Nova Scotia Dental Association

Tag: clinical

  • The current state of the opioid crisis: Insights for dentists in Nova Scotia

    The current state of the opioid crisis: Insights for dentists in Nova Scotia

    By Kyla Romard
    NSDA Clinical Affairs Manager

    The opioid crisis continues to pose a significant public health challenge in Canada, with thousands of lives lost each year due to opioid overdoses. According to recent statistics, the number of opioid-related deaths has surged, with synthetic opioids, particularly fentanyl, contributing to a significant proportion of these fatalities. The crisis is driven by a combination of factors, including over-prescription of opioids, lack of awareness about the risks, and the availability of illicit substances.

    As dental professionals, ensuring patient safety and effective pain management is at the forefront of our practice. With growing concerns about opioid misuse, it is essential for dentists to adopt responsible prescribing habits and to adhere to established guidelines. The Provincial Dental Board of Nova Scotia (PDBNS) has outlined specific recommendations for prescribing opioids in its document, “Guidelines for Prescribing Opioids and Benzodiazepines in Dental Practice.” The purpose of this article is to provide a concise overview of these guidelines to support dentists in making informed decisions regarding pain management in patients.

    Opioid prescribing guidelines

    Indications for use: Opioids should be prescribed only when absolutely necessary and typically only for acute pain management. For most dental procedures, over-the-counter analgesics or non-opioid prescription medications (such as ibuprofen, acetaminophen, ketorolac, and, in some cases, long-acting local anesthetics) should be considered as first-line treatments.

    Patient assessment: It is important to conduct a thorough history and physical examination, obtain diagnostic imaging when appropriate, and make a diagnosis before prescribing any pain therapy, including opioids. In cases where an opioid is indicated, a social history reviewing the patients psychiatric and substance abuse history (including any previous instances of opioid use) should be documented.

    Prescription duration: Limit the quantity of opioid prescriptions to the minimum necessary duration. Short-term prescriptions of three to four days are usually sufficient for managing post-operative pain. If the patient requires opioids beyond this time frame, they should be reassessed clinically prior to being prescribed more opioids.

    Dosage and potency: Prescribe the lowest effective dose and consider using lower-potency opioids where appropriate. Long-acting or extended-release opioids should not be prescribed unless the dentist has specialized training and experience.

    Monitoring and follow-up: Schedule follow-up appointments to assess the patient’s progress and adjust the pain management plan as needed. Monitor for signs of misuse and educate patients on the proper use and disposal of opioids.

    Patient education: Inform patients of the risks associated with opioid use, including potential side effects and signs of dependence. Provide guidance on alternative pain management strategies and emphasize the importance of adhering to prescribed doses.

    General best practices

    • Record keeping: Maintain accurate and detailed records of all prescriptions, including the rationale for prescribing, dosages, and patient responses. This documentation is crucial for monitoring patient care and complying with regulatory requirements.
    • Implement prescription monitoring: Be aware of your province’s prescription monitoring programs. In Nova Scotia, all dentists are encouraged to sign up and use eAccess (a service provided by the prescription monitoring program [PMP] of Nova Scotia). eAccess is a resource which provides prescribers and pharmacists with timely access to information they need to determine the best treatment for patients while promoting the appropriate use and the reduction of abuse and misuse of monitored drugs. Information on registering for eAccess can be found online.
    • Collaborate with other healthcare providers: When necessary, work with physicians, pharmacists, and mental health professionals to ensure a multidisciplinary approach to patient care. This collaboration can help identify patients at risk for substance misuse and provide comprehensive support.
    • Stay informed: Stay updated on the latest guidelines and research related to opioid prescribing. Continuing education and training can help ensure that your prescribing practices remain aligned with current best practices and regulatory standards.

    By adhering to the guidelines set forth by the Provincial Dental Board of Nova Scotia, dentists can help mitigate the risks associated with opioid use while still providing effective pain management for their patients. It is our responsibility to balance pain relief with patient safety and to promote practices that support the well-being of our community.

    For further details, including a more in-depth review on acute pain, pharmacology, dosage recommendations, and more, please refer to the PDBNS resource, “Guidelines for Prescribing Opioids and Benzodiazepines in Dental Practice.”

  • An apple a day: The important role dentists play in counselling patients on nutrition

    An apple a day: The important role dentists play in counselling patients on nutrition

    By Dr. Kyla Romard
    NSDA Clinical Affairs Manager

    As the hustle and bustle of back-to-school season approaches, families find themselves immersed in shopping for supplies, adjusting to new schedules, and preparing meals amidst the chaos. In this flurry of activity, one aspect that often gets overlooked is maintaining good nutrition, especially when it comes to oral health.

    Dentists have a unique role as healthcare providers, as much of our daily interaction with patients occurs through routine examinations and preventative therapy. These annual or semi-annual check-ups are (usually) painless and stress-free for patients, creating an atmosphere that easily lends itself to patient education about a variety of topics, including oral hygiene, restorative treatment options, care of oral appliances, and nutrition.

    Many dentists may consider nutritional counselling to be an intrusive and awkward conversation to have with patients. Others may find it to be beyond the scope of practice, believing their knowledge to be limited on such an expansive topic. However, nutrition is an integral component in both oral and overall health, and dentists should be able to provide some basic nutritional education to their patients. Poor nutrition can lead to oral maladies, including caries, gingivitis, and mucosal pathologies. It may also lead to the progression of periodontitis and the reduction of tissue repair capacity needed to combat recurrent oral diseases or induce proper healing after surgical procedures.

    When it comes to establishing life-long nutritional habits conducive to a healthy oral cavity, dietary counselling can begin as early as three months in utero. Indeed, the systemic effects of diet are most important when teeth are forming, which occurs between the third and sixth month of pregnancy. As such, it is essential your patients who are pregnant or are trying to become pregnant consume enough protein, vitamins (especially A, C, and D), calcium, and phosphorus needed for the development of healthy tooth buds. To reduce the risk of birth defects, you should recommend these patients take a dietary supplement of folic acid and eat foods high in folate and rich in folic acids (e.g. asparagus, broccoli, spinach, legumes, oranges, strawberries, bananas, and grain products fortified with folic acid). Once the baby arrives, dentists can encourage breastfeeding, if possible, but should advise parents that at-will nocturnal breastfeeding after eruption of the first tooth can cause early tooth decay. Should parents choose to bottle feed, it is important to discuss with them the frequency of feedings.

    Parents should also be advised of the following:

    • Avoid putting children to bed with a bottle, as prolonged night-time feedings past the age of six months can increase the risk of caries 
    • Avoid filling bottles with sugar water, juice, or soft drinks

    Most dentists encourage parents to bring their child in for a complete oral exam by age one. During this exam, it is customary to begin a dialogue with parents regarding the child’s dietary habits. Dentists should recommend children be encouraged to drink from a cup by their first birthday. Milk or juice should only be offered with meals (never in a sippy cup), as the increase in saliva during mealtime and decrease in frequency that the teeth are in contact with sugars lowers the risk of tooth decay. Children should be given healthy and nutritious snacks throughout the day, including vegetables, fruits, and cheese, cut in sizes easy for little hands. Foods that are overly sticky or chewy, such as dried fruit, should be avoided, as these are not easy to remove from teeth and create an environment that contributes to cavity formation. Snacks that are high in starches, such as loose cereal, crackers, or teething biscuits, should be avoided for the same reasons. 

    Adolescents and young adults can pose challenging obstacles when it comes to nutritional counselling, as they may be more independent when making food choices. Opting for sugary, high-fat, high-carb foods, while tempting, can cause serious long-term damage to the oral cavity. Teenage boys are found to be the highest rising consumers of sugar-sweetened beverages, such as soft drinks, sports drinks, and energy drinks. In combination with oral appliances (i.e. braces, retainers), which are commonly worn in this demographic, poor nutrition can result in loss of tooth structure and the beginning stages of more serious chronic oral conditions. Nutritional counselling in combination with oral hygiene instruction is imperative in teenage years.

    It is also important to note that eating disorders, such as bulimia, can be first diagnosed by dental professionals due to the pattern of acidic wear on the teeth — most notably the lingual of the maxillary anteriors. Though dentists and other dental professionals are not expected to provide treatment for eating disorders, early diagnosis is important and referral to the patient’s family physician can help aid in successful recovery. 

    Acknowledging the hectic schedules of back-to-school season, dentists can provide practical tips for families to integrate healthy eating habits seamlessly into their routines:

    • Meal prep: Spending some time on weekends to prepare nutritious meals and snacks for the week ahead can save time and promote healthier choices.
    • Smart snacking: Keeping convenient, tooth-friendly snacks, like cut-up vegetables, fruit slices, or cheese sticks, readily available can prevent reliance on less healthy options.
    • Hydration: Encouraging children to drink water throughout the day not only keeps them hydrated, but also helps wash away food particles that can contribute to tooth decay.

    Approaching the subject of nutrition doesn’t have to be overly formal or rigorous. It can be as simple as asking a patient to fill out a questionnaire about their dietary habits, including the frequency of sugar consumption and nutritional supplements they may be taking. Recommendations can be made based on patient’s responses in conjunction with age, gender, and any medical morbidities/comorbidities.

    Dentists can also provide a variety of resources to patients, such as Canada’s Food Guide, which can be easily accessed online. Resources for consumers include healthy eating recommendations, food guide snapshots, and education on understanding food labels. There are also resources for professionals, including dietary guidelines and toolkits.

    In cases where full nutritional counselling is complex, dentists should advise their patients as best they can and refer them to an appropriate healthcare professional (e.g. family physician, a registered dietitian) for further guidance. The more support patients feel from their healthcare providers as a team, the more likely they are to take positive action in regards to their diet and maintain a healthy lifestyle.

    As families gear up for another school year, the guidance provided by dentists serves as a reminder that prioritizing good nutrition can be both manageable and rewarding, laying the foundation for healthier smiles and happier lives.

  • Communicating with patients: Addressing the risks of oral piercings

    Communicating with patients: Addressing the risks of oral piercings

    Rooted in ancient history, with cultural and religious significance, body piercings have become increasingly popular in Canada as a form of self-expression, individuality, spirituality, and adornment.

    Of particular relevance to dental professionals are the intraoral and perioral locations for piercings, including the tongue, lip, cheeks, labial and lingual frenula, and uvula. As dental professionals, it is our responsibility to educate and inform our patients about the various oral health risks and complications these piercings can result in if they are not properly cared for. Communicating these risks to patients requires tact, empathy, and a clear understanding of the potential consequences.

    Before addressing the risks and complications, it is important to acknowledge the perspective of the patient. Many individuals choose to get piercings as a form of self-expression or cultural significance. Understanding and respecting their reasons can help establish trust and open communication.

    Approach the conversation with empathy and non-judgement. Phrases like, “I understand you’re interested in getting an oral piercing as a form of self-expression. I want to make sure you’re aware of the potential risks so you can make an informed decision,” will show the patient you respect their autonomy while also voicing your concerns.

    Educating patients about the specific risks of oral piercings should include the following touchpoints:

    • Risk of hemorrhage: During the piercing process, blood vessels may be torn causing blood loss (at times serious), prolonged bleeding, hematomas, and disturbed wound healing.
    • Nerve damage and numbness: Piercings can damage a number of different nerves in the oral cavity, leading to permanent or temporary numbness or loss of sensation in the tongue or lips.
    • Increased risk of infection: Piercings create entry points for bacteria, leading to the potential for both localized or systemic infections. Systemic infections can potentially result in rare but extremely serious complications, including endocarditis, cerebral brain abscesses, and Ludwig’s angina.
    • Damage to teeth and gums: The initial mucosal trauma of piercings can cause pain and swelling of the involved tissues, resulting in functional problems with chewing and/or swallowing. Longer-term complications can result in gingival recession and/or periodontal attachment loss, as well as hard tissue trauma, including abrasion and tooth fracture.
    • Interference with oral function: Even after pain and swelling has subsided, piercings may still affect speech, chewing, and swallowing, causing daily discomfort.
    • Aspiration: Though rare, it is possible to accidentally aspirate a small piece of oral jewellery should it come apart or break. Oral piercings, most commonly tongue piercings, can also cause complications in patients who need to be intubated in emergency scenarios.

    Despite the risks involved, many patients will opt to get an oral piercing or will present in your office after the fact. In these cases, it is important to remain open-minded and continue to help guide your patients. Recommend jewellery that is hypoallergenic, such as stainless steel, 14-karat gold, niobium, or titanium. Soft rubber ends and acrylic screw caps can offer more hard/soft tissue protection and should also be suggested, especially for tongue piercings. Emphasize the importance of proper care and maintenance of the piercing, including regular check-ups, as well as seeking prompt treatment for any signs of infection of potential complications.

    By communicating openly and honestly, we can build supportive relationships with our patients while providing the knowledge they need for making informed oral health decisions.

  • The act of apology: Why is ‘sorry’ the hardest word to say?

    The act of apology: Why is ‘sorry’ the hardest word to say?

    Admitting fault can be a difficult endeavour — perhaps Elton John said it best when he sang, “Sorry Seems to Be the Hardest Word.”

    For those of us in the dental profession, whose training and practice often entails striving for perfection, errors in patient treatment can cause personal challenges, along with concerns about our professional reputations and, in extreme cases, our liability. Does the act of apologizing for our mistakes and/or professional misgivings help or hinder our relationships with our patients? And what, if any, are the legal repercussions of admitting fault through an apology?

    Mistakes are a part of the human experience. It’s important to acknowledge errors — even those we think are small, misconstrued, or, in some cases, wrong. In a Harvard Health Publishing article titled, “The art of a heartfelt apology,” Dr. Ronald Siegel states, “To preserve or re-establish connections with other people, you have to let go of concerns about right and wrong and try instead to understand the other person’s experience.”

    Indeed, denying, diminishing, or completely disregarding a patient’s concerns can cause small issues to snowball into something out of your control. In fact, experience tells us that dissatisfied patients are likely to share their story with more people as compared to those who are happy with their treatment. In the age of social media, this can have a big impact on our professional reputation, even in cases where it is unwarranted.

    When we are made aware of a patient’s dissatisfaction with the treatment we have provided or mistakes/errors we have been made (which can be real or perceived), our first action is to hear the patient out. It is important to truly listen to their complaint, without interruption and with empathy. Often, simply listening and offering a genuine apology helps the patient feel seen and heard and can resolve the matter at hand.

    What entails a genuine apology? To paraphrase the article cited above, Dr. Aaron Lazare, an apology expert, says this includes four elements:

    • Acknowledge the offense. It is important to take responsibility for your actions. Avoid using vague or evasive language, or wording your apology in a way that minimizes the offense or is defensive and confrontational. Never use the wording, “I’m sorry, but…”
    • Explain what happened. Be mindful to explain how the error may have occurred without excusing it. Focus here on your own actions and not the feelings of the offended patient.
    • Express remorse. If you regret the error or feel ashamed or humiliated, let the patient know. The patient will feel more at ease knowing you are on their side.
    • Offer to make amends. Your willingness to fix the error will go a long way in establishing a more trusting and open relationship. Be sure to take the time to both ask and listen to the patient in what they think the solution to the problem may be. It could turn out to be an easier fix than you had anticipated.

    While apologies are hard enough with those we love and care for, patient apologies may harbour the unwanted layer of admitting legal fault. If we apologize to our patients, are we setting ourselves up for complaints to be raised against us and risking our license? Are we exposing ourselves to legal reprisal from our patients?

    The Apology Act, established in Nova Scotia in 2008, should provide professionals with more confidence when offering atonement. The Act states that an apology, “means an expression of sympathy or regret, a statement that one is sorry, or any other words or actions indicating contrition or commiseration, whether or not the words or actions admit or imply an admission of fault in connection with the matter to which the words or actions relate.”

    Further, “an apology made by or on behalf of a person in connection with any matter:

    • does not constitute an express or implied admission of fault or liability by the person in connection with that matter;
    • does not constitute a confirmation of a cause of action or acknowledgment of a claim in relation to that matter for the purpose of the Limitations of Actions Act;
    • notwithstanding any wording to the contrary in any contract of insurance or any other enactment or law, does not void, impair, or otherwise affect any insurance coverage that is or, but for the apology, would be available to the person in connection with that matter; and
    • may not be taken into account in any determination of fault or liability in connection with that matter.”

    In simpler terms, the Department of Health and Wellness states, “a healthcare worker’s apology to a patient or family member cannot be used as evidence in legal proceedings to establish fault or liability. Instead, an apology is a sign of compassion and empathy.”

    Mistakes are an integral part of human nature and apologies should be, too. Being able to offer a sincere apology helps foster personal growth and can expand our emotional intelligence, leading to healthier and more productive relationships with not only others, but ourselves, as well.

  • When and how to use silver diamine fluoride

    When and how to use silver diamine fluoride

    By Dr. Kyla Romard
    NSDA Clinical Affairs Manager

    As the Canadian Dental Care Plan (CDCP) enters its initial rollout, the NSDA has been receiving many calls from the general public, eager for specific dates and details — information which, at the time of writing, we do not have.

    An unintended consequence of this wait is that many would-be dental patients are intent on postponing appointments until CDCP coverage kicks in. While we urge people not delay dental treatment, the harsh reality is that some cannot afford care without the financial assistance the CDCP promises. In the interim, dentists may begin to provide treatments they have not previously felt the need to use, such as silver diamine fluoride (which, in Canada, is known under the trademarked brand name Advantage Arrest).

    Silver diamine fluoride, or SDF, is an inexpensive topical solution. It is basic in nature, and consists of 25% silver fluoride, 8% ammonium fluoride, 5% fluoride, and 62% water. It is used to treat and prevent dental caries and relieve dentin hypersensitivity.

    The application of SDF is a simple, non-invasive procedure that involves hard and soft tissue isolation with gauze and cotton rolls, exposing only the area to be treated. This area is air dried, and then SDF is applied with a micro-brush. When SDF is applied to a carious lesion, the silver ions act directly against the bacteria found in these lesions, breaking membranes, denaturing proteins, and inhibiting DNA replication. In addition to its antimicrobial properties, the silver component of SDF also forms a protective layer that increases tooth resistance to acid dissolution. The fluoride ions promote remineralization, increasing mineral density and hardness and decreasing lesion depth.

    As a treatment modality for dental sensitivity, topical application of SDF results in the development of a squamous layer on the exposed dentin, partially plugging dentinal tubules and forming a protective layer.

    Indications for use

    In most cases, SDF should not be considered a replacement for definitive surgical management for carious lesions but, rather, an adjunct for arresting caries in both primary and permanent teeth.

    The treatment of carious lesions with SDF is recommended in the following cases:

    • Patients who are at a high risk of developing dental decay, including those suffering from xerostomia or severe early childhood decay
    • Patients who cannot tolerate standard treatment for medical or psychological reasons, including uncooperative children or frail, elderly people
    • Patients with multiple carious lesions requiring more than one visit, in which lesions become symptomatic prior to treatment completion
    • Patients who present with carious lesions that are difficult to treat, such as recurrent decay present at a crown margin or root caries found in a furcation
    • Patients with limited (or no) access to dental care
    • Patients who present with active cavitated carious lesions with no clinical or radiographic signs of pulp involvement

    When using SDF, precautions should be taken, as this solution will stain most oxidizable surfaces black. Skin and soft tissue discolouration can occur within minutes to hours after contact. This side effect is temporary, as natural tissue exfoliation will restore pigmentation in two to 14 days. The use of SDF is contraindicated in patients with an allergy to silver and those with exposed pulp, as well as those with any significant desquamative gingivitis or mucositis. Additionally, women who are pregnant or breastfeeding should avoid treatment with SDF. 

    Application of SDF

    Before treating patients with SDF, it is highly recommended that written informed consent be obtained by either the patient or guardian. Adverse effects (with pictures) should be thoroughly discussed, including the need for re-application and its limits as a restorative treatment replacement.

    Once informed consent is acquired, the following steps should be used in the application of SDF:

    • Protect yourself, your staff, and the patient
    • Patient should wear a plastic drape and safety glasses
    • Minimize contact with gingiva and mucous membranes by:
      • Isolating the tongue and cheek from affected teeth
      • Applying petroleum jelly to gingiva near affected areas (optional)
    • Remove gross debris to allow for better SDF contact with the lesion
      • Caries removal is not necessary
    • Dry affected tooth surface(s) with air syringe
      • Use cotton rolls/gauze/pellets if air syringe is not available
    • Place one drop of SDF in a glass or plastic dappen dish (NOT metal)
    • Dip micro-brush (comes with kit) into the SDF
    • Remove any excess on the side of the dappen dish
    • Apply directly onto ONLY the affected tooth surface(s)
    • Keep area dry and allow to absorb for one minute
    • If there is any excess, remove with a cotton roll, gauze or pellet
      • Avoid air-water spray or compressed air
    • Try to keep area isolated for up to three minutes
    • Place fluoride varnish (recommended, but optional)
    • Dispose of any supplies which have been in contact with SDF into a plastic waste bag and seal to prevent staining
    • Recall the patient at two to four weeks, as it may be necessary to reapply SDF monthly to annually until the cavity is restored or arrested
    • The effectiveness of caries lesion arrest decreases over time
    • Frequency of application after baseline caries arrest has been suggested at three-month follow up, and then semi-annual recall visits over two years

    The code that best describes this service can already be found in the NSDA Suggested Fee Guide under Preventive Services. This treatment should be coded as follows:

    • Topical application to hard tissue lesion(s) of an antimicrobial or remineralization agent
    • 13601: One unit of time + E
    • 13602: Two units + E
    • 13609: Each additional unit over two + E