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The ADAA has an obligation to disseminate knowledge in the field of dentistry. Sponsorship of a continuing education program by the ADAA does not necessarily imply endorsement of a particular philosophy, product, or technique.
Complementary and Alternative Medicine (CAM) is a set of procedures considered to be outside the practice of conventional medicine. Conventional medicine procedures are performed by medical doctors and other healthcare professionals; they are also called allopathy, Western, orthodox, or regular medicine and biomedicine. Allopathy is further defined as the use of antagonists to treat disease or abnormal conditions. Allopathy, or conventional medicine, uses antibiotics toxic to a microorganism to kill it, or provides a vitamin to treat a vitamin deficiency.
Complementary medicine procedures are used in conjunction with conventional medicine procedures. Alternative medicine procedures are used in place of conventional medicine procedures. When CAM therapies are used with conventional medicine it is called Integrative Medicine.
Conventional Dentistry is also called traditional or fee for service dentistry, which means every diagnosis has a corresponding diagnostic and procedural insurance code. In dentistry, conventional procedures are performed by dentists and allied oral healthcare professionals. A dental example of a complementary medicine procedure is using aromatherapy before, during or after dental procedures. An example of an alternative medicine procedure is using hypnosis instead of drugs or medication for pain/anxiety control.
CAM seeks to treat the patient in a holistic fashion, meaning treating the individual as a whole entity. The word holistic is of Greek origin and means "relating to the whole." Holistic dentistry considers all things related to the patient. While some holistic procedures seem unorthodox to mainstream dentistry, new research and patient testimonials may prove their safety and effectiveness, eventually allowing their adoption into the conventional oral healthcare practice standard of care. Dentists who use nontraditional or CAM procedures for patient care may be referred to as alternative or holistic dentists. Any dental procedure performed on the patient that doesn't have an associated American Dental Association (ADA) diagnosis or procedure insurance code is considered nontraditional treatment.
Because dentists have a legal duty to use standard dental treatments, additional written informed consent must be obtained from the patient. Because of increasing public use and demand of CAM, the National Institutes of Health (NIH) has established the National Center for Complementary and Alternative Medicine agency (NCCAM) to study CAM using scientific methodology and to inform the public. CAM procedures are frequently used when a patient with a chronic health problem hasn't responded well to conventional treatment. These conditions include chronic pain, colds and flu, anxiety and depression, gastrointestinal disorders, and sleep disorders. The most common condition treated using CAM is musculoskeletal pain. CAM practitioners that help conventional and holistic dentists include chiropractors, pharmacists, acupuncturists, acupressurists, massage therapists, and nutritionists.
General Categories of CAM
There are five general categories of CAM:
1. Alternative Medical Systems
2. Mind-Body Interventions
3. Biologically Based Therapy
4. Manipulative and Body Based Methods
5. Energy Therapy
Alternative Medical Systems
Alternative Medical Systems are based on theory and practice separate from Conventional/Allopathic medicine. These systems include homeopathy, naturopathy, Ayurveda, Chinese medicine and chiropractic manipulation.
Homeopathy is a set of procedures using highly diluted medications made from animal, mineral and vegetable sources. These "remedies" are used as substitutes for antibiotics bined from the Greek words homoios meaning similar, and pathos meaning disease. The principles of homeopathy date back to Hippocrates. Homeopathy emerged as a highly systematic medical science in the late 1700's in Germany by the practice of Dr. Samuel Hahnemann and is practiced by homeopathic doctors around the world. This methodology incorporates the use of small quantities of medicaments to cause symptoms the patient is experiencing. It is a natural system of medicine that stimulates the body to heal itself. A homeopathic dose of Arnica in dentistry is thought to speed healing, whereas Hypericum desensitizes a tooth.
There are three principles of Homeopathy. The Law of Similars (similia similibus curentur) is "let likes be cured with likes." Homeopathic extracts are administered in an infinitesimal dose to create symptoms similar to those experienced by the patient. The second principle is the Dilution or "minimal dose" concept of the higher the dilution, the stronger the effect. A small dose of a single remedy is diluted thousands of times to address all the symptoms: mental, emotional, and physical. A homeopathic doctor utilizes an extract to cover all symptoms reported by the patient. The third principle is Dynamisation, meaning vigorous shaking to activate the extract.
Naturopathy is an alternative medical system based on therapies of nutrition, medicinal plants, dietary supplements, natural foods, light, warmth, massage, fresh air, regular exercise and the avoidance of medications. Dietary Supplements are products (other than tobacco) taken by mouth that may include vitamins, minerals, herbs, botanicals, amino acids, enzymes, organ tissues (glandular products) and metabolites. They are considered foods, not drugs, and are regulated by the Food and Drug Administration.
Ayurveda (meaning "science of life") is an alternative medical system that emphasizes body, mind and spirit remedies. Diet, exercise (yoga), meditation, herbs, massage, exposure to sunlight and controlled breathing are used to treat and prevent disease. It has been practiced on the Indian subcontinent for over 5,000 years. Ayurvedic medicine strives to restore the harmony of the individual. Yoga is a discipline that focuses on the body's musculature, posture, breathing and consciousness. It is practiced for health and well-being.
Traditional Chinese Medicine
Traditional Chinese medicine is the ancient system of healthcare from China based on the concept of qi (pronounced "chee") energy that flows through the body. Qi energy is thought to regulate spiritual, emotional, mental and physical forces that are influenced by negative energy (yin) and positive energy (yang). Disease occurs when qi is disrupted, causing a yin and yang imbalance. Therapies include herbal/nutritional remedies, physical exercise, meditation, acupuncture and curing massage. Qi Gong (pronounced "chee gung") is a practice that combines movement, meditation, and breathing to improve qi, circulation and immune function. Ginseng is a botanical dietary supplement thought to improve heart function, work as an aphrodisiac and stimulant. Botanicals are plants or parts of plants used for medicinal or therapeutic properties, flavor or scent.
Acupuncture involves placing fine needles into acupuncture points. Acupuncture therapy is divided into several treatment modalities; auricular therapy, Ryodoraku, acupressure, moxibustion, and Chinese acupuncture, which have an indirect influence on the endocrine and reticular formation of the brain stem. The theory behind acupuncture therapy is that the body is made of 14 main channels that include 12 paired meridians and two vessel systems that contain 700-800 acupuncture points. Energy flow from organ to organ is thought to be through these channels. Nerves can be stimulated or sedated by the placement of needles into acupuncture points.
Needles are placed into these points and activated by twirling or electric stimulation. Auricular therapy is the stimulation of internal organs or body parts by placing needles into one or more of 73 different points on the ear. Ryodoraku, the Japanese form of acupuncture, is the electrical stimulation of acupuncture points. Acupressure is the use of finger pressure on acupuncture points until the patient feels a sensation used to reduce the need for pain medication and to promote healing. Moxibustion therapy is the use of burning a tuft soaked in the herb, Artemisia vulgaris, over an acupuncture point. Another technique using acupuncture principles is drug injection. Drugs such as local anesthetics, vitamins B1 or B12, saline or antibiotics injected into acupuncture points that affect a specific organ, are believed to be more effective than intravenous or intramuscular injections.
The indications for acupuncture are anesthesia allergies, acute abscess or cellulitis, patient preference, sinus problems, cold symptoms, or other respiratory disease, or as a supplement to local or general anesthesia (Figure 1). Contraindications for acupuncture are dermatitis, hemophilia, pregnancy, uncooperative patients, patients that may make sudden or uncontrolled movements, exhausted, fasting, emotionally upset or perspiring patients.
Mind-Body Interventions are based on the theory and practice of enhancing the mind to affect body functions and disease symptoms. They include prayer, meditation, mental healing, and creative outlets such as art, music or dance. The most frequently used CAM therapy is prayer: people pray for themselves for health reasons and ask others to pray for their health. Religious prayers are well documented for use in healing and spiritual insight. During the Middle Ages, when a person had a toothache, a prayer was made to Saint Appolonia, the patron saint of dentistry for healing or pain relief (Figure 2).
Dental practitioners may use imagery, relaxation, rehearsals, biofeedback, hypnosis, and paranormal health remedies as complementary or alternative techniques for conventional dental treatment. Many of these nontraditional therapies are recommended for the dental phobic patient. A phobia is a severe anxiety reaction, which leads to avoidance of situations, animals or people. Dental phobics are people with irrational fear of dentistry. It is estimated that there are ten to twelve million people in the United States who are severe dental phobics. Further, it is estimated that 35 million other individuals are very anxious. Both groups of people delay seeking dental care and repeatedly fail to keep appointments.
Reasons for dental anxiety can be from direct experience or indirect experience. An example of a direct experience that causes anxiety can be a past painful dental procedure. An example of an indirect experience that causes anxiety is word of mouth or media induced descriptions of dental treatment that produce fear in the dental phobic. Whatever the reason, affected people will avoid oral health care and self-treat their chronic dental pain. These patients will seek dental care when they can no longer tolerate the pain. Both anxiety and fear are related to pain. Pain is the interpretation of the nervous system and is a response influenced by learning and early development.
Assessing the patient for dental phobia is the first step in building a working relationship. Increase your level of attention to the patient's verbal and nonverbal communication. Communication based upon trust and rapport is always the cornerstone of effective patient management. Use visual, auditory or kinesthetic modes of communication, depending on what the patient uses, to reassure the patient and help establish rapport. The patient who uses visual communication will answer by saying, "I see." The patient who uses auditory communication will answer by saying, "I hear you." The patient who uses kinesthetic communication will answer by saying, "I understand you."
Patients need a sense of control. When you use predictable behavior, explain procedures, and give encouragement and reinforcement, the patients feel a sense of control and know they can stop any treatment at any time. Some dental phobic people require seeing a psychologist first. When the patient is ready to see the dentist, an initial oral exam is scheduled. After the patient is treatment planned, coping mechanisms are incorporated into their psychological visits.
Imagery, Relaxation and Rehearsals
Desensitization is the most common approach to treating the dental phobic, using relaxation and imagery to calm the anxious or fearful patient. Relaxation techniques and visual imagery techniques are often practiced together. Relaxation is the cessation of body or mental effort. Imagery is using all of our senses in the absence of stimuli to create a perception. Controlled breathing is a technique of relaxation. Teaching the patient to breathe normally helps to relax the patient because people who are fearful hold their breath.
Rehearsals are another technique of desensitization in which the patient is placed in a situation and is able to control the stimuli so that the patient can feel a sense of control in the situation. The patient and therapist spend long periods of time becoming accustomed to a source of anxiety and practice the event, such as an anesthesia injection. We know that adequate pain control eliminates the hurt and can help encourage the phobic patient to return for needed oral health care.
Biofeedback is a behavioral science in which humans learn to develop conscious control or change internal body processes using imagery and relaxation techniques. People have forgotten how to relax, which is a key component in biofeedback treatment. Many of the body's responses to stress are controlled by the sympathetic nervous system, the network of nerve tissues that helps prepare the body to meet emergencies by "flight or fight." People calm down when a stressful event is over or when they have done something to cope with it. When the body is repeatedly aroused, one or more functions may become permanently overactive and damage to body tissues results. Biofeedback changes habitual reactions to stress that can cause pain or disease.
Measurements of how physical processes react to stress are used to teach the patient how their bodies react. Devices such as electroencephalograms, electrocardiograms and thermometers measure physical changes such as brain activity, blood pressure, heart rate, muscles and temperature during biofeedback. Scientists cannot yet explain how biofeedback works. Patients who benefit from biofeedback are trained to relax and modify their behavior. Biofeedback is used to improve the body's immune system for healing, for the treatment of the dental phobic patient and the patient with temporomandibular disorders (TMD). Not all people respond to hypnosis, but biofeedback can be used for everybody.
Hypnosis is a technique that uses a natural altered state of consciousness. The hypnotic state is a deeply relaxed state that is similar to the experience felt prior to falling asleep. It is suggested that up to 85% of people do not have good hypnotic ability. For the people who do have hypnotic ability, there are many therapeutic uses of hypnosis. See Figure 3 for the uses of hypnosis in dentistry.
A determination is made as to whether the patient is suggestible for hypnotic induction. Once the patient is tested on how receptive they will be for hypnosis, the next step is to induce hypnosis using verbal suggestions or eye fixation. Eye fixation over stimulates the subject's eye muscles. Once the hypnotic state is entered, physiologic changes occur in the patient, such as eye movement, facial relaxation and slower deep breathing. After the operative procedure, the patient is dehypnotized. The patient was never "asleep," therefore the patient is not awakened, but dehypnotized.
Paranormal Health Remedies
Paranormal health remedies and divinations are less frequently used Mind-Body Interventions. They include past life regression and divinations. Factors that influence past life regression therapy are problems that have not responded to other traditional forms of therapy and phobias that may have roots in a past life. Skeptics claim it is true that patients recall past lives, however, it is highly improbable that their memories are accurate. These memories are from experience in this life, they are imagined, suggested by the hypnotherapist, or they are a mixture of this life experiences and imagination.
Divination means predicting the future or any outcome using a specific course of action. It includes reading astrological charts, numerology, I Ching readings (3 coins are cast, or, the yarrow sticks are divided, and the result is referenced in the I Ching or "Book of Changes," one of Confucianism's Five Classics), Fortune tellers, Tarot cards or tea leaves.
Biologically Based Therapy
Biologically Based Therapy is the theory and practice of using substances found in nature. Practitioners use herbs, foods, dietary supplements, aromatherapy and specific regimens to treat or prevent disease. Biologically Based Therapies have become the CAM technique most frequently used after prayer. Dental mouthrinses containing herbal essences of calendula, chamomile, echinacea, ginkgo biloba, golden seal, green or orange pekoe tea, licorice, myrrh, melissa, peppermint, sanguanaria, tea tree, or watercress are thought to help prevent periodontal problems. Echinacea herbal supplements are thought to stimulate T cell lymphocytes and to increase the production of interferon to protect cells against viral and bacterial infections and to heal inflammation, wounds and swelling.
Dietary supplements in the form of antioxidant vitamins C and E are recommended for gingival inflammation. Ginkgo biloba herbal supplements are recommended for gingival inflammation. Dietary supplements of the mineral magnesium citrate are recommended to improve muscle function in an individual with a high-fat, high-protein diet.
Nutritional diets such as Dr.'s Atkins, Ornish, Pritikin, and Weil are thought to prevent or control illness and to promote health and wellness. Orthomolecular therapies treat disease with varying concentrations of chemicals, such as magnesium, melatonin, and mega doses of vitamins. Other nutritional diets include vegetarian, macrobiotic and the Zone.
Dentists may work with a nutritionist to test and balance body chemistry by analyzing hormones, enzymes, digestion, assimilation, vitamins, minerals, carbohydrates, fats, proteins, and other body constituents. Incorporating body chemistry analysis and providing nutritional guidance can be practiced by holistic dentists. Holistic dentists will use dental materials they believe have few side effects. While amalgam restorations and nickel containing crowns are traditional dentistry, holistic dentists may choose ceramic, porcelain, gold, or composite dental materials.
Biological therapies such as the use of laetrile and shark cartilage are used to treat cancer. Bee pollen is used to treat autoimmune and inflammatory diseases.
Aromatherapy is the inhalation or application on the skin of essential oils to promote healing and wellness. Wellness is the achievement of a good existence. Low doses of essential oils are believed to be the safest when diluted in a carrier oil. Diluted oils are massaged directly over the area that needs treatment, such as on the chest for congested lungs or on the stomach for indigestion. Application by inhalation or bath is also appropriate for essential oil therapy. They can be used in combination with herbs, which is thought to be more effective. Some herbal adjuncts are taken several times a day in the form of teas, tinctures, capsules or tablets.
There are 50 essential oils that are extremely concentrated. One drop of essential oil often represents the potency of one ounce of plant material. Essential oils kill pathogenic bacteria by disrupting their life cycle, leaving beneficial bacteria intact. Bacteria typically do not acquire a resistance to essential oils as they do to antibiotic drugs. Essential oils act quickly in the body, some are detectable on the breath within minutes, and are eliminated from the body within several hours. Repeated applications may be required, especially when treating acute disorders that require keeping a constant level of essential oil active in the body. Figure 4 lists the ten basic essential oils and their effects.
Dilution of essential oil can be in cold-pressed almond, apricot, hazelnut, olive, grape seed or sesame vegetable oils. A safe and effective dilution is 2 percent. Too much essential oil may cause adverse reactions. The amount of Lavender for sedating is in low dilution, whereas high dilution is stimulating. Body massage oils are blends with a saturated oil. The more saturated the oil, the thicker it becomes, causing it to stay longer on the skin. Vitamin E oil is an antioxidant that may be added to extend the shelf life of most vegetable oils. Vegetable oils high in vitamins A, E and F are soothing, contain nutrients that enrich the skin and are among the best carrier oil for essential oils. Refrigerated blends of essential and vegetable oil may be kept six months or more.
Manipulative and Body-Based Methods
Manipulative and Body-Based Methods use the theory and practice of manipulation and/or movement of the body. Dentists may incorporate the use of physical therapy, chiropractic or massage therapies when a patient's chief complaint is chronic facial pain of the head, mouth, neck or throat. Some dentists use physical therapy for relief of facial pain, the treatment of jaw malalignment, muscle tightness and spasm, and Temporomandibular disorders (TMD) because muscular involvement is a major component of the disorder. Figure 5 outlines the physical therapy treatment regimens used in dentistry.
Chiropractic Manipulation is the theory and manipulation of the hard tissue structures of the body. This method of care dates back to the 1890s. Skeletal adjustments are made to correct the vertebral alignment of the spine to restore normal brain and nerve transmission and help recovery from illness. There are two categories of chiropractic medicine. "Straight" chiropractors locate and eliminate subluxations. The majority of chiropractors practice "mixer" chiropractory, a combination of spinal adjustments with other therapies such as hot or cold treatments and nutrition counseling. The chiropractic diagnosis consists of taking an accurate medical history, an examination focused on detecting muscle strength versus weakness and the range of motion of the spine. Radiographs are exposed to identify "vertebral misalignments" and areas of spinal stress.
Chiropractic treatment consists of adjustments (spinal manipulations). The recoil thrust requires the patient to lie face down on a special table that moves slightly downward as thrusts are made to accomplish adjustments. The rotational thrust requires the patient to lie with the upper body twisted counter to the pelvis. Then short, fast thrusts are applied to the spine.
Massage is the manipulation of the soft tissues of the human body. Swedish massage of the head and neck uses various methods of soft tissue manipulation to stimulate circulation through the soft tissues of the body. Effleurage are long flowing or gliding massage strokes toward the heart, tracing the outer contours of the body. Petrissage are massage strokes that lift, roll, or knead the tissue. Friction massage uses circular strokes and vibration. Tapotement massage uses percussion or tapping.
Energy Therapy is the theory and practice of manipulating biofields and bioelectromagnetic fields to affect energy. Biofields have not been proven scientifically but are thought to be energy fields that surround and penetrate the human body. The application of pressure and/or manipulating the body by placing the hands in or through biofields is thought to improve circulation, immune function, and healing. A common biofield therapy is therapeutic touch ("laying-on of hands") that involves passing the clinician's hands over the patient to promote healing.
Bioelectromagnetic fields are electrical currents generated by muscle and nerve tissue. The use of pulsed, alternating or direct current, and magnetic fields treats asthma, cancer, manages pain, or migraine headaches.
Complementary and alternative medicine in dentistry includes various treatment modalities. Many procedures are under scientific investigation to determine effectiveness. Dental patients request CAM therapy in an attempt to save money and to prevent invasive procedures. The Alternative Medical Systems are methods of alternative therapy different from Conventional/Western medicine. Mind-Body Interventions are methods of affecting body functions using prayer, meditation, mental imagery and creativity. Biologically Based Therapy is the use of substances found in nature to promote healing and wellness. Manipulative and Body- Based Methods are based on the manipulation and/or movement of the body to treat for pain and wellness. Energy therapy is based on manipulating energy fields of body.
CAM procedures may eventually become standard practice after scientific verification of efficacy.
Allopathy - conventional medicine - use of antagonists to treat disease or abnormal conditions.
Alternative Medicine - used in place of conventional medicine procedures.
Alternative Medicine Systems - theory and practice separate from Western/Allopathic medicine.
Arnica - herb used as a tincture for external application.
Ayurveda - alternative medical system that emphasizes body, mind and spirit remedies of diet, exercise (yoga), meditation, herbs, massage, exposure to sunlight and controlled breathing practices to treat and prevent disease.
Biologically Based Therapy - theory and practice of using substances found in nature.
CAM - acronym for Complementary and Alternative Medicine.
Cellulitis - inflammation of connective or cellular tissue.
Complementary Medicine - used in conjunction with conventional medicine procedures.
Conventional Dentistry - traditional, fee for service based on diagnostic and procedural insurance coding.
Dental Phobic - people with irrational fear of dentistry.
Dermatitis - inflammation of the skin.
Dietary Supplements - products taken by mouth other than tobacco or FDA approved drugs.
Energy Therapy - theory and practice of manipulating biofields and bioelectromagnetic fields of energy.
Hemophilia - disorder where the blood does not clot.
Holistic - dealing with the whole body and its interconnection.
Homeopathy - set of procedures using highly diluted medications made from animal, mineral and vegetable sources.
Hypericum - commonly known as St. John's wort.
Integrative Medicine - use of combination of CAM therapies and conventional medicine procedures.
Manipulative and Body-Based Methods - theory and practice of manipulation and/or movement of the body.
Mind-Body Interventions - theory and practice of enhancing the mind to affect body functions and disease symptoms, including prayer, meditation, mental healing, and creative outlets such as art, music or dance.
Naturopathy - alternative medicine system based on therapies of nutrition, medicinal plants, dietary supplements, natural foods, light, warmth, massage, fresh air, regular exercise and the avoidance of medications.
Subluxation - partial dislocation of a bone within the joint.
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About the Author
Esther Andrews CDA, RDA, RDH, MA
Esther Andrews earned a Master of Arts from Michigan State University in East Lansing, MI; an Associates of Applied Arts and Science from Grand Rapids Community College in Grand Rapids, MI; and a Bachelor of Science and Associates of Applied Science from Ferris State University in Big Rapids, MI. Currently she practices dental hygiene in Chicago.
Her newest textbook, titled Practice Management for Dental Hygienists was published by Lippincott, Williams and Wilkins in Baltimore, MD.
Honors and awards bestowed include:
• 2005 Dental Assisting National Board Achievement for 30 year continuous Certification,
• 2004 American Dental Assistants Association Journal Award, and
• 2000 Life membership in the American Dental Assistants Association.
She is a frequent contributor to the Journal.