Guided Implant Placement in the Fearful Patient

Read below to get all the deets on one of our most recent surgical cases including how mild oral sedation can help the fearful patient & how guided surgery is becoming the standard of care—and for good reason.  

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This is the planning (top) and postoperative (bottom) image of a recent case we finished in our office that replaced a single missing tooth with an implant through our guided surgery technique.  That was a lot of information in a single sentence for a non-dentite (dentite is an endearing term for dental nerds), so let me break it down for you.

Let’s start with a little background info on the patient.  She started coming to us a couple years ago.  She was scared to death.  The dental office definitely did not make the top of any of her lists except maybe her $*!+ list (sorry, had to as that’s what flowed from my mind first and I feel like blog posts should have the goal of always keeping it real—besides, I didn’t actually say it—I definitely did think it though as that’s a common list my dad often mentions).  I digress.  She was very anxious about dental treatment of any sort but a surgical procedure is definitely something I could not have spoken to her about at the beginning of our relationship.  At her first appointment we gladly explained that dental anxiety is something we see often and are accustomed to managing.  We assured her she’s definitely not alone and that they make drugs for that—no really, a little RX preopertively combined with some nitrous oxide (“happy gas”) sedation during the actual procedure can do wonders for a patient with dental fear and quite honestly, it saves us from needing a nerve pill too.

Overly anxious patients can definitely throw some bad vibes out there that can get even a seasoned dental team off their game.  Nobody wants that.  Everyone involved should be calm and relaxed.  We deal with nervous patients on the daily.  Nervous patients can be talked through it.  Patients with severe dental anxiety are a different story.  Those patients can be dangerous to themselves and the operator if not managed correctly.  Oftentimes, correctly means a little sedation.

When I say sedation you’re immediately picturing those hilarious YouTube videos of all the teenagers after their wisdom tooth extractions.  We can’t blame you.  We think they’re pretty funny too.  That’s a deeper sedation than what we’re talking about here and quite frankly, about 75% of those are exaggerated—still funny—but definitely exaggerated.   The sedation we’re talking about is some oral sedation sometimes with something as mild as Valium.  This has several benefits: 1. With mild oral sedation, there’s no IV involved. If you’re scared of the dental procedure, chances are an IV might freak you out.  2.  With this type of sedation, you still have control of the situation.  You can speak when spoken to and answer questions and take commands—you’re just super chill!  This is important because for a lot of the anxious patients we deal with, they state that not “having control” during a dental procedure is the root of their fear, so anticipating a deeper sedation where you lose more of that control due to a strong sedative will, like the IV for some, cause more anxiety.  3.  It’s quickly reversible.  4.  You won’t say anything so stupid as to land yourself on a hilarious YouTube video.

Back to the case; we started with smaller procedures like cleanings and fillings to build up her confidence and comfort level in herself and us.  Soon, she was doing great.  That doesn’t mean we took away the Valium and nitrous, that just means we learned what works for her and stick to it.  Dental appointments became more regular for her as she no longer dreaded them (or at least not nearly as bad as before).  Upon a routine visit we discovered a nonrestorable tooth which just means saving the tooth was not a viable option which left us with the following options: 1. Nothing (as nothing is always a choice although not advised of course), 2. Remove the tooth and do nothing to replace it (understanding that teeth on either side and above will shift which will negatively impact chewing, hygiene, bone health, and, with this being a large first molar, even face shape), 3. Remove the tooth and replace with a fixed bridge (not our first option as they’re sometimes nearly as much as an implant, cause the cutting down of two healthy teeth that may otherwise not need crowns, and the support of three teeth following now rides on the health and stability of two teeth—-we see a lot of eventual bridge failures), a removable partial denture (definitely the most economical choice but with good reason since it’s also the most uncomfortable option on the list making it the one that most patients are happy to remove permanently once they’re delivered—there’s a lot of these laying around collecting dust), or an implant (the Range Rover of all these options as this is the option that’s most like your natural tooth in looks, function and feel).

Our patient chose to extract the tooth, and reluctantly so but this time not because of dental fear (she knew she’d be okay with our little tricks), but because this is the first tooth she had to be faced with extracting.  It’s like losing a friend or family member when you actually value your dental health and make that connection between dental and overall health.  She explained that she first wanted to get through the extraction before deciding to pull the trigger on the implant, but she let us know this was the route she was leaning toward.

She did great with the extraction thanks to our massaging chair, cozy blanket, dimmed lights, awesome musical selections, and soft voices.  The Valium and nitrous probably didn’t hurt either.  I was extra careful to make sure the extraction was as atraumatic as possible, not just because I wanted to avoid making a fearful patient even more anxious, but because it’s important to maintain the site as much as possible when planning a future implant as this can save bone which can save time and money for your patient later.

Healing went as expected and the patient contacted us to let us know she was ready to proceed with the implant.  We had her back in for a 3D image and optical scans of the site to facilitate surgical planning and a guided surgery for gametime.  With our imaging capabilities, I don’t just plan the implant surgery start to finish, I also plan the crown that will restore that implant start to finish.  In fact, I plan the ideal crown first because what’s the use of an implant if the crown is no good?  By planning the surgery crown down, I can plan the surgical placement in the ideal spot in relation to the final visualized result (the ideal crown).

Once the case was planned, a custom surgical guide was ordered for surgery day.  Think of guided surgery as investing in a blueprint before building your dream home.  If you’re investing in a house, do you want to explain your vision to a contractor then let him guess about everything from dimensions to cost or do you want a skilled contractor using an approved blueprint who has studied the layout and deminsions and used those to get your house and estimate as close to perfect as is achievable?  I pick the blueprints every time!  I don’t like surprises—-well, I mean some are okay, like a diamond ring, or birthday party, or Otis (he was a surprise), but surprises in surgery, my health or my budget—no thanks!

Guided surgery means quicker, safer, easier surgeries with better results and more idealized implant placement.  When you can minimize the length of any surgical procedure, you get quicker healing with less postoperative discomfort.  In some cases, like this one, no incision is even needed with a guided implant placement.  My patient walked away from a one hour appointment, where less than 30 minutes of that was surgical time, with no incision, no sutures and minimal bleeding.

We saw the patient today for a quick postoperative check.  No bruising.  No swelling.  No pain.  No inflammation even.  Other than the healing cap, you can’t tell she had an oral surgery just four days ago.  She reported that she’s needed none of her pain pills and has only had to take ibuprofen once and that was before bed (always when pain is at its worst) and after pressure washing on her second day postpperatively (typically when the worst of the pain and swelling occurs after a procedure).  Of course, I’m convinced now she’s a rockstar after the dental transformation she’s made with us and females are WAY better with postoperative discomfort and directions (sorry guys) so that doesn’t hurt things either.

XOXO, Dr. H 💋

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Crown Replacement in the Esthetic Smile Zone

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Patient’s chief complaint- “My front tooth is ugly and holds my lip out.  I don’t want to smile anymore.”

She had trauma to the tooth 20+ years ago resulting in a root canal treatment then. Root canaled teeth commonly turn dark and are difficult to disguise, even with a full coverage crown at times. A porcelain fused to metal crown was placed first by a previous dentist.  The crown was longer than the contralateral tooth, and it was overbulked causing her lip position to be off and meaning the tooth reflected light much differently than her other teeth.  The metal margin of the crown caused gum recession adding to her esthetic concerns as well.  The tooth directly beside the crowned tooth had a large failing filling that was a result of the same trauma to the neighboring tooth.

We started with an in office whitening as you always want to make sure your teeth are their lightest shade prior to investing in any smile design to get an accurate match.  We then replaced her crown with a custom shaded, all porcelain crown of low translucency and then used a custom mixture of cements and opaquers underneath to further disguise the black tooth.  Again, sometimes the tooth is too dark to match the surrounding smile exactly (even with every little trick), so you especially want a dentist trained in cosmetics handling these cases as they can be challenging in the best of cases.  In this case, the tooth had not been properly prepared before resulting in the overbulked crown so we had to re-prepare the tooth for the new crown to ensure the adequate space for good porcelain layering that could be thick enough to disguise the black tooth and thick enough that, even with the properly prepared countours (the patient’s main concern), there would still be adequate porcelain for strength of the crown.

We placed an all porcelain veneer on the tooth immediately beside the crown where the large, failing fillling was.  A veneer is very similar to a crown except it only partially covers the tooth and is usually for looks, whereas a crown in full coverage and is typically to protect and strengthen a badly broken or heavily filled tooth.

The crown and veneer were made start to finish in our office where we can control every aspect from material selection, margins and bite to custom contouring and custom shading. This also cuts down on turn-around time in these cases where most of our crowns are completed in a single visit with no temporary crowns needed.

Our patient left happy and noticed immediately how much more comfortable her lip and gums were with her new crown in place.

XOXO,  Dr. H 💋

Lower Face Rejuvenation

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Dermal fillers are a fabulous way to see immediate and obvious rejuvenation to the lower face & mouth, yet not so obvious that it looks like you’ve “had work done.” The goal is a natural looking, fresher you. Friends will be guessing about new beauty products or a recent mini vaca.

This case is before & immediately after .8 ml of Juvederm XC & .5 ml of the all new Juvederm Volbella in a stacked technique to treat nasiolabial folds (those deep lines we all eventually get that lead from the corners of our nose down to our mouth), marionette lines (those folds that run from the corners of the mouth to the chin area) , downturned oral commissures (corners of the mouth), perioral lines (those lines that your lipstick bleeds into) and minor volume loss of the lips. The patient was adequately anesthetized intraorally (a big perk of a cosmetic dentist administering your dermal fillers) prior to the procedures for maximum comfort (our patient and staff literally laughed through the whole appointment).  Seeing as I don’t have to worry about the comfort of my patient (that just isn’t achieved through topical anesthetics more commonly used), I can better concentrate on our results.

Results on this case will look even better at the two week re-check appt once the area has healed completely & has had adequate time to hydrate as Juvederm’s mechanism of action isn’t just through the injection of the martial itself.  Juvederm is hyaluronic acid, a remarkable natural product that holds water.  Think along the lines of a sponge.  Thanks to this, hydration (which in itself has awesome aesthetic effects on the skin and tissues) causes your Juvederm injections to look even better after further building natural volume to the once depleted areas.  The immediate gratification of dermal fillers never cease to amaze us either though!  These cases are a team favorite at the office.

Schedule a consult to see how we can rejuvenate your look!

XOXO,

Dr. H 💋

How to care for a toothache…

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So all the snow has meant some snow days for our office which has me snowed in at the pink house, and after eating every carb in the place, snuggling with my precious pups and my even cuter baby (definitely check out our Instagram @junkpony to check him out if you’re not already following us), I’m left thinking about the flood of toothaches that we’ll likely see on Monday; 1. because Mondays are always notorious toothache days and 2. because anytime we’re away from the office for an extended time, toothaches start to pile up as patients are waiting to get in.  In response to this, I wanted to take the time before hitting the hay tonight to make a blog post to help others care for their toothache while waiting for their dental appointment (although I’m hoping you’re not snowed in with a throbbing tooth).

Below you’ll find how to care for a toothache until your scheduled dental visit (*NOTE- You need to schedule with a dentist as these suggestions will help with your symptoms until your visit but will not alleviate the problem, since in the case of true toothaches, generally a root canal or extraction of the offending tooth is the only treatment to “fix” your problem):

  1.  OTC combo therapy: I find that some patients think that prescription painkillers are the only way to knock the pain from a toothache.  This is false.  In fact, it has been proven in study after study that OTC pain relievers alternated actually help with the pain more than narcotic meds.  We suggest patients alternate extra strength tylenol (follow suggested dosing on the bottle) and ibuprofen (up to 800 mg since ibuprofen helps swelling most at this higher dose).  Tylenol will keep an associated fever down and ibuprofen helps with swelling (which is what causes that throbbing associated with a toothache).  The key is alternating every 4 hours between the two to stay on top of the pain; for example, if you start with tylenol, then 4 hours later you would take ibuprofen and 4 hours after that you’d again take tylenol alternating between the two.  *Note- only do this regimen IF you medically can take tylenol and ibuprofen (i.e. you have no medical problems and/or are taking no meds that cause this OTC regimen to be contraindicated).  
  2. Stay ahead of the pain: Just because that throb is easing off, do not slack on the above suggested meds. The pain is easing because of the meds.  It is much easier to hold off pain by staying ahead of the pain.  It’s no fun to start all over because you got lazy with the OTCs.
  3.  Apply cold packs and warm heat:  Most patients think that an icepack to the cheek of the affected side will help ease the pain of a toothache and forget to alternate with heat.  Warm heat (warm washcloth or heated rice-bag) is actually suggested too.  Alternate every 15 minutes between the two and avoid extreme temperatures.
  4. Keep your head elevated:  Sleep/rest propped up on a couple pillows instead of flat or on your stomach.  This will help reduce swelling and may help with draining of the site dependent on the location of the offending tooth.
  5. Avoid chewing in the area: chew soft foods and predominately chew on the opposite side.
  6. Avoid eating extremely hot or cold foods: Stick with luke warm foods and drinks as to not assault the tooth further.
  7. Call your dentist ASAP:  Nothing makes the dental community more mad than a patient that expects us to make his/her toothache a priority in our schedule only to learn after seating you that the tooth had been hurting for weeks or months prior to your scheduling.

Below are things to avoid in treating your toothache (regardless of what your neighbor’s cousin’s wife suggests):

  1. Topicals are pretty useless:  Topical medications do nothing for an actual toothache and only numb the gums sometimes resulting in burns to the gums and therefore resulting in a compound problem now.
  2. Don’t use someone’s left over meds!  You don’t know that these meds are appropriate for you or your situation.  This is dangerous!
  3. Avoid holding aspirin or any other medications against the site!  This, like topicals, does nothing for the toothache and can burn the gums resulting in a compound problem.
  4. Don’t hold liquor or whiskey against the tooth! Why?  See #1 and 3 in this section.  Same concept.
  5. Don’t google your problem! There’s great info on the web.  There’s also terrible information out there.  Somehow when we;re sick, we always believe or listen to the terrible advice.  Just save yourself the time and trouble and instead spend that time working on bullets in the first list and resting.
  6. Do not cancel your appointment because your tooth suddenly feels better! Keep your dental appointment.  True toothaches don’t just resolve.  Nerves inside your tooth may die meaning that the tooth no longer hurts but the infection/potential for infection is there and needs to be addressed by a professional.  Just remember that if it’s not treated this go around, it will blow up again and the dentist you stood up may not be so quick to get you back on the books, or you may be out of town, or your dentist may be out of town.  Bottom line, the problem always returns and usually with vengeance.  See also #7 in the first list.

Lastly, report straight to the nearest ER if…

you have swelling that is approaching your eye

OR

you have swelling below your chin that is affecting breathing at all !!!

 

Next blog post will cover what causes toothaches and how to prevent them.

XOXO, Dr. H

In case you’re due when she’s due, don’t fret…

With the news of Dr. Hughes expecting, you may be asking yourself,

“What if my dental appointment is due when Dr. Hughes’ baby is due?”  

 

To answer your questions about care while Dr. Hughes is out for maternity leave, we wanted to ease your concerns with the following information.

1.  General Supervision Hygiene Appointments—  Our hygienists will put their general supervision certificates to good use while Dr. Hughes is out with the new addition.  Under general supervision guidelines, qualified hygienists can see healthy, existing patients of record who are on a regular recall schedule by providing prescribed x-rays and dental hygiene services while the doctor is out.  The treating hygienist will review the x-rays and notes from the appointment with the doctor who will make diagnosises and order any needed follow-up appointments for said patient.  Megan and/or Ashton will inform you at your upcoming hygiene appointment as to whether your next hygiene visit will fall during Dr. Hughes’ time away and whether you qualify to see the ladies under general supervision guidelines during that time.  If you approve of a general supervision hygiene visit, then they will schedule you accordingly so that your recall schedule with us stays on track.

2.  Dentist Coverage—  Aside from the general supervision hygiene days we have planned, Dr. Hughes is working hard to find coverage while she’s out.  We are aware that most patients will want to delay any non-urgent dental treatment needs until Dr, Hughes returns to the office, but we are working to find a dentist to provide your urgent dental treatment in our office with the same great staff you’re accustomed to seeing.

3.  Dr. Hughes doesn’t plan on being away long—  Don’t expect Dr. Hughes to take an extended maternity leave.  She will be back in action as soon as possible.

Dr. Hughes has some BIG news! Watch this surprise ending.

After 10 years of marriage with 5 years of trying to expand their family, being told they had “unexplained infertility”, and some unsuccessful medical intervention, Dr. Hughes and her husband were presented with the choice of in-vitro fertilization or adoption.  They chose adoption, but after some difficulty and a few disappointments with this process too, they decided to be happy where they were in life with the blessings God HAD decided to bestow upon them; we won’t go any further as to not ruin the video for you.  Please watch to see their surprise ending!

Special thanks to David Williams at Blue Room Productions for producing this awesome announcement.

More advanced Botox/Juviderm training with the American Academy of Facial Esthetics…

A member of the Academy of Facial Esthetics, Dr. Hughes along with Tooth Booth registered dental hygienists, Ashton and Megan, were in the ATL last week training with the academy on more advanced Botox and Juviderm techniques, which included methods to perform eyebrow lifts, cheek augmentation, lip augmentation, treating hypertrophied massetter muscles causing a resultant over-squared jaw and facial pain, and treatment of mid and lower face deficiencies caused by the loss of collagen and elasticity that often accompanies the aging process to provide our patients at The Tooth Booth with the very best in TOTAL facial esthetics involving not just their smiles, but the surrounding tissues that affect their smiles.

The girls are away for MORE continuing education this week…

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Did you know that dentists are only required to have around 30 hours of continuing education every 2 years, but the ladies at The Tooth Booth usually exceed that amount prior to March in that first year?…and we’re not talking about the lame free CE in the back of the dental publications but CE from some of the leading dentists and companies in the world!

Dr. Hughes, Sam and Megan have been in Phoenix this week attending advanced courses on CEREC dentistry at The Spear Dental Institute.  CEREC is CAD/CAM technology that allows Dr. Hughes and staff to make a single appointment crown in many cases meaning no temporary and no second appointment for their patients (and no messy, gaggy impressions).