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NICOTINE REPLACEMENT THERAPY

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Cigarettes contain nicotine and by smoking regularly and for long hours, your body becomes dependent on it. Giving up smoking can cause nicotine withdrawal symptoms which are :

  • Restlessness ,impatience
  • Eating more than usual
  • Anxiety / tension
  • Headaches,irritability / anger
  • Difficulty in concentration + Depression
  • Loss of energy,dizziness
  • Sweating
  • Insomnia
  • Stomach or bowel problems
  • Heart palpitations
  • Tremors
  • Craving for tobacco

Stop smoking medicines along with nicotine replacement therapy are effective aid to tobacco cessation & can help control these symptoms.

What are these?

3 types –

  • Champix tablets (varenicline)
  • Zyban tablets (bupropion)
  • Nicotine replacement therapies (gums,patches,lozenges,microtabs,sublingual tablets,insulators,cigs,nasal sprays)

How does it work?

Tobacco intakers who are motivated to quit the habit & are dependent on nicotine should be offered NRT.

  • Prescribed for 6 to 8 weeks,in blocks of up to 2 weeks,contingent on continued abstinence.
  • If one type of NRT is not working for the patient ,the health professional is advised to prescribe a suitable type informing about the dosage & maximum amount to take a day.

Is it safe?

NRT is safe because of the facts that the nicotine levels are low and it’s less addictive delivery mechanism (unlike smoking tobacco where the nicotine reaches the brain quickly) and also because most of the harmful problems are caused by the other components of tobacco smoke ,not by the nicotine.

NRT is safe for most adults and in people with stable cardiac diseases, but caution needed in unstable,acute cardiovascular disease,pregnancy,or breastfeeding or in those aged under 18 years.

Brownie points-reduces the constant urge to munch on food,thus reducing weight gain.😊

When should one stop using NRT?

Most courses of NRT recommend use for about 12 weeks.This is because it takes this much time for the brain to adjust to working without the high doses of nicotine that the cigarettes supply.However there is no hard and fast rule.After starting the therapy,most people mistake the lack of discomfort for the belief that the addiction is over,leading to stop using the product too soon. This can result only in reappearing of the symptoms.

The best method is to take the help of the health professional when you start the therapy and keep them updated about the progress.

Lastly ,we all are not the same….each tobacco smoker’s tendency & pattern to quit may vary & it depends on different factors like age,gender,environment, general physical and mental health.

Sources:S.S Hiremath textbook of preventive and community dentistry, http://www.healthunlocked.com(Quit Support)

TOBACCO CESSATION MOTIVATION

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Tobacco is the leading preventable cause of death in the world and is the only consumer product that kills when used as intended by its manufacturers ;which may become deadly for non-smokers also.

FACTS & FIGURES:

  • Tobacco causes 1 in 10 adult deaths worldwide,nearly 5 million deaths a year or one death every 6.5 seconds,killing 50% of regular users.
  • Total global smoking prevalence is 29%;47.5% men & 10.3% women.
  • By 2030,70% of deaths in the world is attributable to tobacco.
  • It’s a known or probable cause of about 25 diseases.
  • Smokeless tobacco causes oral cancer,especially in lips,tongue,mouth and throat area.
  • Breathing Environmental Tobacco Smoke(ETS) (i.e .side stream,exhaled smoke from cigarettes,cigars and pipes)causes serious health problems & aggravates allergies and increase the severity of symptoms in children & adolescents, with asthma and heart diseases.
  • People who start using tobacco early have more difficulty in quitting,are more likely to be heavy smokers and if young people donot begin to use tobacco before the age of 20,they are unlikely to start the habit.
  • The World Bank estimated that smoking prevention is among the most effective of all health interventions.
Deadlier than ever-how cigarettes have evolved over last 50 years.

EFFECTS OF NICOTINE :

  • Electroencephalographic desynchronisation.
  • Increased circulating levels of catecholamines, vasopressin, growth hormone,adenocorticotropic hormone,cortisol,prolactin,and beta-endorphin.
  • Increased metabolic rate
  • Lipolysis,increased free fatty acids.
  • Heart rate acceleration, nicotine can increase the heart rate by 10-15 beats/min.
  • Cutaneous & coronary vasoconstriction
  • Increased cardiac output & blood pressure by 5-10 mm Hg
  • Skeletal muscle relaxation
  • Nicotine can induce pathogenic changes to the endothelium associated with atherosclerotic process.
  • Halitosis,staining of teeth and soft tissues(smokers melanosis),drying of mouth.

‘Nicotine itself is not carcinogenic unless it undergoes nitrosation to form nitrosamines(during tobacco curing & combustion).’

HOW TO ASSESS TOBACCO DEPENDENCE?

A question-answer session with the individual would be very helpful ….

The total score can be calculated to know the dependence.

THE 5 A’S :

  • ASK- health care professionals / dentists should ask the patient about his or her tobacco intake habits which includes the questions discussed above,during every visit.
  • ADVICE-health care professional / dentists should continually advice patient to quit the habit thereby emphasizing the importance of the issue.
  • ASSESS- patients readiness & motivation to quit the habit must be assessed- cause this is a ‘major lifestyle change & requires preparation, readiness & several failed attempts’.
  • ASSIST-health care professionals/ dentists should assist those individuals who are motivated- by informing,suggesting and prescribing a pharmacological cessation aids ( nicotine replacement therapy ) and providing or referring the patient to counseling ( individual, group or over telephone ) and behavioral therapies and support services where available.
  • Lastly,ARRANGE-follow up services are often critical & the dentists can help the patient be tobacco free by providing services like advising availability of national hotlines,support from non-smoking friends or colleagues,or community based support groups.
The best time to quit smoking was the day you started,the second best time is today.

Lastly ,dentists play a major role in helping a patient quit smoking because we might be the first to detect an abnormality( be it a small stain or an abnormal mass ) in the oral cavity during routine examination. Do your part ,every small step counts……

Sources- S.S Hiremath textbook of preventive and community dentistry ,www.alhambraesd.org ,www.tobaccofreekids.org

RUBBER DAM

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Rubber dam was introduced byBarnum, a New York dentist in 1863

Advantages of using a rubber dam

• It is raincoat for the teeth
• It helps in improving accessibility and visibility of the working area
• It gives a clean and dry aseptic field while working
• It protects the lips, cheeks and tongue by keeping them out of the way
• It helps to avoid unnecessary contamination through infection control
• It protects the patient from inhalation or ingestion of instruments and medicaments
• It helps in keeping teeth saliva free while performing a root canal so that tooth does not get decontaminated by bacteria present in saliva
• It improves the efficiency of the treatment
• It limits bacterial laden splash and splatter of saliva and blood

• It potentially improves the properties of dental material.
• It provides protection of patient and dentist.

Disadvantages of using a rubber dam

• Takes time to apply 
• Communication with patient can be difficult 
• Incorrect use may damage porcelain crowns/crown margins/ traumatize gingival tissues 
• Insecure clamps can be swallowed or aspirated.Contraindications of use of rubber dam

• Asthmatic patients
• Allergy to latex
• Mouth breathers
• Extremely malpositioned tooth • Third molar (in some cases).

Rubber dam equipment

• Rubber dam sheet• Rubber dam clamp • Rubber dam forceps• Rubber dam frameRubber dam accessories•Lubricant/petroleum jelly• Dental floss• Rubber dam napkin.

Rubber Dam Sheet

  • The rubber dam sheet is normally available in size 5 × 5 or 6 × 6 squares in green or black color
  • It is available in three thicknesses, i.e. light, medium and heavy
  • The middle grade is usually preferred as thin is more prone to tearing and heavier one is more difficult to apply
  • Latex-free dam is necessary as number of patients are increasing with latex allergy
  • Flexi dam is latex-free dam of standard thickness with no rubber smell.

Rubber Dam Clamps

  • Rubber dam clamps, to hold the rubber dam onto the tooth are available in different shapes and sizes.
  • Clamps mainly serve two functions:
    1. They anchor the rubber dam to the tooth.
    2. Help in retracting the gingiva.

Rubber Dam Forceps

  • Rubber dam forceps are used to carry the clamp to the tooth.
  • They are designed to spread the two working ends of the forceps apart when the handles are squeezed together.
  • The working ends have small projections that fit into two corresponding holes on the rubber dam clamps.
  • The area between the working end and the handle has a sliding lock device which locks the handles in positions while the clinician moves the clamp around the tooth.
  • It should be taken care that forceps do not have deep grooves at their tips or they become very difficult to remove once the clamp is in place.

Rubber Dam Frame

Rubber dam frame supports the edges of rubber dam .Frames have been improved dramatically since their old style with the huge ‘butterflies’.Modern frames have sharp pins which easily grip the dam. These are mainly designed with the pins that slope backwards.

• Rubber dam frames are available in either metal or plastic. 

• Plastic frames have advantage of being radiolucent.
• When taut, rubber dam sheet exerts too much pull on the rubber dam clamps, causing them to come loose,especially clamps attached to molars.
• To overcome this problem, a new easy-to-use rubber dam frame (Safe-T-Frame) has been developed that offers a secure fit without stretching the rubber dam sheet. Instead, its “snap-shut” design takes advantage of the clamping effect on the sheet, which is caused when its two mated frame members are firmly pressed together. In this way, the sheet is securely attached, but without being stretched. Held in this manner, the dam sheet is under less tension, and hence, exerts less tugging on clamps—especially on those attached to molars.

SAFE T FRAME

Rubber Dam Punch

  • Rubber dam punch is used to make the holes in the rubber sheet through which the teeth can be isolated.
  • The working end is designed with a plunger on one side and a wheel on the other side.
  • This wheel has different sized holes on the flat surface facing the plunger.
  • The punch must produce a clean cut hole every time.
  • Two types of holes are made, single and multihole.
  • Single holes are used in endodontics mainly.
  • If rubber dam punch is not cutting cleanly and leavingbehind a tag of rubber, the dam will often split as it is stretched out.
  1. Rubber Dam Template
    • It is an inked rubber stamp which helps in marking the dots on the sheet according to position of the tooth.
    • Holes should be punched according to arch and missing teeth.
  1. Rubber Dam Accessories
  2. Lubricant or Petroleum Jelly
  3. It is usually applied on the undersurface of the dam.
  4. It is helpful when the rubber sheet is being applied to theteeth.
  6. dental floss
  7. It is used as flossing agent for rubber dam in tight contact areas.
  8. It is usually required for testing interdental contacts.

Rubber Dam Napkin

• This is a sheet of absorbent materials usually placed between the rubber sheet and soft tissues.
• It is generally not recommended for isolation of single tooth.

REFERENCE – NISHA GARG TEXTBOOK OF ENDODONTICS AND GROSSMAN’S TEXTBOOK OF ENDODONTICS

RUBBER DAM PLACEMENT

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  1. Placement of Rubber Dam
  2. Before placement of rubber dam, following procedures should be done:
    • Thorough prophylaxis of the oral cavity.
    • Check contacts with dental floss.
    • Check for any rough contact areas.
    • Anesthetize the gingiva if required.
    • Rinse and dry the operated field.
  • Methods of Rubber Dam Placement.
  • Method I: Clamp placed before rubber dam
  • Select an appropriate clamp according to the tooth size.
  • Tie a floss to clamp bow and place clamp onto the tooth
  • Larger holes are required in this technique as rubber dam has to be stretched over the clamp. Usually two or three overlapping holes are made.
  • Stretching of the rubber dam over the clamps can be done in the following sequence:
  • – Stretch the rubber dam sheet over the clamp
  • – Then stretch the sheet over the buccal jaw and allow tosettle into place beneath that jaw
  • – Finally, the sheet is carried to palatal/lingual side andreleased.
    This method is mainly used in posterior teeth in both adults and children except third molar.

Method II: Placement of rubber dam and clamp together

  • Select an appropriate clamp according to tooth anatomy.
  • Tie a floss around the clamp and check the stability.
  • Punch the hole in rubber dam sheet.
  • Clamp is held with clamp forceps and its wings are insertedinto punched hole.
  • Both clamp and rubber dam are carried to the oral cavityand clamp is tensed to stretch the hole.
  • Both clamp and rubber dam is advanced over the crown.First, jaw of clamp is tilted to the lingual side to lie on thegingival margin of lingual side.
  • After this, jaw of the clamp is positioned on buccal side.
  • After seating the clamp, again check stability of clamp.
  • Remove the forceps from the clamp.
  • Now, release the rubber sheet from wings to lie around thecervical margin of the tooth.
  • Method III: Split dam technique: This method is split dam technique in which rubber dam is placed to isolate the tooth without the use of rubber dam clamp. In this technique, two overlapping holes are punched in the dam. The dam is stretched over the tooth to be treated and over the adjacent tooth on each side. Edge of rubber dam is carefully teased through the contacts of distal side of adjacent teeth.

Split dam technique is indicated:

• To isolate anterior teeth
• When there is insufficient crown structure
• When isolation of teeth with porcelain crown is required. In such cases placement of rubber dam clamp over the crown margins can damage the cervical porcelain.
• Dam is placed without using clamp.
• Here two overlapping holes are punched and dam is stretched over the tooth to be treated and adjacent tooth on each side.

REFERENCE- NISHA GARG TEXTBOOK OF ENDODONTICS