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حصريا تحميل كتاب DENTAL SECRETS, FOURTH EDITION مجاناً PDF اونلاين r nFOURTH nEDITOR IN CHIEF nSTEPHEN T SONIS, DMD, DMSc nClinical. حصريا تحميل كتاب DENTAL FOURTH EDITION EDITOR IN CHIEF مجاناً PDF n niv nPREFACE TO THE 4TH nIt has been some time since last edition Secrets. لينك مباشرلتحميل كتاب DENTAL SECRETS, FOURTH EDITION مجاناً PDF اونلاين r nFOURTH nEDITOR IN CHIEF nSTEPHEN T SONIS, DMD, DMSc .

Readers of older editions will note some changes in contributors. The science and practice of dentistry continues to evolve. Hopefully, this book will help. Once again, Dental Secrets is written for those who like to learn by those who love to teach. What are the objectives of pretreatment evaluation of a patient? Establishment of a diagnosis 2. Discovery of concomitant illnesses 4.

Periodontology 7. Endodontics 8. Restorative Dentistry 9. Prosthodontics Pediatric Dentistry and Orthodontics Oral and Maxillofacial Surgery Infection and Hazard Control Dental Public Health Insurance Insurance is a means of protection from financial loss.

It is a form of risk management, primarily used to hedge against the risk of a contingent or uncertain loss.

An entity which provides insurance is known as an insurer, insurance company, insurance carrier or underwriter. Compare gas and electricity tariffs and feel the power! If you've felt a pang of nervousness before opening the latest correspondence from your gas and electricity supplier, you're living in fear of a monster energy bill. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein.

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In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided i on procedures featured or ii by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications.

It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. ISBN pbk. Sonis, Stephen T. Series: Secrets series.

Dental Care--Examination Questions. WU Readers of older editions will note some changesin contributors. The science and practice of dentistry continuesto evolve. Hopefully, this book will help. Once again, Dental Secrets iswritten for those who like to learn by those who love to teach. Costa Jr. Levi Jr. Tip: The patient presents with a gross negative generalization. Distortions and deletions of information need to be explored.

Not liking you, the dentist, whom she has never met before, is not an accurate representation of what she is trying to say. It is important to do active listening and allow the patient who comes to the office with some negative expectations based on past situations to express her thoughts and feelings.

The previous dentist might not have developed listening skills and left the patient with a negative view of all dentists. It was horrible. What may be the significance of his statement?

Did the patient have an impaired airway with past rubber dam experience, or has some long-ago experience been generalized to the present?

Does the patient have a gagging problem? A therapeutic interview clarifies, validates, reassures, and allows the patient to be more compliant. A year-old man is referred for periodontal surgery. During the medical history, he states that he had his tonsils out at age 10 years and, since then, any work on his mouth frightens him. He feels like gagging. How do you respond? Tip: A remembered traumatic event is generalized to the present situation.

Although the feelings of helplessness and fear of the unknown are still experienced, a reassured patient who knows what is going to happen can be taught a new set of appropriate coping skills to enable the required dental treatment to be carried out. The interview fully explores all phases of the events surrounding the past trauma when the fears were first imprinted. You recommend extraction to prevent further infection and potential involvement of adjacent teeth.

Save it! Tip: The command by the patient to save a hopeless tooth at all costs requires an understand- ing of the denial process, or the clinician may be doomed to perform treatments with no hope of success and face the likely consequence of a disgruntled patient.

The interview should clarify and inform while communicating a sense of concern and compassion. With each of these patients, the dentist should be alerted that something is not routine. Each patient expresses some concern and anxiety. This is clearly the time for the dentist to remove the gloves, lower the mask, and begin a comprehensive interview. Although responses to such situations may vary according to individual style, each clinician should pro- ceed methodically and carefully to gather specific information based on the cues presented by the patient.

The following questions and answers provide a framework for conducting a therapeutic interview that increases patient compliance and reduces levels of anxiety. The basic goal is to establish a therapeutic dentist-patient relationship in which accurate data are collected, presenting problems are assessed, and effective treatment is suggested.

The patient should feel heard and validated, which leads to a feeling of safety and trust. The clinician should be attentive to what the patient verbalizes i.

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While listening carefully to the patient, the dentist can observe associated gestures, fidgeting movements, excessive perspiration, or patterns of irregular breathing that might indicate underlying anxiety or emotional problems.

However, some patients also may feel insecure or emotionally vulnerable because of such disclosures. Patients may feel the fear of rejection, criticism, shame, or even humiliation from the dentist because of their neglect of dental care.

Thus, patients may react to the dentist with rational and irrational comments, and their behavior may be inappropriate and even puzzling to the dentist. Furthermore, patients who perceive the dentist as judg- mental or too evaluative are likely to become defensive, uncommunicative, or even hostile. Anxious patients are more observant of any signs of displeasure or negative reactions by the dentist.

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The role of effective communication is extremely important with such patients. Communication founded on the basic concepts of empathy and respect gives the most sup- port to patients.

Although the dentist tries to maintain an attitude that is attentive, friendly, and even sym- pathetic toward a patient, he or she needs an appropriate degree of objectivity in relation to patients and their problems. It is important to strive to be as neutral and nonjudgmental as possible so that the patient can feel safe and trusting.

Giving full attention while listening demonstrates to the patient that you are physically present and comprehend what the patient relates.

Appropriate physical attending skills enhance this process. Careful analysis of what a patient tells you allows you to respond to each statement with clarification and interpretation of the issues presented. The patient hopefully gains some insight into his or her problem, and rapport is further enhanced.

Looking at the patient without overt staring establishes rapport. Facial expression. A smile or nod of the head in affirmation shows warmth, concern, and interest.

Vocal characteristics. The voice is modulated to create a calm tone, emphasize meaning, and help the patient understand important issues. Body orientation. Facing patients as you stand or sit signals attentiveness. Turning away may seem like rejection. Forward lean and proximity. Leaning forward tells a patient that you are interested and want to hear more, thus making it easier for the patient to comment.

Proximity infers inti- macy, whereas distance signals less attentiveness. In general, 4 to 6 feet is considered to be a social consultative zone. A verbal message of low empathetic value may be altered favorably by maintaining eye contact, leaning forward with the trunk, and having appropriate distance and body orienta- tion.

However, even a verbal message of high empathetic content may be reduced to a lower value when the speaker does not have eye contact, turns away with a backward lean, or maintains too far a distance.

For example, do not tell the patient that you are concerned while washing your hands with your back to the dental chair. Most people express information that they do not fully understand by using generalizations, deletions, and distortions in their phrasing. By probing further, the dentist may discover specific fears or behaviors that the patient has deleted from the opening generalization. Questions that do not have specific yes or no answers give patients more latitude to express themselves.

More information allows the dentist to have a better understanding of patients and their problems. A communication technique called facilitation by reflection is helpful. One simply repeats the last word or phrase that was spoken in a questioning tone of voice. The goal is to go from a generalization to the specific fear to the origin of the fear. This process is therapeutic and allows fears to be reduced or diminished as patients gain insight into their feelings. Negatives should be avoided in commands.

Positive commands are more easily experienced, and compliance is usually greater. To experience a negation, the patient first creates the positive image and then somehow negates it.

While experiencing something, only positive situations can be realized; language forms negation. If you ask someone not to see elephants, he or she tends to see elephants first. While you take another deep breath, allow your body to relax further. Providing pathways to achieve a desired end may help patients accomplish something that they do not know how to do on their own.

Patients may not know how to relax on command; it may be more helpful to suggest that while they take in each breath slowly and see a drop of rain rolling off a leaf, they can let their whole body become loose and at ease. Indirect sug- gestions, positive images, linking pathways, and guided visualizations play a powerful role in helping patients achieve desired goals.

Most people record experience in the auditory, visual, or kinesthetic mode. They hear, they see, or they feel. Some people use a dominant mode to process information. Language can be chosen to match the modality that best fits the patient. If patients relate their problem in terms of feelings, responses related to how they feel may enhance communication. Things look less frightening now. Positive supportive statements to the patient that he or she is going to do well or be all right are an important part of treatment.

Reassurance given too early, such as before a thorough examination of the pre- senting symptoms, may be interpreted by some patients as insincerity or as trivializing their problem. The best time for reassurance is after the examination, when a tentative diagnosis is reached. The support is best received by the patient at this point. Certain words or descriptions that are routine in the technical terminology of dentistry may be offensive or frightening to patients.

The words cutting, drilling, bleeding, injecting, or clamping may be anxiety-provoking terms to some patients. Furthermore, being too technical in conversations with patients may result in poor communication and provoke rather than reduce anxiety.

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It is beneficial to choose terms that are neutral yet informative. One may prepare a tooth rather than cut it or dry the area rather than suction all the blood. This approach may be especially important during a teaching session when procedural and techni- cal instructions are given as the patient lies helpless, listening to conversation that seems to exclude his or her presence as a person.

Then it can be extremely stressful to the patient and pro- vider. Women tend to be more phobic than men and younger individuals more than mature adults. Unless this cycle of avoidance is treated by a knowledgeable and caring dentist, a patient may never seek anything but beyond emergent care, with a resultant progression toward edentulism. Second, preparatory explanations may deal effectively with fear of the unknown and thus give the patient a sense of control.

Allowing patients to signal when they wish to pause or speak further alleviates their fear of loss of con- trol. Finally, well-executed dental technique and clinical practices minimize unpleasantness. Usually, dental-related fears are learned directly from a traumatic experience in a dental or medical setting. The experience may be real or perceived by the patient as a threat, but a single event may lead to a lifetime of fear when any element of the traumatic situation is reexperienced.

The situation may have occurred many years before, but the intensity of the recalled fear may persist. Associated with the incident is the behavior of the doctor in the past. Thus, for defusing learned fear, the behavior of the present doctor is paramount. Fears also may be learned indirectly as a vicarious experience from family members, friends, or even the media.

Cartoons and movies often portray the pain and fear of the dental setting. How many times have dentists seen the negative reaction of patients to the term root canal, even though they may not have had one? Feelings of helplessness, dependency, and fear of the unknown are coupled with pain and a possible uncaring attitude on the part of the dentist creates a conditioned response of fear when any element of the past event is reexperienced. Such events may not even be available to conscious awareness.

Dental fears may be seen as similar to classic Pavlovian conditioning. Such conditioning may result in generalization, in which the effects of the original episode spread to situations with similar elements. For example, the trauma of an injury or details of an emergency setting, such as sutures or injections, may be generalized to the dental setting.

Many adults who had tonsillectomies under ether anesthesia may generalize the childhood experience to the dental setting, complaining of difficulty with breathing or airway maintenance, difficulty with gag- ging, or inability to tolerate oral injections.

Modeling is vicarious learning through indirect exposure to traumatic events through parents, siblings, or any other source that affects the patient. According to studies, patients perceive the dentist as both the controller of what the patient perceives as dangerous and as the protector from that danger. This is the purpose of the clinical interview. The result of this exchange should be increased trust and rapport and a subsequent decline in fear and anxiety. What constructs are important to understanding dental fears?

Psychological theorists have suggested that events and situations are evaluated by using inter- pretations that are personality-dependent i. Emotions evolve from this history. Positive or negative coping abilities mediate the interpreta- tive process—people who believe that they are capable of dealing with a situation experience a different emotion during the initial event than those with less coping ability.

The resulting emotional experience may be influenced by vicarious learning experiences e. Belief that one has the ability to cope with a difficult situation reduces the likelihood that an event will be appraised as threatening, and a lower level of anxiety will result.

A history of failure to cope with difficult events or the perception that coping is not a personal accomplishment e.

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Because fears of dental treatment are learned, relearning or unlearning is possible. A comfort- able experience without the associated fearful and painful elements may eliminate the condi- tioned fear response and replace it with an adaptive and more comfortable coping response. Through the interview process, the secret is to uncover which elements have resulted in the maladaptation and subsequent response of fear, eliminate them from the present dental experience by reinterpreting them for the adult patient, and create a more caring and pro- tected experience.

During the interview, the exchange of information and insight gained by the patient decrease levels of fear, increase rapport, and establish trust in the doctor-patient relationship. The clinician only needs to apply an expert operative technique to treat the vast majority of fearful patients. Control through knowing is increased with these preparatory communications. A simple instruction that allows patients to signal by raising a hand if they wish to stop or speak returns a sense of control.

Also, patients can be given the choice of whether to lie back or sit up. Denial is a psychological term for the defense mechanism that people use to block out the experience of information with which they cannot emotionally cope. They may not be able to accept the reality or consequences of the information or experience with which they will have to cope; therefore, they distort that information or completely avoid the issue. Often, the underlying experience of the information is a threat to self-esteem or liable to provoke anxiety.

These feelings are often unconsciously expressed by unreasonable requests of treatment. For the dentist, patients who refuse to accept the reality of their dental disease, such as the hopeless condition of a tooth, may lead to a path of treatment that is doomed to fail. The subsequent disappointment of the patient may result in litigation issues. A phobia is an irrational fear of a situation or object.

The reaction to the stimulus is often greatly exaggerated in relation to the reality of the threat. The fears are beyond voluntary control, and avoidance is the primary coping mechanism. Phobias may be so intense that severe physiologic reactions interfere with daily functioning. In the dental setting, acute syncopal episodes may result. Almost all phobias are learned. The process of dealing with true dental phobia may require a long period of individual psychotherapy and adjunctive pharmacologic sedation.

However, relearning is possible, and establishing a good doctor-patient relationship is paramount. Post-traumatic stress disorder PTSD is an anxiety disorder that develops subsequent to a traumatic event, such as sexual or physical abuse, serious accident, assault, war combat, or natural disaster.

Symptoms include intrusive memories, avoidance behaviors, mood disorders, and high levels of physiologic arousal. Past traumatic events, whether remembered or suppressed in the subconscious, may trigger behavioral responses that occur when similar or even vicarious events occur in the present.

These events may be through direct experience, such as an accident, combat wound, or sexual abuse, or associated with observation of such events. The triggered behavior in the patient may be generalized fear and anxiety, and even extreme panic. Patients with PTSD who come for dental treatment may feel very vulnerable and can some- times find the experience retraumatizing.

This is because the patient is often alone with the dentist, is placed in a horizontal position, is being touched by the dentist, who is hierarchi- cally more powerful and often male , is having objects placed in the mouth, is unable to swallow, and is anticipating or feeling pain. Many PTSD sufferers avoid going to the dentist, often cancel or reschedule appointments, have stress-related dental issues, and experience heightened distress while undergoing procedures.

Similar to treating other anxious patients, dentists want to practice active listening, show compassion, and try to give the patient as much control in the situation as possible. You might offer an initial appointment just to talk, place the chair in an upright position, keep the door open, have an assistant present, check in frequently to see how the patient is doing, offer reassurance, and explain the procedures as you proceed.

Also, you can offer soothing music, blanket, or body covering e. Make sure that the patient has been instructed to stop you whenever their anxiety level is getting too high.

Premedication may be helpful. If the patient is unable to tolerate being in the dental chair because her or his anxiety is uncontrollably high, you might want to refer this patient to a professional who specializes in the treatment of anxiety disorders. Counseling and antianxiety medications can be helpful in the treatment of PTSD and, in some cases, may be a prerequisite to dental work being carried out. The gag reflex is a basic physiologic protective mechanism that occurs when the posterior oropharynx is stimulated by a foreign object; normal swallowing does not trigger the reflex.

When overlying anxiety is present, especially if anxiety is related to the fear of being unable to breathe, the gag reflex may be exaggerated.

A conceptual model is the analogy to being tickled. Most people can stroke themselves on the sole of the foot or under their arm without a reaction, but when the same stimulus is done by someone else, the usual results are laughter and withdrawal. Hence, if patients can eat properly, put a spoon in their mouth, or suck on their own finger, they are usually considered physiologically normal and may be taught to accept dental treatment and even dentures with appropriate behavioral therapy.

In dealing with these patients, desensitization involves the process of relearning. A review of the history to discover episodes of impaired or threatened breathing is important. Childhood general anesthesia, near-drowning, choking, or asphyxiation may have been the initiating event that created increased anxiety about being touched in the oral cavity.

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Patients may fear the inability to breathe, and the gag becomes part of their protective coping mechanism. Thus, reduction of anxiety is the first step; an initial strategy is to give information that allows patients to understand their own response better. Instruction in nasal breathing may offer confidence in the ability to maintain a constant and uninterrupted air flow, even with oral manipulation. Also, diaphragmatic breathing, which involves inflating the lower part of the abdomen, can be helpful.

This technique may be especially helpful for taking radiographs and for brief oral examinations. For severe gaggers, hypnosis and nitrous oxide may be helpful; others may find the use of a rubber dam reassuring.

For some patients, longer term behavioral therapy may be necessary. How is it related to fear? Anxiety is a subjective state commonly defined as an unpleasant feeling of apprehension or impending danger in the presence of a real or perceived stimulus that the person has learned to associate with a threat to well-being.

The feelings may be out of proportion to the real threat, and the response may be grossly exaggerated. Such feelings may be present before the encounter with the feared situation and may linger long after the event. Associated somatic feelings include sweating, tremors, palpitations, nausea, difficulty with swallowing, and hyperventilation.

Fear is usually considered an appropriate defensive response to a real or active threat. Unlike anxiety, the response is brief, the danger is external and readily definable, and the unpleasant somatic feelings pass as the danger passes. Fear is the classic fight-or-flight response and may serve as an overall protective mechanism by sharpening the senses and ability to respond to the danger.