otago dental school bds

Otago Dental School BDS

Sydney Dental Hospital Staff Dentist OS Registrar SVDS Dip Hyp ISLHD: LHI SHH Staff Specialist After Hours Emergency Oral Surgery Paediatric Special Needs TOOLBOX

Otago Dental School BDS 1980

Sydney Dental Hospital Staff Dentist OS Registrar SVDS Dip Hyp ISLHD: LHI SHH Staff Specialist After Hours Emergency Oral Surgery Paediatric Special Needs TOOLBOX

ISLHD: SHH TWH LHI Staff Specialist After Hours Emergency Oral Surgery Paediatric Special Needs TOOLBOX

�  Equipment* �  Facilities: access

�  Financially accessible �  Services and availability

�  Skills and techniques

�  Self: keep fit mentally and physically: Self hypnosis. �  Systematic desensitisation: photos, demonstration, Oral S.D-home

�  Flexibility: accommodate and utilise patient idiosyncrasies* �  Waking Suggestion techniques

�  Formal hypnosis

�  Sedation: RA, GA facility �  Referral or working in with other specialties

�  Multiple strategies for individuals as required: holistic �  Evolving tool box

�  Equipment �  -Facilities: access

�  Financially accessible: pension rates, vouchers �  Services and availability*







•  ADA Accreditation: OHS, sterilising, protocol •  Disabled access. Disabled toilet •  Open plan: wheel chair and stretcher friendly •  Non clinical: homely •  Staff compatible, relaxed, happy atmosphere •  Desk welcoming, accessible and open •  Back ground music •  Air conditioning •  Familiarity: staff and layout •  Individualised: flexible for any needs •  Be on time: Special Needs in particular •  Fees uncomplicated, fair and affordable

Able to accommodate ambulance or disabled van

Closed surgery for privacy such as formal hypnosis

�  Equipment �  Facilities: access


�  -Skills and techniques

�  Self: keep fit mentally and physically: Self hypnosis �  Systematic desensitisation: photos, demonstration, Oral S.D-home*

�  Flexibility: accommodate and utilise patient idiosyncrasies �  Waking Suggestion techniques




�  Patience and dedication �  Tactile �  Verbal: tone may be more important than content �  Persistence and patience at home �  Learning new skill cf. self hypnosis

Systematic desensitisation: Exercises. 1- Photos for autistic patients 2- Oral systematic desensitisation 3- Multiple short appts. 4- Doing simple tasks first

Oral Desensitisation increases a person’s tolerance to touch around the face and mouth by slowly introducing touch to the extremities (legs, hands) and gradually working towards the head, shoulders and then to the face and mouth.

Break down task into series of achievable steps to achieve the whole Step One

1.  Identifies own tooth brush

2.  Turns on cold water

3.  Wets toothbrush

4.  Unscrews toothpaste cap

5.  Squeeze toothpaste on brush

6.  Puts toothbrush onto front of teeth with teeth together

7.  Brush outer surfaces all teeth including gum margins , back teeth, front teeth

Step Two

1.  Open mouth: brush inner surfaces of back and front teeth

2.  Rinse off brush

3.  Rinse mouth

4.  Screw on toothpaste cap

5.  Put tooth brush away

Teeth together: brush outer tooth surfaces and gum margins

Teeth apart: brush inner surfaces teeth and gum margins





�  -Flexibility: accommodate and utilise patient idiosyncrasies* �  Waking Suggestion techniques




Stephen �  26 year old with Aspergers: referred for xo under GA

�  Attention to detail: loves old phones

�  Photographic memory: door

�  LA syringe dissection prior to extraction

�  Mother: wishing for appreciation

Betty

�  Intellectually disabled

�  Jumps unpredictably. Good finger rests.

�  Usually ok for a while following a ‘jump’

Peter �  Severe cerebral palsy, intel disabled.

�  Long wheel chair

�  Lavender foot massage

Greg:

�  Carer: well matched, positive




�  Systematic desensitisation: photos, demonstration, Oral S.D-home �  Flexibility: accommodate and utilise patient idiosyncrasies

�  -Waking Suggestion techniques* �  Formal hypnosis

�  Sedation: RA, GA facility

�  Referral or working in with other specialties �  Self: keep fit mentally and physically: Self hypnosis.


�  Most people working with children inadvertently become experts at using suggestion techniques to change and guide their behaviour.

�  Story telling: distraction, animal metaphors, reframing, education, morals

�  Everyday trance: day dreaming �  Driving �  Running, swimming. Any ‘automatic’ physical activity �  Subliminal: advertisements �  Direct, indirect. Next slide.

�  Talk to parent with child listening: indirect suggestions using language appropriate to child’s age

�  ‘That tooth looks to be very sick and sorry. He could go to the tooth hospital or maybe give him to the tooth fairy tonight? The Tooth fairy? ‘

�  ‘What do you think that tooth would like? (Presupposition). Usually tooth fairy. �  Place topical (sleepy paste) early on �  Story to distract: Sleepy juice to help that Mr tooth go sound asleep....now close

your eyes to help that sick tooth go sound asleep, because he is looking very tired....maybe a little pinch now and what do you think you will be able to do with that tooth tonight... Will you perhaps place him under your pillow for the tooth fairy? And what do you think you might find there in the morning....don’t tell me now, but think about it and remember to tell me after that tooth wiggles out while he’s still fast asleep.’ (Kept patient in cuddle and fingers supporting tooth whole time. I find that some kids will otherwise get out of the chair and then difficult to regain control)

�  Pinch needle for LA and cuddle to stabilise �  Trent’s father was sitting quietly in the corner. �  Extraction complete. I asked again what do you hope to find under your pillow

tomorrow? �  Answer?

• Topical early on to give time to take effect • Suggestions such as close your eyes now so we can help this tooth go fast to sleep...............tooth snoring ....... • Avoid negative suggestive words such as: needle, hurt, pain, sting • Avoid anxiety suggestions such as: mozzy bite, squeeze my hand..... • 2mls Articaine 4% with A 1/200,000. Gentle and slowly into labial sulcus • Nothing sudden or quickly unless unavaoidable. Stabilise needle. (Pinch & cuddle technique) • Young children palatal injection not necessary if wait long enough • Good LA gives the operator confidence and allows a pleasant procedure. • Don’t proceed until good LA achieved






�  -Formal hypnosis: Kate Extraction Phobia*



Hypnotherapy:

•  A spontaneously occurring or induced alternative state of awareness (with or without relaxation, which may or may not be evident) in which an individual develops a focused concentration on some idea or image with the expressed purpose of maximizing potential, creating a CHANGE, and/or reducing or resolving some problem.

•  [2] (Kohen and Olness, 2011)

•  ‘Can help children develop skills, not pills.’

�  5-10% (25%) highly suggestible to hypnotic suggestion

�  79% (50%) moderately susceptible

�  Spiegel: estimates about 25% cannot be hypnotised

MRI

�  Highly suggestible: greater co-activation between the executive-control network (the dorsolateral prefrontal cortex) and the salience network (dorsal anterior cingulate cortex)

�  Low hypnotizability subjects showed little connectivity between these two areas.

Erikson and Barber: not so clearcut:

Subject-hypnotist relationship, motivation and cooperation are most important.

�  Anyone with an adequate attention span, average intelligence and a cooperative attitude can be hypnotised.

Intellectually disabled:

�  Utilise different means of suggestion: tactile, tone of voice, photos...

�  13 year old girl presented for 4 premolar extractions for orthodontics �  Allowed LA. Extraction phobic �  Interview to determine and clarify the exact nature of the problem �  Previous trauma: No LA �  Splitting and linking: Reframing. This time LA �  Explain the facts of the procedure truthfully with non-threatening language �  ‘Now and then patients might feel a bit more than pressure and vibration, but

nothing that they can’t handle.’ �  Desensitisation: demonstration: seeing is believing �  Introduction to hypnosis �  Induction: non authoritarian, flexible Script, feel in control �  Leading and pacing, flexible, utilization, reframing, confusion �  Dissociation: basement �  Post hypnotic suggestions �  Normal during extractions: some anxiety, coping, cooperation, desensitising �  Patient reaction following extractions: initial surprise then fizzer when over �  Suspect Katie would have scored low on hypnotisability scale �  Eriksonian Approaches in Dentistry: James M Auld: Tidy, practical overview.






�  -Formal hypnosis: Jo gagging problem*



�  Woke up one month previous unable to wear full upper and lower dentures

�  Periodic dizziness and nausea 5 years following middle ear operation

�  Medications unsuccessful �  Patient distressed by problem. Unemployed and anxious �  Dentures 3 years old. First dentures ever �  Exam: Gag on minimal stimulus �  OPG clear except retained root. �  Diagnosis: Dental: dentures retention compromised,

otological, psychogenic: vicious feed back cycle. �  Very motivated to deal with this problem

�  Aim: change to allow construction of new dentures with better retention. Stop anxiety vicious cycle.

�  Hypnotisability

�  Indirect/non authoritarian induction: flexibility and low risk. Loosely based on Joseph Barbers Rapid Induction

�  Pacing and leading. Verifiable and non verifiable

�  Age regression when he was comfortable and then see himself that way in the future with his new dentures.

�  Post hypnotic suggestions, ego strengthening, relaxation for future appts, seeing an optimistic future.

�  Dissociation/association with dentures: ‘surprising that your mind is not aware of every part of your body: when healthy they just melt into the back ground....just like a well made and comfortable denture...like it is part of you, but apart from you.

�  Abreaction: hyperventilating, disorientated, not responding

�  Reframing abreaction. ‘That was an interesting reaction....possibly something surfacing so you can deal with it? Might be surprised...better.

�  Reframing: Important tool: Barber and Ericksonian. ‘Teaches

a different game thereby making the old one obsolete. Makes whatever the subject does a success and evidence that his trance is deepening. Enables change through sometimes paradoxical perception’.

�  Waking suggestions. Building expectations at each 5 appts. �  SD; 3 deep breaths before each procedure at each visit �  Altered techniques: fast setting impression material, not over

filling tray, breath through nose, some gagging normal, etc. �  Providing good dentures with good retention. �  Good teeth can be a positive metaphor for life in general �  Conclusion: multifactorial approach to enable a successful

out come. I suspect that Jo would probably have scored as highly hypnotisable.






�  Formal hypnosis*


�  Multiple strategies for individuals as required: holistic �  Evolving tool box....constantly updating

Toolbox �  To accommodate all

�  Flexibility �  Individualised

�  Suggestion: multi faceted

�  Multifactorial, holistic

A successful outcome enabled from a positive change.

otago dental school bds

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