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A goal of many modern dental practices is to inspire and share knowledge with patients so that they are empowered to be healthy, happier, and more confident. Every system placed in the practice, every employee hired, and every piece of new technology should resonate with this purpose. Threats to communication in the dental practice today include distraction, competition, and commoditization. In today's technology-driven world, clinicians and their dental teams must work harder and smarter to capture the attention of patients. Additionally, patients must be educated to have an improved understanding of the diagnosis and treatment that will be delivered. How technologic tools are leveraged is essential in enhancing patient communication and remaining on the cutting edge. This article will focus on trends in dental technology adoption, taking a closer look specifically at the use of computer-aided local anesthetic delivery and its efficacy in pain reduction and patient communication.
Technology for Enhanced Patient Care
When a patient comes into a practice for a second opinion, one primary way clinicians can demonstrate their level of care is by using technology that more clearly showcases a problem and how it can be solved. An example is a clinician showing a patient a lesion using near-infrared (NIR) transillumination technology. This type of non-ionizing light makes the enamel appear transparent while the lesions trap the light, making the porous lesions appear as dark areas. NIR transillumination can be used either in addition to radiographs for a comprehensive imaging protocol, or for patients whose medical history, age, or preferences preclude imaging with ionizing radiation. When services are based only on price, there is no patient loyalty; loyalty builds through direct experience and understanding. A true connection and trust will solidify a relationship with a patient, ensuring a patient will continue to come back to a specific clinician.
Technologic advancements are heralding a significant change in the way dentists practice and the value they are able to provide to patients. Advancements in areas such as imaging, CAD/CAM,1-3digital impressions,4,5 lasers,6,7 and dental informatics8,9provide new opportunities for dentists to expand their skill set, reduce patient discomfort, increase efficiency, and improve overall quality of dental healthcare. Dentist perceptions of the purpose and efficacy of new dental technology can vary widely, depending on how individual dentists think about improvements to quality of care, along with factors such as ease of use and a dentist's current skill level.10 Literature and peer interactions also play a role, along with attending presentations on the technology. There is much to consider from the rapid technologic changes of the last decade, including developments leading to possibilities such as total maxillofacial reconstruction (with computer-aided design and manufacturing) in a single stage,11 digital scanning to facilitate more accurate impressions,12 digital radiography,13and even the use of virtual reality for training in skills such as dental anesthesia.14
Changes in healthcare delivery technology are set to impact not only the performance of practitioners, but also the empowerment of patients, who now have more access than ever to knowledge about their care.15 Innovative systems related to informatics in healthcare can change how patients conceptualize their relationship to their bodies and to medical services.16Therefore, it is crucial for clinicians to stay updated on technology, on how patients understand it, and on how clinicians should deploy it on a daily basis. In a 2013 report on current trends in dentistry prepared for the American Dental Association, Diringer and Associates explained that individual consumers will be more likely to pay out of pocket for dental services and seek more value from clinicians while becoming more conscious of costs.17,18 Therefore, dentists should begin adopting new dental services and take a closer look at the expectations of their current and future patient demographic. Dentists can find opportunities for continuing education on skills for new devices and software paired with courses relating to implementation of enhanced patient communication and informatics integration. Taking these first steps can help a dentist rise above slower adopters as competitors market their advanced practices to the more wary and knowledgeable consumer.
Computer-Aided Local Anesthesia Delivery
One significant technology that could change a patient's sense of safety, comfort, and trust in the office is a computer-assisted local anesthetic delivery system that has been shown to be effective in pain reduction.19Due to a fear of needles, many patients do not go to the dentist or continue recommended care.20 This common patient fear is a serious concern in regard to patient retention. Computer-assisted local anesthetic delivery systems are powerful because they allow better control over both the pressure and volume of the anesthetic.21 They have features such as assistance with aspirating, enabling the clinician to use a "cruise control" option to ensure a slow rate of aspiration.
A study of a computer-assisted local anesthetic delivery system for pediatric dentistry found that it was associated with significantly reduced pain ratings and a lower heart rate than anesthesia delivered through the traditional syringe route.22With a computer-assisted local anesthetic delivery system, patients are expected to remain much more relaxed. Another study of 10 patients resulted in 2 of 10 subjects finding a syringe to be more painful than a computer-assisted local anesthetic delivery system.23 Computer-assisted local anesthetic delivery systems can be beneficial for treatments such as an anterior or middle superior alveolar nerve block. The clinician can bisect the first and second premolar midway between the free gingival margin and the mid-palatal suture. The technology can also be placed at the junction of the horizontal and vertical component of the palate. The tissue will blanch at the insertion point as the anesthetic is flowed in at a precise rate. There is no collateral numbing of the lips, whereas the maxillary incisors, canines, and premolars are numb.24
Computer-assisted local anesthetic delivery systems can also be used in root planing and scaling. If a clinician adds the posterosuperior alveolar block injection for the molars, the need for multiple injections is eliminated. Less anesthetic is needed, there is no collateral numbing, and hand fatigue is decreased. When a clinician tells patients that they are not receiving the normal anesthesia route, the clinician is demonstrating a commitment to patient comfort and security. Moreover, using a palatal approach of the anterosuperior alveolar nerve block with a very short, 30-gauge needle ensures a single injection of all the maxillary teeth and canines.24
Another tool that can lead to patient retention and trust is the use of the local anesthetic agent articaine.25Articaine has a rapid onset that makes it effective when using local anesthetic on molars. Researchers found that articaine demonstrated more effective pain minimization during the injection phase compared with lidocaine.26 The chemical name for articaine is 3-N-propylamino-propionyl-amino-2-carbomethoxy-4-methylthiophene hydrochloride. The onset of action of a drug is related to its dissociation constant (pKa). Research has shown that "a lower pKa means that more uncharged base molecules are present to diffuse through the nerve sheath, and thus the onset time is decreased. Articaine has a lower pKa than lidocaine."27 In addition, articaine has a longer duration of action than lidocaine. The course "Articaine and lidocaine: how their chemical properties can impact your clinical use" notes that "local anesthetics are bound in different degrees of intensity to the proteins found in tissues including the nerves. This parameter affects anesthesia duration. The more highly protein bound an agent is, the longer it will stay and have an extended duration of action.… Articaine protein binding is higher than that of lidocaine" (with articaine having a 95% protein binding, compared with lidocaine having a 65% protein binding).27
Clinicians are often busy and want to get treatments under way as quickly as possible, which makes this technology especially beneficial. In the past, this technology was misunderstood as being capable of handling only single-tooth anesthesia; however, it can be used in most other situations as well. It should be noted that, when carrying out a treatment in a tight space, such as injections in the palatal tissue area, clinicians are cautioned to not overuse a high epinephrine such as 1:50,000; if too much is used, necrosis could result.
A beneficial feature of some computer-assisted local anesthetic delivery systems is technology that enables clinicians to do site-specific injection using primary anesthesia. The technology can also function as a backup. Clinicians can deliver just one-quarter cartridge per route. The delivery time is approximately 1 or 2 minutes, whereas the duration of the anesthesia is about 40 to 60 minutes.28 The clinician does not need to get up and wait. The technology takes away the guesswork inherent in this type of anesthesia. It also enables clinicians to know that they are directly into the periodontal ligament (PDL) intraligamentary tissue. The technology continuously monitors the constant exit pressure and ensures that clinicians can see that they are in the correct area of the gum.29
For single-tooth anesthesia, a beneficial setup is one-quarter carpule of 4% articaine x 1:200,000 epinephrine at the line angle at the distal. This method is easier for a very short needle, which will not feel painful to the patient. If the tooth is a molar, the clinician can do the distal-lingual and the mesiolingual and then be considered finished without needing to wait.30
In the Handbook of Local Anesthesia, Stanley F. Malamed, DDS, discussed how 3% of children will have a soft-tissue self-injury after local anesthesia.31 With computer-assisted local anesthetic delivery systems, there is far less concern. For example, if a clinician wants to anesthetize tooth No. 19 and No. 30, whether the patient is a child or an adult, the treatment can be done in the same visit. Patients with time constraints will be happy to have both teeth done at the same time. Similarly, it is well-known that the inferior alveolar nerve block has the lowest success rate, but the rate of success is much higher with this technology. Through a multi-cartridge button, the clinician can place the first carpule and then have staff load the second carpule, only to push a button. The clinician can deliver 1.75 carpules in the inferior alveolar, and the excess liquid will ensure that the patient becomes very numb.32Of course, if the anesthetic is not delivered to the correct injection site, neither conventional local anesthetics delivery nor computer-assisted will be effective.
Another way to put this technology to use is with a patient who has a history of not getting numb very easily and asks for more anesthetic. At one point, a clinician may have put the injection in, taken it out, and then waited until after a syringe was secured to give the patient extra anesthetic. Now, the clinician can simply add the extra anesthetic all at once. According to Dr. Malamed, computer-assisted local anesthetic delivery systems have increased doctors' ability to guarantee the pain-free delivery of local anesthesia to patients.31 It is more comfortable to deliver these injections, especially in areas that are difficult to administer painlessly, such as palatal injections and PDL techniques. With computer-assisted local anesthetic delivery systems, patients have been known to say, "Was that it?" or "Did you even use a needle?" If a patient is curious about the technology, it is a good opportunity to educate them about how it improves the patient experience.
Of course, this technology does have a small learning curve, but ultimately it is much easier to use for providing painless injections, as opposed to a syringe. It is important that a clinician uses new technology skills to capture the attention of old and new patients. Having the technology on its own demonstrates that the dental practice has a specific philosophy emphasizing heightened care for the patient. Therefore, patients will know that their comfort is of utmost priority. They will discern that the practice can provide a noticeable improvement over other practices that do not offer the technology, making the practice more valuable and unique. Additionally, computer-assisted local anesthetic delivery systems reduce the stress of performing injections throughout the day; consequently, one of the major anxieties of the dental profession is abated.33
Patients are much more likely to remain loyal to a practice if they understand its intentions and feel connected to its purpose. A philosophy of care should include a reason why the dental team wants to provide a certain level of care to their community. This philosophy can inspire the entire team and make a good impression on patients. In a world where distractions are common, using technology that reduces pain and demonstrates a commitment to patient comfort will encourage patient retention and stimulate practice growth. Computer-aided local anesthetic delivery is one important technology that shows patients a practice's commitment to an overall better experience of dentistry. Such technology also reduces strain on dental professionals who commonly deliver anesthetic throughout the day and provides a launching point for the practice to showcase modern technologic advancements for financial and social benefit.
About the Author
Cynthia K. Brattesani, DDS
San Francisco, California
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