sure everything is detailed. That even comes to front office stuff, so if patients are expecting claims to go out for their reimbursement on time, we have office policy that it is done at the end of each day. We make sure all patient emails and patient phone calls are returned by the end of the same business day. It’s all in attention to detail that people who may or may not be able to evaluate the dentistry, are able to evaluate non-dental clues which will give them an idea of how thorough you may be in performing the dentistry that they hope to obtain with you.

Next, we will discuss emotional support. I’m actually far too emotional for my own good – guilty as charged. I am highly empathic. I tend to be very caring about people to a fault. If I’m out with my wife and daughter, they may tease me frequently that I don’t know necessarily what I did with them yesterday. But on the other hand, they tend to always be surprised how quickly I can meet a complete stranger and how a complete stranger may tell me their entire life story. It’s something that doesn’t normally happen but I think if a potential patient is looking at this, and they’re looking for potential dentists in whatever country or city they’re in, you want to find someone who is naturally warm. You may have people who may be intellectual geniuses. You may have gifted hands skills in dentistry but they may be the kind of people that emotionally are not someone that you would choose to talk to after work, if you were having an emotional problem unrelated to dentistry. So, sometimes that emotional rapport is really important particularly for someone who is having concerns and anxiety with dentistry. I can tell you, at the end of the day, for every patient who has procedures performed. I personally will either email or text every one of our patients to check on their well-being. Every one of them knows that they have my personal email. They have my personal phone and texts, so all of my patients can reach me if they need it. I’ll tell you the interesting thing about it is that nobody abuses it. I can’t tell you how many doctors I have been to over the years. Everyone has their private unlisted number for this, or has the private number for that, and the patients can’t get to them. Well, if a patient has a justifiable concern for dentistry, and if they have pain at night, or something is bothering them, they should be able to reach the doctor that performed the procedure. Here we have that. Emotional support is important in the office and outside of the office also.

Next, we will discuss top medical care. It is not unusual for people who actually have significant dental fear and that neglected their teeth for a long time, to have corresponding issues with their physicians as well. In this practice, as I mentioned, we have 16 specialists and dentists, but we also have another dozen physicians affiliated that we brought into the office building so that we cover a lot of broad swatch of medicine besides just dentistry. Collectively we have 28 dentists and physicians in our affiliated group. That may not be something that a lot of other practices have access to, but if I’m speaking to dentists in dental practices, it is worthwhile to expand your dentistry beyond dentistry and recognize that holistically, you are taking care of a whole patient. There may be some patients that have fear issues that might be of true psychological origin. There might be some patients who may be afraid of dentistry. They may have had addictions to medicines or illicit drugs before that can actually change their pain thresholds and their ability to respond to dental anesthetics and dental pain medications. So, it is not unusual for the kind of patient who wants to avoid dentistry. They very well may need physicians beyond dentistry that can be anywhere from internal medicine to drug and alcohol counselors. We actually have access to that too in our group. You may want to look at expanding your horizons and what other medical services, other dental practices can offer. It’s a big deal.

Here, I’m talking about that professionally and physically powerful people are commonly more afraid of dentistry than the little old lady, who is 5 ft tall and 91 lbs. It is not unusual that if someone is a classic Wall Street, the phrase master of the universe, they’re controlling big companies and they have vast numbers of employees and billions of dollars in their budges or beyond, they’re used to being so in control of the world that they don’t like feeling vulnerable. That’s also true if you get a very big, 6 foot 4, muscular guy who was professional or college athlete. Those types of people are also not used to feeling vulnerable. On the issue of vulnerability, the reason why is such a scary thing particularly for physically and/or professionally powerful people is because the teeth and the genitals are the two most sensitive parts of the human body. It is understandable why these two are such a sensitive part of the body. It is because people will use them to reproduce. In much the same way, if you look at animals, they are not cognitively thinking “oh, she’s good looking or he’s good looking”. There are other things going on in much the same way if you watch an animal eat. I can watch our dog at home eat. Our dog is not looking and saying, “Oh, that’s a cheeseburger, that’s asparagus, and that’s a chicken”. They don’t do that. They’re looking at it to differentiate food from non-food. The way animals do that, don’t have our cognitive processing ability, is by looking at an object, smell it, touch it, and feel it between their teeth. It’s a combination of all those things combined that tells an animal, hopefully they’re right and not wrong or else they may not survive, the differentiation between food and non-food. So, it is important for teeth to be very sensitive. There is an adaptive reason about why teeth are so sensitive and if people are physically and professionally powerful, they should understand that they have less reason to feel silly or stupid or embarrassed. If they recognize teeth are actually very sensitive, sense organs. They need it for their own survival.

Here is a chart provided by Dr. Nitin Rajput and ADA provided the American Dental Association, but I believe it was sourced by my partner and an intern, David Liang. This actually talks about something that I have seen for my 32 years and this also showing that wealthier people tend to actually be more frightened. It’s kind of counterintuitive. Wealthier people who have greater access to dentistry and ideally better dental care tend to be more afraid. Even though they may arguable have access to better dentistry. The reason is because a lot of these people are also more like masses of the universe, more professionally powerful, and they also don’t like feeling that way as well.

Regarding gender and terminology, there is some discussion that women in general may be more afraid than men. I can’t tell you in my practice I can make that differentiation. I can tell you that men and women don’t like dentistry particularly if they’ve had bad experiences. Here, we’re talking about what we do in our practice. We offer extra time to talk with our patients. We also offer a lot of extra time to be comfortable and sometimes people may actually see that they may come into my office and they may not be in the best mood. We may make comments, sit in my office for 5-10 minutes since they may have had a stressful commute, or just need to chillax and do nothing. They may need to sit in their treatment room with a little nitrous oxide after a procedure has been discussed and treatment plans and paperwork is done. They may just want to sit in the treatment room for a little while, with nitrous oxide on laughing gas and music. Their eyes closed and leave them 15 minutes to just do nothing. I describe this to students as if you can imagine that you’ve had a very difficult day at you office and your meeting one of our best friends for happy hour. If you have that first glass of scotch or beer, or wine, and you take the first few sips of it, you don’t feel an immediate sense of relief. It may take a little while perhaps until you’ve had half a glass of wine. Maybe you’ve downed the first glass of wine, until you begin to feel the sensation of “ahh”. Dentistry is no different. So again, what’s really important is the need to have time for patients, not to rush them into procedures, not to rush to get them numb, not to rush to get them started. You want to give them all the time they need so they can feel the entire experience as non-rushed. You’re really taking your time for them.

Another thing that we’re discussing here is what I’ve discussed earlier about discussing benefits and risks, treatment options, treatment time, cost, methods for fear and pain control. We discussed this already, I skipped ahead. I mentioned about photo-documentation. People really like that. They like knowing that they can see what’s been done and how it has benefited them because if they just open their mouths at the beginning of the procedure and close it, and they don’t have the benefit of seeing anything in between, they don’t necessarily feel they’re achieving the full value of what they’re getting. Now I can tell you we do have some patients who are not fans of dentistry, who specifically say they don’t want to see pictures and if we have patients who don’t want to see pictures, I respect that. I’m not forcing pictures on anybody. But of all our patients, the vast majorities want to see the photo-documentation at the end. That includes the patients who are fearful of dentistry.

Now, my face, if you look at my face. How can you be afraid? The point of my pictures on the website is not because I’m arguably the best looking dentist in New York. That’s not the issue. The issue is humor. The old saying is “humor is the best medicine.” I will say that humor is the best dentistry.” A lot of my clinical approach to patient treatment is to make it sillier, fun. Not to the point where I actually diminish the actual profession or my actual work, but I try to make it a fun experience. A lot of my patients feel that way. It’s important. Humor is really important if you have that inclination.

Some of the things we do differently is we have a big team. Having a big team offering multi-specialty cosmetic reconstruction does provide us gravitas. It does make patients feel that there is something more substantial in this practice that they may not obtain elsewhere. So for dentists who have an interest in building at least a part of their practice that can attract people who are fearful of Dentistry, you actually want to build a nucleus of a practice that’s growing, where dentistry and specialists want to aggregate together because there is a level of prestige in the size of the practice, especially when patients know that there may be multidisciplinary, multi-specialty consultations before agreeing on an overall treatment plan. We discussed laughing gas and anesthesiologists. Our anesthesiologist is an MD anesthesiologist. It’s not someone who’s taken a weekend course, or a dentist who takes a weekend course and says “Yes, now I can provide you anesthesia.” We strongly do not recommend that. We strongly recommend that if you’re going to have someone perform intravenous, also known as IV anesthesia, then someone who has minimally 1 or 2 years in additional training and certification in anesthesia. Ideally something we have here is the MD anesthesiologist whose only skill set is only anesthesiologist. That’s important. We talked about presenting detailed information and discussion. We don’t rush. We provide a clear understanding of treatment, time, and fees. We actually also offer patients optional cost savings with our associate dentists. Because we do low volume dentistry, our office is a higher fee office. We tell you that up front to all of our patients that come in. There are patients who say “Jeff, I love you. Are there other options because I need to pay rent” and we do have other options for that as well. We publish and teach a lot of these methods to keep our patients comfortable. Patients do find that comforting as well.

We talked about photo-documentation and here we’re talking about master clinicians, military officers and professors. Each average 30 years of experience. These are our dentists and the senior dentists and specialists. Again, there’s a gravitas. There is an authority of having that in one place; if you have fear or anxiety, it can make people comfortable. We also minimize waiting time. There’s nothing worse than if you’re afraid of something and having to be stuck in a waiting room, waiting for 2 hours. We don’t do that. We actually try to get our patients in within 5 or 10 minutes of an appointment. Sometimes things can happen and we get pushed back, but by large, I would say the vast majority of our patients are seen 5-10 minutes on schedule time. Again, I talked about access to doctors. All of our patients have my phone and can reach me any time.

We do seek, in this practice, difficult and challenging cases. I publish a lot. My winters, six months of the winter, I tend to work 7 days a week and I write. I’ve published thousands of pages online on on the work we provide. I wish many times that I wasn’t a naturally inclined writer because I could have a lot more fun in my winters. However, I am. And again, patients who are not fans of dentistry, when they see how many cases we have performed like them in our practice, they can follow before and after cases. That gives many people immediate sense of relief. I have published and have 20 years professorships between Columbia and NYU dental schools where I would teach in the clinics. I found that I could not teach this kind of dentistry in a dental school setting. So after a number of years, I actually created, in our practice right here, the only private dental practice in New York State where it was legally considered to be an off-site location of both Columbia and NYU dental schools. So I could do a lot of teaching here, and bring students in to watch me perform this kind of Dentistry here. I couldn’t do it in the dental school setting because they didn’t have the waiting room experience that I wanted. I didn’t have the clinical chair time that I wanted. I could only do that here. The program that I had with the two schools ended about 4-5 years ago, so please don’t call me up and say you want to see me within the dental school. I did 20 years so that’s not available now. But, I’ve done a lot of teaching there. There are a lot of young and middle aged dentists that I’ve taught over the years, who’ve learned a lot of that also. Some of them can be seen on our website as well. Some of these dentists are around the country. A lot of my former students are around the world, so if you’re not in NY, I know a fair number of dentists who are really wonderful.

Here, we’re talking about students from around the world and again were talking about higher volume practices may be well intentioned, but a higher volume practice frequently means what the American PPO preferred provider organizations, managed care, insurance dental practices, union dental practices. In different countries they may refer to them differently but if you’re going to a practice that tends to just take your insurance and that’s all you care about, that kind of practice is probably the kind of practice that will more likely exacerbate rather than alleviate your dental anxiety. This is because if you’re going to a dental office that’s higher volume, because it’s taking your insurance as full or most payment, they’re not going to have the time to really give you. At least I can tell you that in the US, I can certainly tell you in NY, a lot of the higher volume dental practices will typically turnover patient visits for procedures frequently in 30 minutes. I can tell you that from me, I’ve been doing this 32 years in private practice; I might take 10-15 minutes just to let my patient get numb with Novocaine. I might let them get relaxed with laughing gas for 5-10 minutes. I might let them get numb for another 5-10 minutes. I can tell you, I can spend 20 minutes of a patient visit, just getting them relaxed and getting them numb. If you’re going to the high volume practices, they can’t do that. Of course then your diagnosis may not really be dental anxiety – your anxiety may not be dental fear – your diagnosis may not be dental phobia. The diagnosis just really may be you’re going to the wrong dentist. You could be going to the wrong dental office. So if you’re hearing the video and you’re saying wow that could be me, then maybe you’re getting the deal you thought you were getting by going to an insurance dentist who takes your insurance. Maybe seek out somebody who can actually give you the time you need and may actually give you better dentistry. You may actually find that what you thought was dental phobia, might just be going to the wrong dentist.

Here, we are talking about giving Novocaine differently. I’m also talking about their different brands of Novocaine. I’m using the term of Novocaine as a generic term. We typically in Dentistry don’t actually refer to Novocaine even though it’s a brand name actually. But there are all different kinds of chemistry. So let’s talk about Novocaine chemistry. There are many different brands. There is Lidocaine 1:100000, Lidocaine 1:50000, Septocaine, Carbocaine. Besides Novocaine, there are all different brands with all different chemistries. It is very important that actually if someone finds that they don’t respond to a specific chemistry brand of Novocaine, it’s important to actually go to dentists that actually have more than just one brand of Novocaine. So that’s a really important point. The rest of this that I am talking about how to give Novocaine under the nose, or palate and using the narrow needle, I covered earlier. I was overly anxious before I got to this slide. I know it’s a great slide. But it’s the idea of different brands of Novocaine is really important. I have found patients who are actually not responsive to some brands on different chemistries of Novocaine, whereas, they will respond to others. That’s a very important consideration for dentists. It’s a very important consideration for people who are not fans of dentistry.
Here, we’re talking again about time. We fully covered this also. I’m talking about that we take our time for our patients to get numb and relaxed. All this does take time and cannot be typically offered in an insurance dental office because insurance offices by design work on higher volume, so be aware of that. You don’t get something for nothing.

I talked about teeth being one of the most sensitive parts of the body. We went through that. It’s also not uncommon for patients who’ve had cancer surgery, open-heart surgery, and really delayed labor in child birth. People who have had some of those horrible medical surgical procedures, it’s not uncommon for them to say that Dentistry, or dental pain, is actually worse than all of that. I said earlier the reason is that the nerve endings in teeth are much different than nerve endings in different parts of your body. You can actually make an incision in your forearm from top to bottom, and that postoperatively could be less painful than drilling a tiniest amount at a tooth. As an example, if you want to have an experiment, you can actually take a tweezer and pluck an eyebrow hair and then take the tweezer and pluck a hair in your nose. Yes it’s disgusting if you have to talk about that, however; if you think about it, you put those two hairs side by side – one plucked eyebrow hair and one plucked nose hair – side by side they look identical in size and configuration. However, if you plucked an eyebrow hair, it’s not going to really hurt at all. If you pluck a nose hair with a tweezer, it’s going to hurt a lot more than an eyebrow hair. Why? And again the reason is because the nasal hairs are protecting something that’s going into your body. It makes sense that it should be more sensitive and your teeth are analogous in that situation.

We talked about professional athletes. It’s important to carefully reduce all possible pain for a patient. It’s important to reduce their pain before they even start a procedure in relaxing them, because sometimes their pain can be emotion. So, valium, nitrous oxide and a drink of alcohol work. I’m not saying to mix alcohol with valium or nitrous oxide. Give them something that they’re comfortable with and control pain before you begin. Make sure to give good Novocaine during. Make sure if a patient has pain during a procedure, you stop. I could also suggest that if my students and young dentists watch me perform, it’s very rare in the middle of a procedure that I ever have to stop and give more Novocaine. So, it’s very important to learn the skill of how to give Novocaine comfortably and also profoundly. Comfortably so the patient doesn’t have pain from the injection, but profoundly so that they are profoundly numb during the procedure. Also, we talked about what type of medical prescription that you may give post-operatively, so if the patient has pain that night or the next few nights, they’re covered. We covered IV sedation, intravenous and IV. The American Academy of Pediatric Dentistry said that anesthesia care provider must have completed a one or two year dental anesthesia residency, or medical anesthesia residency approved by the American Dental Association or the American Medical Association. You don’t want to have IV sedation by some dentist who’s taken a weekend course. There are a lot of weekend courses given on how to provide intravenous sedation. Beware, don’t go near that. Stay away, it’s not safe. Getting to this, people who are scared of dentists can overcome their fear with the right dentists. I’m not saying it’s me, I’m saying there are a lot of other good dentists who might be a better fit for you, wherever you are. If you find that you’re going to someone and you’re finding that a lot of the dentistry that you’re having performed is failing prematurely. It’s also an issue, If you don’t feel the rapport with the dentist and feel you’re being rushed. Find the right dentist. It can make the world of a difference for the rest of your life.

Summary questions. Are we ready? Are dental anxiety scales a reliable evaluation tool? Yes. Are socioeconomic factors associated with dental phobia? Yes. What are the factors that lead to dental anxiety? Physical, chemical, psychological or all of the above? All of the above. My sources will be available online. This is also posted on youtube. But if you want more information, check out the rest of the website,