Lupine Publishers | Patients’ Complaints after Scaling and the Self-evaluation of Hand Instrumentation for Scales by Dental Hygienists

 Lupine Publishers | Journal of Pediatric Dentistry

Abstract

Objectives: This study was performed to understand such chief complaints through scaling operation performed by dental hygienists, as bleeding, or instrument sensation for dental patients and how to improve by explain the control method of them, in order to supply the better operation in the future and contribute the improve for the patient’s oral health.

Subjects and Method: Thirty five female dental patients who had received the scaling from 35 dental hygienists were participated in this clinical study, from the periods on March, in the year 2020 at G city, and the questionnaire method was performed with such questions as chief complaints after scaling with Likert 5 scale scores.

Results: The complaints or merits after scaling were examined as followings as bleeding complaint was 3.51±1.29 points, hyper-sensation of the tooth was 3.74±1.26 points, tooth crack or fracture as 2.68±1.18 points, abrasion as 4.02±1.15 points, possible for eating hot and hard foods as 3.20±1.32 points, early detect of caries as 2.17± 0.92, points, chance for consultation about implant or denture as 3.22±1.19,, possible for drinking acidic beverage as 3.20±1.32,points , possible for finding enamel hypoplasia as 2.20±1.23, points and possible for removal of filling or prosthodontic materials as 2.88±1.30 points. The evaluation of dental hygienist for the hand instrument manage skill is revealed as 4.11±1.10 points for supra-gingival calculus removal, 2.51±1.29 points for sub-gingival calculus removal, 4.17±0.95 points for using 1~2 mm lateral surface of scaler blade, 2.77±1.23 points for using the back surface of the scaler blade, 2.60±1.11 points for start scaling after demonstration with the tip guide. 3.22±1.35 points for grasping scaler slightly and insert it around the tooth as like as probe use, 3.14±1.37 points for vertical movement with slow motion of the tip along the long axis of the tooth on sub-gingival area, 2.88±1.34 points for using scaler tip with slight pumping touch at the tooth surface, 3.48±1.33 points for moving the blade vertically with inserting it on col area and 2.94±1.34 points for put the scaler tip locate beside the proximal area of the neighbor tooth on scaling at proximal area.

Conclusion: The abrasion or hypersensitivity were the big complaints from patients on scaling and dental hygienists were evaluated as high score in such item of scaling skills as supra-gingival calculus removal and using 1~2 mm on lateral surface of scaler blade, but got the least score in such item on sub-gingival calculus removal.

Keywords: Dental Scaling; control dental; dental hygienist; pain; dental calculus

Introduction

The periodontal care can be performed through such method as the non-operative periodontal treatment, operation and scaling or oral prophylaxis and professional mechanical tooth cleaning. Non-surgical periodontal care is aims for diminishing the gingival inflammation and eliminate the periodontal pocket through the removal of dental plaque and calculus surrounding the tooth, in order to re-attach or re-generation of the periodontal tissue. Moreover, it can be done as a pre-treatment procedure for severe periodontal surgery through performing the removal of plaque and calculus, polishing the root surface, applying the chemical therapy or occlusal re-adjustment. On the other hands, surgical periodontal treatment can be determined as operation surrounding gingival tissue through incision or excision of the periodontal tissue. It can be operated the calculus removal and root planning through the security of operating sight and re-forming of the gingival out line form through the suture after operation, in order to easy success for oral hygiene [1]. Scaling can be defined as the removal of plaque and deposit calculus on the tooth surface as well as the removal of tooth stain as caffeine or nicotine, in order to diminish the micro-organisms or changing the compositions at sub-gingival area, to result for prevention of periodontal disease by eliminating the etiology of tooth loss, as an effective method for periodontal disease. Periodontal disease is one of the most popular dental disease in the world-wide and dental hygienist is one of the proper dental workforces to manage the periodontal disease through performing the preventive cares as scaling. it should be needed for expert skill for scaling for dental hygienist and one pf the skill check would be instrumentation skill check for them at each potion of detailed areas at oral portions, because of elimination or diminish the oral micro-organisms through the removal of calculus or plaque by expert scaling. Although the scaling is a good measure to prevent periodontal disease, there has been revealed such complaints from the patients as hypersensitivity of the tooth, gingival bleeding, pain, abrasion of the cervical area of the tooth, removal of the filling or prosthodontic materials and the operators have to find their chief complaints to notice them to patients or do their best to avoid it with careful skills on scaling. It would be a good way for operator as dental hygienist to learn and training the bleeding control or stopping method before scaling about the procedure and anatomical structure of the blood vessel in the oral cavity or blood pressure control method or drug of choice as using Epinephrine derivatives or Bosmin agent. Another complaints or side effect from the scaling should be understood for operators in order to diminish them to perform the successful scaling. The aims of this study have been suggested to understand the chief complaint or oral status changes as well as checking and evaluation the operators scaling skill done by dental hygienist, in order to supply more safe and expert operation to dental patient in the future.

Subjects and Method

Subjects

Thirty five dental hygienists who have been working at dental clinics at Gwangju city, Korea were participated in this study for checking the scaling skill and also 35 dental patients who has visited dental clinic and received the scaling by 35 dental hygienists were joined to ask for chief complaint or side effect after scaling.

Method

This questionnaire method of examination was performed after achieved the certification for IRB (Institutional Review Board) from Bio ethic committee of Honam University as number as 1041223 201912-HR 18. Self-evaluation for managing the hand instrumentation skill of scaling by-themselves with using the 5 scaled score evaluation sheet after scaling, at Kwangju city on March in the year 2020. 10 questions such as supra-gingival calculus removal, sub-gingival calculus removal, using 1~2 mm lateral surface of scaler blade, using the back surface of the scaler blade, adjusting tip guide for scaling. grasping scaler slightly and insert it around the tooth as like as probe use, vertical movement with slow motion of the tip along the long axis of the tooth on subgingival area, using scaler tip with slight pumping touch at the tooth surface, moving the blade vertically with inserting it on the cervical area and putting the scaler tip insertion with proper location at the proximal area of the neighbor tooth on scaling at proximal area. Also 35 of their patients for scaling were joined to be asked for some complaints or side effects of scaling with use of 9 questions such as bleeding complaint, hyper-sensation of the tooth,, tooth crack or fracture, abrasion, possible for eating hot and hard foods, early detect of caries, chance for consultation about implant or denture,, possible for drinking acidic beverage, possible for finding enamel and possible for removal of filling or prosthodontic materials, by supplying the questionnaire sheet. The data was collected through the calculation of average mean points and standard deviation with 5 points as full score for each question and compared and analysis with their points with statistical analysis. Data were analyzed by use of the computer program as SPSS 18.0 for the data of mean and standard deviation with t value and significance, for 5 points of full score for each question.

Result

General characteristics for subjects

(Table 1). Through the general characteristics for patients of this study, the oral hygiene level was 3.00± 0.72 points, gingival bleeding was 1.20± 0.40 points, tooth-brushing level was 2.37± 0.49 points and the frequency of scaling was examined as 1.22±0.42 points. The average age of the subjects was 45.25±9.45 years old (Table 2). The complaints or merits after scaling were examined as followings as bleeding complaint was 3.51±1.29 points, hypersensation of the tooth was 3.74±1.26 points, tooth crack or fracture as 2.68±1.18 points, abrasion as 4.02±1.15 points, possible for eating hot and hard foods as 3.20±1.32 points, early detect of caries as 2.17± 0.92, points, chance for consultation about implant or denture as 3.22±1.19,, impossible for drinking acidic beverage as 2.80±1.32,points, possible for finding enamel hypoplasia as 2.20±1.23, points and possible for removal of filling or prosthodontic materials as 2.88±1.30 points (Table 3). The evaluation of dental hygienist for the hand instrument manage skill is revealed as 4.11±1.10 points for supra-gingival calculus removal, 2.51±1.29 points for sub-gingival calculus removal, 4.17±0.95 points for using 1~2 mm lateral surface of scaler blade, 2.77±1.23 points for using the back surface of the scaler blade, 2.60±1.11 points for adjusting tip guide for scaling. 3.22±1.35 points for grasping scaler slightly and insert it around the tooth as like as probe use, 3.14±1.37 points for vertical movement with slow motion of the tip along the long axis of the tooth on sub-gingival area, 2.88±1.34 points for using scaler tip with slight pumping touch at the tooth surface, 3.48±1.33 points for moving the blade vertically with inserting it on the cervical area and 2.94±1.34 points for put the scaler tip insertion with proper location at the proximal area of the neighbor tooth on scaling at proximal area.

Table 1: General characteristics for patient subjects (n=35, full score =5.0points).

Table 2: Patient’s complaint the oral and habitual state changes after scaling. (Full score=5.0 points, n=35).

Impo.: Impossible for eating, Impo. Acidic beverage; Impossible for drinking acidic beverage, Prostho: Prosthodontic appliance material.

Table 3: Self-evaluation points for the skill of the hand instrumentation for scaling done by dental hygienist.

( n=35, full score =5.0 points).

Discussion

Scaling and root planning are very important for dental treatments. Scaling is a process eliminating plaque, calculus, necrotic tissue and so on, and root planning makes root surfaces of infected teeth smooth after scaling. Scaling and root planning reduce the number of sub-gingival pathogenic organisms, and they return unhealthy sub-gingival to a healthy state; therefore, they promote healing of periodontal tissue by inducing epithelial tissue attached to root surface. Until now, the studies about the effectiveness of hand and powered instruments for scaling and root planning, the influence on changes in the root surface and dentin hypersensitivity after periodontal treatment have been conducted. The differences of studies about the effectiveness of various instruments for scaling and root planning and the influence on changes in the root surface were shown by a type of instrument, sharpness, the experimental method of in vivo and in vitro, time and the frequency of strokes, pressure on the instruments and the contact angles. Table 1 showed the general characteristics of patients of subjects and the oral hygiene state was 3.00± 0.72 points in 5.0 points of full score as appraised as normal state of oral hygiene. It was distributed as 9 as 25.7% in well state, 17 persons as 48.6% in poor and the rest 9 as 25.7% in severe poor state. Gingival bleeding score was checked as 1.20± 0.40 points as much subjects were found as bleeding. 80.0% of them have bleeding as usual and 7 persons as 20.0% of them had no bleeding at all before scaling. Tooth-brushing level was checked as 2.37±0.49 points estimated as general level and the frequency of scaling level was as 1.22± 0.42 points as low level. The average age of them was 45.25±9.45 years old as middle-aged group. This study was performed for checking patient’s complaint for scaling or some symptoms or side effect from receiving the scaling, and these data from the patients would be contribute to understand them and to minimize the complaint or side effect for scaling by dental hygienists in the future. Recently, a various oral application method has been studied like varnish using mucus which is mixed 5% NaF with colophony resin [2].

Age and oral health consciousness affect its importance [3] oral health disorder Ju et al. [4] reported that the coverage of insurance coverage twice a year and the expansion from the high school level would be more appropriate than the current one. Oral health beliefs about the level of beneficial effects of toothbrush behavior were higher for subjects who wore toothbrushes three times a day and wore toothbrushes before going to bed [5]. Recently, it has been recognized that the symbiotic status of bacteria in the oral cavity is important because bacterial diversity is maintained, rather than antibacterial concept which reduces microorganisms themselves [6]. Table 2 showed that the complaints or merits after scaling were examined as followings as bleeding complaint was 3.51±1.29 points, hyper-sensation of the tooth was 3.74±1.26 points, tooth crack or fracture as 2.68±1.18 points, abrasion as 4.02±1.15 points, possible for eating hot and hard foods as 3.20±1.32 points, early detect of caries as 2.17± 0.92, points, chance for consultation about implant or denture as 3.22±1.19,, impossible for drinking acidic beverage as 2.80±1.32,points , possible for finding enamel hypoplasia as 2.20±1.23, points and possible for removal of filling or prosthodontic materials as 2.88±1.30 points. It means that the important chief complaints of scaling patients were gingival bleeding and hypersensitivity after scaling. It could be occurred the gingival bleeding through irritating the inflammatory gingiva on the time of the removal of calculus and hypersensitive dentin could be occurred by removal of calculus which would be a role of protection from outer irritation as cold or hot air or water, at the cervical area of the tooth surface. it needed to let patient understands this theory of bleeding and hypersensitivity through the oral education before scaling. The other symptoms were revealed as better after scaling than before, at large or a little bit. Anyway, patient education to inform the side effect or symptoms should be done to dental patient for scaling before operation. Park et al. [7] emphasize that the oral health belief on level of beneficial impact according to the toothbrush behavior was higher for the subjects with toothbrush 3 times a day and toothbrush before going to bed.

The evaluation of dental hygienist for the hand instrument manage skill is revealed as 4.11±1.10 points for supra-gingival calculus removal, 2.51±1.29 points for sub-gingival calculus removal, 4.17±0.95 points for using 1~2 mm lateral surface of scaler blade, 2.77±1.23 points for using the back surface of the scaler blade, 2.60±1.11 points for adjusting tip guide for scaling. 3.22±1.35 points for grasping scaler slightly and insert it around the tooth as like as probe use, 3.14±1.37 points for vertical movement with slow motion of the tip along the long axis of the tooth on sub-gingival area, 2.88±1.34 points for using scaler tip with slight pumping touch at the tooth surface, 3.48±1.33 points for moving the blade vertically with inserting it on the cervical area and 2.94±1.34 points for put the scaler tip insertion with proper location at the proximal area of the neighbor tooth on scaling at proximal area. From the results, dental hygienists could well perform the elimination of the calculus at the supra gingival deposition otherwise hard for sub-gingival portion. it should be training more and re-examination system for remnant deposition of calculus would be recommended to educate on training cause. Also, it revealed high score for using side surface of the scaler blade but low score to use a back side of scaler blade on scaling. It revealed average 2.5 points to 3.5 points for all check items. It means that the most dental hygienists could perform the scaling with middle leveled or a little bit high leveled ability and left some upgrade in the future. it would be recommended to training repeatedly for dental hygienists to operate scaling with one step by one step periodically.

Conclusion

This study was performed with questionnaire method about the patient’s complaint for scaling and self –evaluation for hand instrumentation skill done by dental hygienist in order to deliver the operation with improvement in the future. 35 dental hygienists who have been working at dental clinics in Kwangju city and 35 their scaling patients were participated in this study. The questionnaires for complaints or side effects were checked for scaling patients and hand instrumentation skills were checked for self-evaluation for dental hygienists after scaling. From the results, the obtained conclusion was as followings.

a) It was revealed that the main complaints after scaling were gingival bleeding and hypersensitive dentin and the others were not so big leveled problems.
b) Dental education for patient’s complaints or side effects should be done before scaling operation in order to minimize the patient’s complaints.
c) Dental hygienists have done well for removal of supragingiva calculus deposit and using 1~2 mm lateral surface of scaler blade, but not so high leveled score in the other items, left to be improvement.
d) Periodic training for dental hygienist should be needed to remind and to improve the hand instrumentation skill for scaling.

Acknowledgements

I express my gratitude to the dentist and the dental hygienist Moon Sun-Hee who contributed to the writing of this paper. We also thank patients and dental hygienists who participated in the questionnaire as individuals who contributed research materials, expertise, or time.

Conflict of Interest

There is no economic interest or conflict of interest.

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Lupine Publishers | The Use of NLP (Neuro Linguistic Programming) at Dentistry

 Lupine Publishers | Journal of Pediatric Dentistry

Abstract

If we can establish good communication with the patients who do not go to dental clinics gladly and behave timid, it will take us to the success. Since, the right communication between people makes everything easy. We can use NLP for receiving these signals, understanding the body language and all human relations. Linguistic scientist John Grinder and Mathematician Richard Bandler have taken an example of three people, who have excelled with special abilities at their fields, and have found out that all three have used interestingly similar patterns although they have different attitudes. Later, they have modeled the other people who has perfect performance like Anthropology Gregory Bateson and have prepared a book to use these methodologies. At the NLP, “N” stands for our neurologic system, “L” stands for use of language and “P” stands for coding our experiences and using them at decision-making. We can examine preparing our personal map by changing our filters with the help of NLP. Every individual has different map so, it is necessary to try to understand the world maps belong to other individuals, or rather to understand and accept, appreciate. In order to achieve success in relationship, the person at other side of you must trust you. The language using is very important, all we use the same language however the words we select may awake negative impact on the patients (Figures 1-5). NPL is a wide-scope communication model. Each person has a (genital) private area. Dentist office is a scary and different environment equipped with unusual instruments and to where people do not go frequently. This bothers the patients, especially the children. The first task surely belongs to the parents for preparation of the children to the treatment. To prepare the children coming to the clinic with prejudgment to the treatment requires too much patience and effort. Greeting the patient with smiling face and warmly, namely first impression, is crucial. The clinic should be introduced to the child patient, the information regarding why the treatment is necessary and what will happen should be given, the questions of the child should be listened in a great attention and right answers should be given. Heads and eyes should be on the same level when talking to the child. Does every method efficient every time at NLP? No, sometimes the success may not be achieved with one try, another technique is applied at second session, the patterns should be individual after familiarizing the person. The picture of own personality of a person consists of many pieces like a puzzle. The NLP specialist provides to form a pretty picture by combining these pieces harmonically. The eliminates the fears of the person by providing to think from different aspects. Fear arises at subconscious to protect the person. NLP specialists can recover the patients from these fears after few sessions.

Mini Review

There is a sentence of “Fear is the one generally the person has created in imagination” at the celebrated Desiderata poem of Max Ehrman. If we can establish good communication with the patients who do not go to dental clinics gladly and behave timid, it will take us to the success. Since, the right communication between people makes everything easy. You can understand if the patient, coming to you first time, is relaxed or not from his/her body language, glances, breathing and receive good or not good signals from him/ her. How can we get these signals, how can we understand the body language? Here we can use the NLP for all human relations. What is NLP? The NLP which is started to use almost at every fields recently, was actually first discovered at California in 1970s. Linguistic Scientist John Grinder and Mathematician Richard Bandler, have taken an example of three people, who have excelled with special abilities at their fields. The first of these three people is worldlycelebrated Hypnotherapist Milton Erickson, the other is famous Jewish Psychotherapist Fritz Perls and, the third is Virginia Satir who is referred as the mother of Family Therapy. How can these three people sign great successes by slamming their colleagues? Bandler and Grindler have found out that these three separate successful people have used interestingly similar patterns although they have different attitudes. Later they have modeled the other people who has perfect performance like Anthropologist Gregory Bateson and have prepared a book to use these methodologies. The meaning of the NLP letters.

Figure 1.

Figure 2.

Figure 3.

Figure 4.

Figure 5.

Neurological (Neurological): It is related with our neurological system and our manner of experiencing the world using our senses. It transforms several sensorial information’s into conscious and unconscious consideration processes. These consideration processes affect our physiology, emotions and behaviors.

Linguistic (Linguistic): It refers to the use of language. It provides us to tell how we perceive our experiences at the world and the world. The words we use affect our experiences too.

Programming: It is something we do intrinsically. We code our experiences and use our consideration patterns to enable us to solve problem, make decision, evaluate, learn, and improve. We do not always notice this happening consciously. Additionally, we do not know that the ability of recoding our experiences to get more reasonable results and organizing the internal programs, is inside of us. The mind and the body consist a system affecting each other. We can affect our physical situation by changing our mental situation or affect our mental situation by changing our physical situation. We all use our senses to explore the world. We get information from our environment and stock the impacts as picture. Seeing, hearing, smelling, tasting, touching (Figures 6-10). However, it is impossible to perceive everything presented to us instantly. We only get the ones passing through our own perception filters and the others stay out. These filters are individual. The filters of the person are based on his own experiences, culture, nurture way, beliefs, values and assumptions. The thing which is right to me is justified according to the thought coming from my inside and formed with my perceptions. But the same right thing may not be right to another one. Well, can these filters be changed? Yes, we can control the preparing of our personal map by changing filters with the help of NLP [1,2].

Figure 6.

Figure 7.

Figure 8.

Figure 9.

Figure 10.

We can transform our world into wealthier and more exciting place by changing filters. “THE MAP IS NOT SAME WITH REGION”. Every individual has different map so, it is necessary to try to understand the world maps belong to other individuals, or rather to understand and accept, appreciate. Beauty, Peace, Freedom, Equality; The concept of Beauty involves different meanings according to each person. When saying Beauty, Mr. Ahmet sees the mountains far away, Mr. Mehmet sees shiny beach, Ms. Hasibe sees the face of the person she loves. Freedom is coalescing with God to one, use of time properly to other, and cheating his spouse to another one. We can understand the causes of the wars if we take into account these differences of mind maps. The conflicts between the people arise because of these differences. The most important thing to do here will be getting rid of limited maps by changing perception filters. To provide efficient communication, it is necessary to understand the world maps of other people or the person across us, to appreciate them. We must be open, curious and eager to experience. Every person has sufficient resources and potential since birth, however the use of this depends on that person’s choice. Communication is a circuit, when one person pays attention to the other, he receives what the other one says and does into his system, he contacts with his own senses and react conveniently with his own manner. When the other person pays attention to this person too, the circuit is consisted. In communication, what the other person understands is important rather than what we tell. In order to achieve success in relationship, the person at other side of you must trust you. Now we turn to the Dental Clinic, observe the behavior differences and the reasons of the patients with examples: Each person has one (genital) area, when we think the individual at the center of a circle, this circle which radius is about 50 cm, is the private area of that person, and this person allows only inseparable friends and relatives to get into that circle [3,4]. When we come across the people we do not know very well, we claw and shake hands but always keep that private area. Dentist office is a different environment that the people do not go frequently, equipped with unusual instruments, getting smell of sanitizer or drugs, scary sounds coming from aerator works, having presence of the staff and doctors with smock. The person coming here is mostly anxious, there are lots of questions in his mind, such as will I be have injection, will I feel pain, will my tooth be pulled, will the doctor reprimand me if he detects my mouth hygiene is insufficient. The things will not go well, if you do not prepare the patient psychologically, not relax him, take him directly to the treatment room, sit him to the chair and tie his veil immediately

Today the doctor and assistant are working sedentarily in treatments. The doctor sits on his right side, the assistant sits on his left side and the forced entrance of two stranger people he does not know before, one from right and one from left, to the patient’s private area, will increase the uneasiness of the patient more. This situation is getting more sensitive especially for the child patients. When one child patient comes to the dentist first time, it certainly requires allocating time, give information with a special manner and soft behaviors and not to start to the treatment without consent of the child. The language used is very important, all we use the same language however the words we select may awake negative impact on the patients. NPL is a wide-scope communication model. Our bodies, heart and spirit are the parts of one system and affect each other in different ways. Communication is an exchange of sensual experiences. There is certainly action and reaction in communication, good or bad action will be resulted whether we want, or we do not want. Communication is directly related with body language. When conveying bad news, touching to the patient’s arm softly substitutes too many words. Of course, our voice tone plays also great role here.

Preparing the Children to the Treatment

Of course, the first task here belongs to the parents. If the parents avoid from the dentist and show their fears within their dialogs at home, the child will record all the talks like a stereo even the child plays at one corner as if not concerning with them. The child will conclude that it is not a good thing if the most trusted people since his birth, speaks that much negatively about doctor. And one day when the parents take him to the dentist, the child not only will reject the treatment but also not want to go inside the clinic. The parents will be surprised very much and will ask themselves why this rejection happens although he is coming first time, he does not know anything. To prepare the children coming to the clinic with prejudgment to the treatment requires too much patience and effort. In such situations, it requires to talk with the parents. Generally, the Technician of Mouth and Tooth Health (can be said also assistant) will open the door for the patient coming to the clinic. Since the doctor engage with the patients at treatment rooms, they need to take responsibilities of very important tasks such as greeting the patient, preparing the patient to the treatment. In short, all the clinic staff along with the doctor should be very equipped with the communication skills. Greeting the patient with smiling face and warmly, namely first impression, is crucial. It should be acted with the principle of “Clinic is our home, patient is our guest.” If the first impression is not good, then the patient will think if he goes to that clinic second time again, although how so ever the treatment of the doctor is good. The entrance of the clinic, the decoration of the environment, the colors selected play a role on the patient feels better.

There are art objects at the cabinet seen at the picture and an egg-man statue on the radiator On the wall, pictures that will make people smile or look at them with pleasure should be preferred and excessive modern, unclear, pessimistic paintings should not be presented. A lightly playing of relaxing music background contributes the tranquility of the place. There must be actual magazines along with the picture books for the children at the clinic. Especially, the children picture books introducing dentist’s office can be read with the assistant while preparing the child to the treatment. Assistant should introduce the clinic to the child patient, information should be given about why the tooth treatment is necessary and what will be done, meanwhile the questions of the child should be listened gingerly and right answers should be given. When the child patient taken into the treatment room, it shouldn’t be wanted to sit him to the chair before introducing all the objects in the room, the explanations should be made like look, this is the chair on which tooth treatment is done, you will sit here, I will sit near you, doctor will sit on the other side and we all help your teeth to be healthy. Crouch down when talking to the child, in short, do not call him from on high. Glance from overhead and calling from on high may cause a sense of child as if the other one is stronger than him, the other is the authority. So, be careful at heads and eyes be on the same level when talking to the child. In such a conversation where the eyes are at the same level, the child decides that you value him as an individual and takes first steps toward trusting you. During a conversation where the eyes are at the same level, you make observation, understand his body language, glances, breathings, shortly if he is comfort or not. If there will be any treatment requiring anesthetize, it should be told to the child meticulously. You can give the injection within the nylon bag and must tell that the liquid inside will be injected under the gum, then that region will be anesthetized, and he will never feel any pain. Then, will the injection hurt? This question will be absolutely coming. The answer should be as yes but very little. Touch the arms with dental probe slightly, make explanations such as look, this hurts a bit, right, but you could bear, the injection will hurt just a little as a bite of a fly. The child understands that you always tell the truth and he will trust you. Again, we turn to the mistakes of parents. The mother bringing his child to the clinic is generally exciting. One day, a 6-year old boy came to our clinic first time, my assistant cared about him, he made the necessary explanations, then the child was taken to the treatment room, there was a baby back tooth problem required an amputation treatment, I gave information about the injection as written above, I answered all his questions which were asked intelligently, the mother was sitting on a corner at the treatment room. The child gave permission to the injection calmly, my assistant conveyed the injection which he prepared, just that time the mother stood up and said my boy, i will hold your hand, this was an unnecessary behavior but we allowed. Just as I prick, exciting mother tightened his boy’s hand hardly, this flux went from the child’s arm to his brain and he pushed my hand with the idea of “if my mother is that much anxious, it won’t be done good things to me”, he run away by getting out of his chair.

Yes, there are plenty of patients being afraid of injection. When coming to the clinic, he mentions this and says that make a treatment without injection, I am afraid. Phobias, fears are not but a kind of obsessions within the brain, these can be changed and eliminated. The fears were formed generally because of bad experiences before, at childhoods. Once we have burnt our hands on the fire, we would not approach to the fire anymore. If we have felt too much pain in the dentist’s office, every time we think dentist, the picture of that moment wakes on our eyes. How can we erase these negative thoughts? Let’s move on the examples.

new patient whom we have put full denture to his jawbone, came for control two days later, it was understood from his appearances that he was not glad. He said that he couldn’t have eaten anything, all his mouth was hurting, then he also added that he was so regretful having denture. All his body language and words were totally negative. First, we have listened him calmly, approached with emphatically, agreed on the inconvenient of the denture pain. Later we have passed to our questions. What did you eat at night? “Dear, I had soup (he had said that he could not have eaten anything, now some soap drunk), took two spoons from potato’s puree (this makes two) but as soon as I bite that Inegol meatball, I leaped up.” Yes, at first our patient generalized, when he said the life was awful, I could not eat anything, the situation specified and ended up at the Inegol meatball. Later I have started examination in mouth slowly, I pressed the right side of the denture lightly, asked if there was any pain, he said no, then when I pressed the left side, he said yes, just there. We have made this detection with our patient and hopelessness appearance of the patient started to vanish slowly. I said that I would rasp this hurting part completely and you would be comfort immediately and you could eat Inegol meatball this night.

took away the part I marked at lab and asked him to try again after polishing that place. His eyebrows totally got relax position, he said yes, it is all right now, we sent off the patient with pleasure after applied ointment with lidocaine on redness and minor wound and said he would use this ointment for several days. Thus, we minimized even zeroed this problem which was great for the patient. The second example emphasizes the importance of asking question at the application of NLP: I came across my friend on the road, I asked how he is, how is going on. The answer: “Do not ask, I am bothered, I am out of sorts.” Well, what is your problem? “I’ve got some financial difficulties.” I went to ask but I paid attention that my questions were carefully selected not random questions. Since when have you been in difficulty? “For last month.” What happened in last month? I got a counter done for the store, additionally I ordered new goods, I am sweating to pay back. I evoked him, who has started to believe that he was always distressed, he has experiencing difficulty just only last month, the problem minimized, now it is time to reassure a bit. I said that you are actually rising your standards, you have made a good decision, you have made a good work, everything will be great when your debt finishes. Thus, my friend’s negative will turn into positive, the troubles at his brain will be erased, good feelings will substitute, and I could see this situation on my friend’s face. Does every method efficient every time at NLP? No, sometimes the success may not be achieved with one try, another technique is applied at second session, the patterns should be individual after familiarizing the person. The picture of own personality of a person consists of many pieces like a puzzle. The NLP specialist provides to form a pretty picture by combining these pieces harmonically.

It is not necessity that this picture be visual, it can also be the picture of aural or feelings. When we turn back to our child patients, while we meet the child patient coming first time to our clinic, i prefer taking off my clinic smock, thus I break the formality between us and give an impression of not being different from the uncle neighbor. This makes him relaxed, then I tell him why we need to dress smock, I introduce the instruments over the unit of tooth, I tell what their functions, I show mouth mirror and probe, even i offer to change our roles, I want him to dress smock, to sit on my place, and examine me. They enjoy too much, they find tooth unit very interesting, I hand over the water spray and make them use it, then I introduce absorption motor, I explain why it should work with water and why the water needs to be absorbed, and I provide him to absorb the water in the glass with cannula, I tell that I can see more easily the inside of a mouth by changing the level of the chair and adjusting reflector. They enjoy making me sit on the chair and raising it, even dashing water spray into my mouth and sometimes their dashing water on my face make them smile and fear from the dentist vanishes. It will be appropriate for children to sit on the dental chair with their mother. He feels himself safer in her arms. First the mother is examined, the child sees that his mother is calm and that she is not affected from the examination by entering her mouth with a mirror, and then the child allows to be examined.

Mother Frank said: “I understood that fear is no use at all, it does not work at all.” We can ensure the person get rid of his fears by making him thinks in different ways. Fear arises at subconscious to protect the person. NLP specialists can relieve patients from these fears in a few sessions. The unpleasant events that we have experienced occupy our brains, and this will haunt us for life, and it will always be somewhere over there. NLP specialists are able to uncover and dispose of these bad events in their sessions and comfort the patient. Communication includes more than words. Not talking at all is also a communication method. In communication, body language is 55 percent, tone of voice is 38 percent, words are only 7 percent effective. As a result, communication is a circuit, what we do affects the other, and what he does affects us. If you notice that you have conveyed a different message than you intended while watching people’s reactions, we will accept this as a useful feedback and continue our practices by changing the way we communicate until we get the response we want. One last example from our clinic again: Ms. Seyda, in her 60s, was sitting in our treatment chair. Ms. Seyda, you probably do not brush your teeth well. Me, how can you say something like that, I brush my teeth three times or even four times a day. (she frowned her eyebrows, stopped looking at my face, started to look at the upper left wall corner, made clear with her whole body that she rejected me that moment. I accepted this as feedback, I realized that I could not express what I want to say well, the way I expressed was wrong).

a) No, of course your teeth are very clean, your mouth is sparkling, I did not mean it, I just wanted to emphasize that it would be better if you change your brushing technique.
(eyebrows came down, head turned towards me).
b) Oh, yeah, how is that technique?
c) Let me explain Ms. Seyda, the strong right-left movements with the brush have eroded the neck parts of your teeth.
d) The protective enamel layer, which is very thin in this region, is worn, the second layer of the sensitive tooth is about to be exposed and this will lead to excessive sensitivity.
e) So, that is why my teeth are so sensitive, doctor, can you tell me how to brush them?
f) The body language of Ms. Seyda started to be positive, curiosity and desire to learn arose. The technique was shown to her, the communication was completed, and the patient left the clinic satisfied.

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Lupine Publishers | Social and Psychological Impact of Traumatic Dental Injuries in Children and Adolescents: A Review of Literature

 Lupine Publishers | Journal of Pediatric Dentistry

Abstract

Traumatic dental injuries in childhood are quite commonplace, with a reported occurrence of up to 30% globally. The effect of traumatic dental injuries can have adverse effects on the child, his family and the dentist treating the child. This is an area which has always been neglected. The psychological effect of TDIs are individual for each patient and as such should be treated as a whole. Children who had suffered a traumatic dental injury seems to have the worse oral health related quality of life and they are more likely to have low self-esteem when their dental injuries are not properly treated. Children who have dental anomalies are judged poorly by their peers and the society as a whole and these judgements are increased many folds due to the presence of social media. At present there is a lack of proper research to study the psychological effect of traumatic dental injuries. Currently though there is advancement in the field of managing traumatic dental injuries there is still a lack of awareness regarding the young patient’s experience and values.

Keywords: Traumatic dental injuries; psychological; children

Introduction

Facial esthetics play an important role in self-identification, selfimage, self-presentation, and interpersonal confidence. The face is an important part of human development and facial expression is the most important element in non-verbal communication. The significance of the teeth in a smile should not be underestimated. Psychologists define a traumatic experience as an intense and sudden event that overwhelms the person’s capacity to cope with the memories and feelings that are triggered by it. Such traumatic experiences may lead to psychological symptoms, such as depression and anxiety [1]. The psychological effect of TDIs are individual for each patient and as such should be treated as a whole.

Stages of Psychological Development

Toddlers

Toddlers aged about 1.5 to 3 years are developing a sense of doing things on their own. The child has a very strong drive to investigate the boundaries set by adults to try out his or her own power and abilities, and to experience new, thrilling situations [2]. A traumatic experience such as intense pain puts limits on the child’s expanding world [3]. Furthermore, the experience of pain is imprinted on the mind of young children [4,5].

Later preschool childhood

During later childhood, aged 3–5 years, children develop a clear concept of themselves as ‘me’, knowing they are a separate person and no longer dependent on their parents in familiar situations. Development brings the child into a world of magic, oscillating between reality and fantasy. A feeling of guilt may intensify the psychological impact. Furthermore, at this age, children perceive the body as a bag containing feelings, tears, food, a heart, and blood; it is frightening if there is a hole in the bag, so it has to be mended as soon as possible.

School age

School age (6–12 years) is a period of life characterized by intense development in social skills and cognitive growth. Around 9 years of age, the child reaches an adult conception of life and death, namely, a full understanding that everyone who lives will also die, including oneself. This leads to a deeper understanding of the transient nature of life and might cause an easily evoked fear of death and illness [6]. Such a fear could be triggered by a TDI event associated with intense pain.

Adolescence

Adolescence (13–20 years) is the final period of the child’s development into adulthood. Intellectually, the young person is capable of formal operations [7]. Thus, an adolescent has adult intellectual concepts, but less experience than an adult. Teenagers often experience mood swings, as they are trying to achieve a stable inner identity and self-esteem. This is a process that goes on for years and takes great energy. Emotionally, the teenager will pass through different periods, the first of which is dominated by regression, as the wish to remain an innocent child clashes with the need to grow up. The last period also represents the final emotional separation from parents and the security of childhood, in which there is loss and often some degree of depression until the young person finds a new sense of belonging [8]. A traumatic experience with intense pain during this period of development may exaggerate any expression of regression, aggression, or depression.

Psychosocial Aspects of Traumatic Dental Injuries

The aspect of oral conditions on an individual’s physical and psychosocial wellbeing can be assessed through subjective indicators called Oral Health Related Quality of Life (OHRQoL) measures. The aim is to assess major changes in behavior that upset social function and consequently alter people’s quality of life [9]. Studies on oral health and quality of life should address four areas:

a) Pain and discomfort.
b) Functional aspects related to the ability to chew and swallow food without difficulty and speak and pronounce words correctly.
c) Psychological aspects related to physical appearance and self-esteem; and
d) Social aspects reflecting social interaction and communication with people [10,11].

These dimensions were described by Locker [12], based on The International Classification of Functioning, Disability and Health developed by the World Health Organization (WHO) [13]. According to Locker [12], mouth injuries and diseases cause damage that can directly lead to disabilities or indicate the following symptoms: pain and discomfort, functional limitation, and dissatisfaction with one’s own appearance. These symptoms can trigger physical, psychological, or social limitations, and consequently, disability. In turn, pain and discomfort can lead straight to disability. Oral health problems have been increasingly recognized as having an important negative impact on quality of life for individuals and populations. Traumatic dental injuries occur most commonly in the anterior sextants of the dental arches [14]. The psychosocial problem may occur due to the incident that caused the TDI or because of esthetic impairment by a broken or blackened tooth [15], an increase in dentin sensitivity attributed to the exposure by fracture [16] or another functional problem [15]. The magnitude of the psychological impact depends on the type of event or associated violence. For example, when TDI is the result of aggression, physical assault or abuse, the potential to generate psychological stress is much higher than when resulting from sports activities or an accidental fall. These conditions can cause serious esthetic, psychological and social damage, besides producing significant costs for the TDI victim and their family [17].

Ways to Explore the Impact of Traumatic Dental Injury

Quantitative way

To date, our knowledge of TDI impacts in children has been largely based on findings from quantitative research. Oral health related quality of life (OHRQoL) questionnaires have been used by researchers which have been validated for different age groups as well as in different languages [18–22].These questionnaires have been designed to measure the impact of dental anomalies or injuries on the child’s everyday life [22,23]. To calculate a total OHRQoL Score children are asked about the number of impacts that they had in the past three months on their daily life. Questions belonging to different fields of life are generally asked such as social life, wellbeing, oral symptoms, and physiological functions.

Qualitative way

The first documented case of the impact of a traumatic dental injury on social life was published 60 years ago [24]. It documented the case of a 9-year-old boy who was an active member of two choirs. The boy had an injury in which he suffered from uncomplicated fracture of four permanent incisors. Due to this the boy developed a lisp. The boy was removed from his position in the choirs and as a result the boy suffered from mood swings and sleep disturbances. The similarity of the psychosocial impact the boy had to the theoretical model of OHRQoL was striking [25,26].

Concern regarding appearance

Youths today are more concerned with their appearance. They are more concerned about following the norms setup by society. They are also concerned about the judgement of their peers and society as a whole. These judgements can have lifelong impact on their social life, career, and judicial outcomes [27-29]. Children who have suffered from dental anomalies as a result of TDIs have low self-esteem and are prone to bullying in schools. They are worried about the unkind comments that are thrown at them by society [30]. Hence it is the responsibility of the dentist to be sympathetic and provide timely treatment according to the child’s social standing.

Psychological effects of TDI The nature and the circumstances of TDI can lead to mental health problems in children. A study in the UK showed that one in six children suffer from post-traumatic stress disorder up to eight months after the injury [31]. Hence it is necessary for pediatric teams responding to dental emergencies to properly assess the children psychologically after a TDI and put them under proper care for their emotional support [32].

TDI, its treatment and its effect

The treatment of TDI has a psychological consequence of its own on the concerned children and their families. When the TDIs are complex the concerned treatments are prolonged, and this places high demands on the concerned children and their families. Studies in the UK, Canada and USA have shown these [33-36]. In a study in Toronto which tried to find out the impact of avulsion injuries on the children and their families, it was found that the children had to visit hospitals nine times in a year on an average. They received over seven hours of dental treatment and lost two weeks of schooling at an average [33].It is also necessary to follow the long term consequences and prognosis of the teeth treated after a TDI throughout adolescence and early adulthood [37].

Economic consequences

The patient should be informed about means of reducing a possible economic impact of the TDI (i.e. support from public or insurance companies). knowledge and skills to make an accurate diagnosis and perform appropriate and prompt emergency treatment. Lack of postoperative information might add to emotional stress during emergency treatment as the child anticipates future problems. Give information in as concise and positive a manner as possible, emphasizing the likelihood of recovery and also give written information. Pain adds significantly to both physiologic and psychological stress. This means that immediate and skillful pain control should be given very early at the emergency ward or if possible, at the place of injury. Post traumatic follow up gives an excellent opportunity to talk the whole treatment through, from the moment of the injury until the expected end result. This will reduce negative feelings about dental care.

Conclusion

There are many implications of TDIs. They may be social or psychological. In most cultures, the face is regarded as the most precious characteristic of human identity. A smile is an essential feature both for children and adults. A traumatic dental injury may affect the appearance due to a fracture, discoloration of teeth or avulsion of teeth. The trauma event in itself might have serious psychological effects. Keep in mind that even the youngest child will remember. Negative effects could be reduced by means of good emergency care. The dental team must be aware of and understand the anxiety of both children and parents. Awaiting treatment is a stressful experience for children, especially if they are also exposed to the frightening sight of other emergency patients and are in unfriendly surroundings. Even with recent advancement in the management of TDIs to improve dental wellbeing there is lack of awareness about the psychological and economical implication of TDIs.

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