Most of us are placing implant crowns, using screw retained crowns. If the crown needs to be recovered, or the screw needs to be changed or tightened, the restoration can be removed by accessing the screw through the screw channel.

One of the main advantages of screw-retained crowns is the ease of retrieval. I have discovered two ways to make retrieval easier for myself, which involve the colors of the Teflon tape and composite I use.

1. Now I have colored Teflon tape on hand, and when I place the screw, I put colored tape on top of the screw instead white tape. If I need to remove the composite, I more readily see my gray or yellow tape than I would white tape.
2. I also like to use a composite color that is not be an exact match with the implant crown. This way I can easily see the material to be removed to access the screw channel… if I need to remove the crown.

If you plan ahead to have colored Teflon tape on hand, you can do what I do. Teflon tape is available in multiple colors at Home Depot and other hardware stores.

In a previous blog, I wrote about how we use multiple flavors of topical in my dental practice and the positive patient experience this creates. In this article, we will look at the topical application technique we use to create maximum patient comfort.

I have often debated in my mind whether topical actually makes patients feel more comfortable when anesthetic will be injected. The scientific literature confirms it works great on the surface of mucosa, but it does not reach nerves under the gums or in teeth. From working with my patients, I know it makes a difference to them in how they perceive the injection feels. And there are studies in which patients overwhelmingly self-report that the initial pinch feeling of the needle entering the tissue is reduced after topical.

Before applying topical, thoroughly dry the area so the topical goes directly on the tissue you want to numb. If topical is applied to saliva, its effectiveness is greatly reduced. Ideally, let the topical work for 60 seconds but minimally 30 seconds prior to beginning the injection. My technique is to thoroughly dry the mucosa, swab the dry area with topical, leave the cotton tip applicator in place against the mucosa, cover it with a 2×2, and have the patient close to hold it in place while I watch the clock for 60 seconds to make sure I am not rushing.

To deliver anesthetic I use The Wand computer-assisted anesthetic delivery technology. While I am waiting for the 60 seconds, I explain to the patient that the anesthetic delivery may be different than they have experienced before and how the anesthetic will be delivered.

In my last blog, I wrote about the value of offering patients a choice of topical flavors. I can also fill some of the 60 seconds by asking the patient if the topical administered tastes like the flavor of topical they selected. As soon as the 60 seconds have passed, I immediately remove the 2×2 and cotton tip applicator and begin delivering the anesthetic.

There is good science behind some types of topical acting faster than 60 seconds, so you may want to do some research and select one of these types.

Even if you think topical is not effective, think about the placebo effect topical has on the patient. We are doing something to improve their comfort. We are actively doing something to make the procedure more comfortable and to help them through the process. I believe this act of caring has value to the patient that even exceeds the value of the numbing effectiveness reported in clinical trials.

Cannabidiol, commonly known as CBD, is getting significant attention in new advances of pain management for its non-psychoactive therapeutic properties. Topical CBD oil has been suggested as a way to non-invasively treat pain caused by temporomandibular disorders. But does the science currently support CBD oil or even prove its efficacy versus a placebo?
CBD smoothies, CBD cream, CBD bath bombs… the consumer market is flooded with a variety of premium products touting everything from anxiety reduction to chronic pain treatment. If you haven’t been asked for your medical opinion about CBD yet, you may be soon.

Topical CBD oil is expensive and trendy. Roll-on applicators are often combined with other active ingredients like menthol and arnica to soothe the symptoms of pain. Roll-on CBD may be infused with essential oils, so it even has a therapeutic aroma. With attractive green packaging and clever names to boot, the purchase can be a no-brainer for those suffering from aches and tension in their jaw.

Evidence-based dentistry demands a suspicious eye. Is all this external dressing, pleasant smells, and clever marketing covering up a dearth of clinical evidence? Let’s take a dive into the science:

What CBD Is and What CBD Isn’t

Cannabidiol has come to prominence as the safer alternative to tetrahydrocannabinol (THC). Evidence has shown it may be effective in the treatment of childhood epilepsy.¹ There is even an FDA-approved CBD-based treatment, Epidiolex, for two severe forms of epilepsy.²

Besides this specific use in the management of epileptic seizures, CBD is sold as a supplement.¹ The number one issue here is the lack of regulation over supplements. You can’t be certain that the amount of CBD stated on the label corresponds to the actual levels in the formulation.¹ Even more concerning, there is no widely accepted, clinical trial approved therapeutic topical or oral dose of CBD designated for the management of chronic pain.¹ Can a treatment be ethically recommended when there is no consensus on effective, safe dose?

Unlike THC, CBD does not cause a high. But it can have side effects such as nausea or even impact the level of medications in the blood.¹ We know very little about the effects of cannabidiol in the context of large sample size human clinical trials. How long should a patient apply CBD for? At what dose should they apply it? How regularly? The answers to these questions are not currently known.

CBD and TMD: Friend, Foe, or Placebo?

A 2020 systematic review with meta-analysis of topical intervention efficacy for temporomandibular disorders compared the current data on treatments such as nonsteroidal anti-inflammatories (NSAIDs), cannabidiol, capsaicin, bee venom, and more.³ Topical therapies are especially attractive because of the serious consequences to long-term oral NSAID use for TMDs.³

Topical doses of a drug or therapeutic can bypass the debilitating side-effects of systemic treatment.³ Topical NSAIDs include diclofenac sodium and methyl salicylate.3 Therapies like bee venom and CBD are called “nutraceuticals,” which refers broadly to food-derived alternatives to pharmaceuticals, usually sold as supplements.³

The 2020 review was only able to find 9 studies regarding topical treatment of TMDs that met rigorous criteria for quality of evidence while also qualifying as randomized controlled trials.³ For topical NSAIDs, the review found no clinically significant difference compared to a placebo.³ Interestingly, ultrasound therapy was found to reduce pain, but applying an NSAID gel with ultrasound had no statistically significant difference compared to ultrasound without the gel.³

The effect of bee venom and capsaicin was similarly inscrutable, with few relevant studies including the proper data values or standard deviations to conduct a meta-analysis.³ The evidence in general was low quality or showed little effect.³

CBD also suffered from a lack of high-quality evidence in the form of studies in humans.³ Animal models have shown that “transdermal cannabinoids” may reduce pain and inflammation, but there is currently no clear evidence for long-term benefits in humans.³

Why is the research for topical treatment of TMD-associated pain so poor? The answer is small sample sizes, poor blinding, and unreported funding sources.³ Because of this, we don’t know whether demonstrated effects, if any, apply to a larger population.

Statistics have less meaning in small sample sizes. Poor blinding means that bias cannot be controlled. Lack of clear funding disclosures may also influence blinding and make it difficult to trust whether research was conducted in good faith.

The Future of CBD in Dentistry

Though data regarding CBD for TMDs is severely lacking, the future may offer some hope. If motivated researchers feel passionately about reducing the burden of chronic pain for sufferers of temporomandibular disorders, they may be able to put forward the time, money, and effort necessary to distinguish the minimum safe yet therapeutic dose of CBD.

They will also have to determine its ideal application parameters and any necessary or helpful active ingredients. They’ll need large numbers of study participants, including hundreds of individuals for control and experimental groups, and a well-considered experimental design.
That outcome may take many years. In the meantime, topical CBD will remain the equivalent of a high-end massage oil.

References:

1. MD PG. Cannabidiol (CBD) — what we know and what we don’t. Harvard Health Blog. Published August 24, 2018. https://www.health.harvard.edu/blog/cannabidiol-cbd-what-we-know-and-what-we-dont-2018082414476
2. FDA Approves First Drug Comprised of an Active Ingredient Derived from Marijuana to Treat Rare, Severe Forms of Epilepsy. FDA. Published March 27, 2020. https://www.fda.gov/news-events/press-announcements/fda-approves-first-drug-comprised-active-ingredient-derived-marijuana-treat-rare-severe-forms
3. Mena M, Dalbah L, Levi L, Padilla M, Enciso R. Efficacy of topical interventions for temporomandibular disorders compared to placebo or control therapy: a systematic review with meta-analysis. J Dent Anesth Pain Med. 2020;20(6):337-356. doi:17245/jdapm.2020.20.6.337

I think pre-operative rinsing is here to stay. Science supports it is effective against viruses, including COVID19. And it is easy to do.

Pre-operative rinsing has been discussed in dentistry for a long time, especially before hygiene visits. Today this is an even more relevant conversation, and we are examining its efficacy again with renewed interest. Here are three to consider:

Hydrogen Peroxide Mouthwash

We know hydrogen peroxide works. It is highly effective against the virus and is recommended as a pre-operative rinse right now. A readymade hydrogen peroxide mouthwash is Peroxyl. You can also take 1% hydrogen peroxide and mix it 50/50 with a flavored mouthwash. The required time for effectiveness is a minimum of 30 seconds. Some publications are recommending the patient rinse with hydrogen peroxide for two 30-second cycles. If 30 seconds is too long for a patient, they can increase the number of times they swish for fewer seconds. You can set a timer to guide the patient and make sure the patient is swishing at least 30 seconds in total.

Iodine Based Mouthwash

The literature indicates iodine based rinsing solutions are also highly effective against the virus. There are iodine based mouthwashes you can purchase for use in your practice. As some people are allergic to iodine, you will need to carefully screen patients before use, asking if they have a known or suspect allergy. Can they have betadine on their skin? Can they eat shellfish? If iodine should be avoided, then you will want to use hydrogen peroxide.

Chlorhexidine Mouthwash

The process of rinsing with chlorhexidine before an appointment and/or adding chlorhexidine so it comes through the water spray of a Cavitron or Ultrasonic Scaler is not new news. For a long time, we have been using chlorhexidine mouthwash as an adjunct to oral hygiene following periodontal treatment. There is science that chlorhexidine kills microbial cells withing 30 seconds of contact in the sulcus biofilm, but is it effective as an antimicrobial pre-operative rinse to reduce the risk of COVID19 exposure? We do not know. We cannot point to the science that would tell us it is equally effective against the virus as other options. However, I have heard studies are underway with good clinical results so far.

When we send tooth color or shade information to the dental lab, the most important aspect is the value. This is the light reflectiveness of the tooth. We describe it as looking bright or gray. Choosing value is important, and it is often overlooked.

Value is the amount of light reflected off of an object. Low value occurs as light goes through an object or is deflected away from our eyes. High value occurs as light is reflected back to our eyes. Teeth that are lower in value appear grayer. Teeth that are higher in value appear brighter.

Value was difficult for me to choose until I started using the VITA 3D-Master Linearguide system that uses the same designators as the VITA Toothguide 3D-Master system, but additionally has a dark gray card that allows you to make value comparisons from 0 (zero)–the most reflective, to 5–the least reflective. I just put the dark gray value lineation card (shown above) against the patient’s teeth and move it from right to left to find the value that has the same light reflectiveness as the tooth. Based on the value I choose, the VITA 3D-Master Linearguide tells me which cards in the system to use to select the chroma and hue.

When I bought my dental practice in Glendale, Arizona, eight years ago, they were offering patients a choice of flavors for topical anesthetic. I truthfully thought it was silly and that we would stop doing it. With experience, however, I came to realize that giving a choice was valuable for both patients and team members. Today we are still offering a choice of flavors.

When a patient is seated, the dental assistant will say, “As you know, as part of the process for getting you numb, we will be using a topical anesthetic. We have five flavors and you get to tell me which flavor you would like to use today.”

It is really interesting to listen to the dialog, but also to realize what is happening for the patient. The choice gives the patient an opportunity to settle into a conversation and something to focus on other than that they will be getting an injection and the logistics of that.

The process almost creates a fun, quirky conversation, as the patient thinks about the choices. Sometimes patients say, “You choose, and I’ll guess which one it is. Let’s see if it really tastes like that.” When patients pose themselves this challenge, the whole time I am giving the injection, they are trying to figure out which flavor of topical we have used.

Sometimes patients ask, “Which flavor is your favorite?” or “What do other patients like most?” In this case, we talk about it.

We have the mint flavors everyone else has but we also rotate in cherry, strawberry, bubble gum and pina colada. In summer, we offer watermelon. At any one time, we typically have five flavors and they vary throughout the year. A patient who has come in a few times, may even start the conversation with, “Do you have any new flavors for me to try today?”

One of my favorite conversations is whether the pina colada actually has rum in it and how funny it would be if we could just use the rum. An ice-breaker conversation such as this is a great way for us to ease the tension at the front end of an appointment that will require anesthetic. It truly adds an element of fun that has become for us a practice distinguisher.

It can be very frustrating to take a series of dental photos only to realize there were scratches or watermarks on the mirrors when you review the images later on a computer. Cleaning mirrors without damaging them can be a challenge.

I happen to like the [chromium or titanium] coated buccal, lingual, occlusal and anterior contact Intraoral Handle Mirrors from PhotoMed®. These feature a stainless steel handle that keeps fingertips out of the photograph. And, if your patient is cooperative, they can hold the mirror to free up your assistant. All of the handle mirrors from PhotoMed are single-sided, autoclavable, and can be cold sterilized.

In my practice, we try to protect our mirrors as much as possible from scratches, because once they happen, there is nothing you can do about it. Watermarks, on the other hand, can be eliminated and also cleaned away.

To avoid watermarks, we always wrap our mirrors in a paper towel before putting them in the autoclave bag. To clean away fingerprints and water spots, we use premoistened lens cleaning wipes that are designed for cleaning eyeglasses. They can be purchased in bulk, and we find them economical, efficient, and effective in cleaning our intraoral mirrors for crisp intraoral photo images. We keep a box in every operatory, where they do double duty in cleaning our eyeglasses and loupes.

Most dentists have some stories about buying and trying different types of face shields as we have started to practice again. The challenges of fit, being comfortable and working with loupes are common conversations. I have tried six types to date with more on the way.

I started with “What can we get?” Then I moved on to “What will be the most comfortable and best on our loupes?”

I and my two hygienists wear loupes. I wear a 4.0x power, flip-up loupe. The hygienists wear 1.5x power loupes. In addition to the loupes, we wear a light.

We’ve tried face shields that hang from a visor. This is the kind my assistants love and wear all the time. However, this type of shield does not fit over my loupe. It fits over my hygienists’ loupes but by the end of the day, they have a headache from the pressure of the temple pieces on the visor.

We tried the disposable face shields that hang from a headband with foam padding. They did not fit over loupes.

A third type from Bio-Mask® turned out to be my hygienists’ favorite and the one I wear when I am doing a consult and not wearing my loupe. This type of visor frame has replaceable face shields. It is lightweight and comfortable (due to its weight, adjustable head strap, and foam padding), and it is designed to be worn with loupes. The replaceable shields can be washed with hot soapy water. The shields are designed to protect from splatter and spray that might come over the top of the visor, so you have full-face protection. I can wear it over my loupe by enlarging the headband and resting the front of the visor frame on my light.

Just recently I came across a different face shield designed to wear over dental loupes that I really like. It’s the PRO-TEX® extra-wide 13″x 7″ shield (model FSX). It clips directly onto the frame of my loupe. I wear eyeglasses, a face mask, my loupe with a light, and then clip the face shield to my loupe frame. This is the least pressure on my ears and temples that I have discovered. The shield can be washed between patients with warm soapy water.

I know a lot of people are praising loupe face shields from Ultra Light Optics®. I am looking forward to trying these when they come in because they are designed so you can mount your light outside the shield and not have to reach under the mask to flip down your light.

In dental school most of us learned to use the same two sizes and lengths of dental anesthetic needles. Once I got out into practice and started to experiment with different sizes and lengths, I changed my protocol.

I discovered through my years of practice that I like to use an extra short 30 gauge needle that is 12 mm long for maxillary anesthetic injections and for mandibular injections that are premolars and forward. What I like about the extra short needle is that it does not bend. For these two types of anesthetic injections, the extra short needle is long enough and easier to control than the “short” one we learned to use in dental school. As a bonus, if a patient asks to see the needle, I usually hear them say, “Oh, that’s not so bad.”

On a mandibular block, I prefer to use a 27 gauge needle that is 25 mm long. What I like about this size is that it gets me to the depth I need and is easy to manipulate. Rarely do I need a longer needle that is more difficult to control.

In light of today’s heightened need to reduce aerosol viruses, weighing the benefit of using a rubber dam may outweigh the challenges of using one. But I have found a barrier solution that is easy to use, highly efficient for isolation and reduction of aerosols, and more patient-friendly. It is actually a rubber dam replacement called OptraDam® Plus from Ivoclar Vivadent.

For some time now it has been part of my restorative toolkit, because the isolation improves restorative outcomes and, once again…it is efficient, easy to use, and patient-friendly. I call it “the friendlier version of a rubber dam.”

OptraDam® Plus comes prepacked in two sizes, regular and small. It has a figure 8 OptraGate for holding the lips out of the way and has a solid rubber dam back that is pre-marked for where to punch the holes. It is easy to insert and more comfortable in place. Because it does not require a lot of retention, I can use it without a clamp. This means I do not have to deliver palatal anesthesia on the maxillary or long buccal anesthesia on the mandibular. This is much kinder and gentler for the patient. It does not come in a Latex-free version, but it is a barrier solution you may want to consider.