The COVID-19 pandemic which has spread from China, through Europe and is now increasing in the United States, in addition to the reaction by the World Heath Organization, Centers for Disease Control, state governments, state dental boards and the ...
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The Endo Blog - 5 new articles


Your Brain and the COVID-19 Pandemic


The COVID-19 pandemic which has spread from China, through Europe and is now increasing in the United States, in addition to the reaction by the World Heath Organization, Centers for Disease Control, state governments, state dental boards and the non-stop media coverage, is causing tremendous anxiety and uncertainty among the dental community.  Congress has enacted legislation (HB6201) to expand sick leave and the dramatically expand the Family Medical Leave Act (FMLA) which will now apply to business under 50 employees, causing dentists to scramble to decide how these changes could affect their business.  The 2 trillion dollar stimulus package, S3548 Care Act, contains loans for small businesses to keep people employed provides some hope for dentists hoping to keep their teams in tact, but comes with the stress of trying to get approval before the money runs out.  This environment has created tremendous anxiety and stress for dentists.  Your practice needs leadership now more than ever!  As leadership coach, Joel Small says, "Your leadership legacy is being forged right now!"

Modern neuroscience has come a long way with the devlopment of the fMRI (functional Magnetic Resonance Imaging).   This technology allows researchers to see the brain in action by visualizing the neural activity in real time.

David Rock, of the Neuroleadership Institute, coined the term neuroleadership to describe the application of the findings of modern neuroscience to leadership. This article will help you understand how your brain works and provide some tips to help you to better manage your own anxieties and negative emotions and better communicate, teach, train and mentor your team.

A Quick Summary:

The brain can be divided into the limbic system and the cortex.

The limbic brain is considered the primitive part of our brain because it is focused on survival.  It is constantly scanning our world for threats and rewards.  It the the emotional center of our brain and closely tied to memory.  It has the ability to work at tremendous speeds and has inconceivable capacity.  The limbic brain is the strongest part of our brain and will typically overpower/override our cortex.  This part of your brain is causing you, and your team, to feel great anxiety in the current situation.

The cortex, and especially the prefrontal cortex (PFC) is the younger, conscious part of our brain.  It is the center of conscious thought, reasoning, decision making, memorizing, inhibiting, recalling and moderating social behavior. The PFC is slower, limited in capacity and easily fatigued.  While our cortex can easily be overpowered by the limbic brain, modern neuroscience shows that intentional or mindful use of our PFC can change the electrical activity of our brain.  By consciously activating this part of your brain, you can inhibit some of the negative emotions and threats you and your team are currently feeling.

Your Brain During the COVID-19 Pandemic:

Right now, in the midst of the COVID-19 pandemic, your limbic brain is highly aroused and likely overpowering you prefrontal cortex, making it harder to make decisions and keeping you focused on the negative emotions and threats you are feeling.  These threats include how to keep our teams employed, how to make rent, how to manage debt and cash flow, how to manage patient and employee concerns, how to interpret the laws that have been passed and applying and qualifying for loans with the CARE Act, just to name a few.  Add to the fact that many employment lawyers and accountants are recommending layoffs or furlough for that team that you have worked with side by side for years.  The 24 hour, non-stop media plays a huge role in activating a threat response in our brains to the current situation.  Constant coronavirus headlines, drastic modeling predicting dire consequences make it worse day by day.  Everything around you is stimulating the "fight or flight" reaction of the limbic brain.  It's no wonder that we are all feeling threatened!

Overarousal of the limbic system overpowers and reduces the resources to the prefrontal cortex.  This inhibits understanding, critical thinking, decision making, memorizing and inhibition, all of which you need to be the leader your practice. When the prefrontal cortex is overpowered, the we tend to do more "automatic" thinking and tend to respond more negatively to situations.  We say things that we don't mean and that may trigger threats to the people around us.  Because the limbic system is more affected by threats than rewards, you will find that threats to the limbic system come on faster, last longer and are harder to change.  It becomes difficult to see the positive and we become more risk averse.  We can only see the glass half full.

Neuroscience has shown that intentional use of the prefrontal cortex can change the electrical activity of the brain.  The following techniques can be used to "put the brakes" on the negative emotions/anxieties that your limbic brain is currently focused on.  These techniques can be helpful in every aspect of your life and help you as a leader.
  1. Symbolic Labeling:  The act of consciously putting words to the emotions that you are feeling, expressed to yourself or others, actually stimulates the right ventrolateral prefrontal cortex (RVLPFC) which is the center of inhibition for your brain.  This will help inhibit the negative emotions/anxiety that you are feeling due the powerful limbic response of your brain.
  2. Reappraisal: Reappraisal is another conscious activity of the prefrontal cortex which has been scientifically shown to inhibit the limbic response of the brain.  Reappraisal is the conscious activity of looking at your situation from different perspectives.  This requires more focus and energy, but has been shown to be more powerful than symbolic labeling at changing your brain's activity.  Reappraisal can be done in the following ways:
    1. Reinterpreting: Consciously choose to reinterpret your current situation.  Look for the positives and find opportunities in your situation.  For example, "I have time to re-evaluation our systems" or "I have time to get more CE done" etc.
    2. Normalizing: Take a few minutes to focus upon what is normal about your situation.  For example, "I am in the same boat as all the other dentists around me. We are all working through this together. etc."
    3. Reordering: Consider reordering what your values are in the situation. "My team or family's health is the most important thing right now." "I have to make this tough to decision to protect our practice so our team can have a job in the future."
  3. Healthy Brain Habits:  Re-evaluate these habits in your life and prioritize them for better brain function.
    1. Sleep - get enough
    2. Nutrition - find balance
    3. Exercise - make time
    4. Breaks - time correctly
    5. Mindfulness Training - practice
Understanding how our brain works will not only help us in times of great anxiety and concern, but will also help us as leaders in our practices.  Stay tuned for more brain hacks that will help you as a leader in your practice.


RESOURCES:







    

Perspectives on the Pandemic - Interview of Dr. John Ioannidis of Stanford University

 

This is a follow up interview to his recently published article.  I think you will find this a fair, balanced, rational and "science-first" approach to data surrounding the COVID-19 pandemic.
    

Coronavirus Aid, Relief and Economic Security Act (Care Act) Passes the House

The CARE Act has just passed in the House of Representatives.  Here are some of the initial provisions of the act, with  more details to come:


The legislation passed by Congress contains several provisions to provide emergency assistance for Small Businesses affected by the pandemic.  The next step is for the Small Business Administration (SBA) to issue guidance to banks such as Chase on how and when to provide much needed loans to our small business clients under the Act.  We will update this information as we learn more.
This is our current understanding of the provisions in the bill for Small Business owners:
§  Paycheck Protection Loan Program expands loan eligibility under the SBA 7a program with the intention to assist businesses with covering costs related to payroll (including healthcare and certain related expenses), mortgage interest, rent, leases, utilities and interest on existing debt.
§  Borrowers will need to certify that they’ve been impacted.  There will be no personal guarantees or collateral associated with the loan. Detailed application requirements are still to be determined.
§  Loan amount maximum is 2.5 times average monthly payroll or up to $10 million.
§  There will also be a payment deferral and loan forgiveness program. 


Summary provide by our partners at Chase Bank.  More Details to come...
    

Dr. John P.A. Ioannidis Questions the Decision Making Surrounding the CoVid-19 Pandemic

Dr. John P.A. Ioannidis, is a Professor of Medicine, Health Research Policy at Stanford University. He is a professor of statistics and one of two directors of the Meta-Research Innovation Center at Stanford (METRICS).  In a recent article, he has weighed in on the evidence surrounding the current CoVid-19 pandemic and the drastic measures being taken to "flatten the curve".  A must read in these times of panicdemic.



John P.A. Ioannidis MD - "Why Most Research Findings are False"
    

The Buzz About Endodontic Irrigation

There is lots of discussion about Endodontic irrigation.  The introduction of new technologies, such as Gentlewave, and the accompanying marketing associated with this product have increased the  attention to the importance of endodontic irrigation.  Many of you may remember the cliche you heard in dental school that if you properly clean the canal system, could could fill it with bird feces and it would be successful.  While we know that bird feces would reintroduce bacteria into the canals - the funny point of the saying was to stress how important the cleaning of the canals is to the success of endodontic treatment.

Just like endodontic shaping techniques, there are multiple endodontic irrigation solutions and delivery techniques.  Furthermore, there are myriads of combinations and concentrations of each of these irritants.  To make this further cloudy, a Cochrane Systemic Review of endodontic irrigants reports "Although root canal irrigants such as sodium hypochlorite and chlorhexidine appear to be effective at reducing bacterial cultures when compared to saline, most of the studies included in this review failed to adequately report these clinically important and potentially patient-relevant outcomes. There is currently insufficient reliable evidence showing the superiority of any one individual irrigant. The strength and reliability of the supporting evidence was variable".

For the purpose of the is article, we will consider NaOCl as the gold-standard, most used irrigant in the world and will avoid the discussion about concentration (although I prefer full strength).

Delivery of the NaOCl irrigation can be done several ways:

Passive Irrigation - syringe only with instrumentation files pushing the irrigation to the apex
Active Irrigation - sonic or ultrasonic energy used to stir or active the irrigation throughout the canal system
Lasers Activation - use of laser irradiation is typically recommended in addition to traditional NaOCl irrigation protocols
GentleWave - combination of acoustic and hydrodynamic energy to deliver irrigants through canal system

In our practice at Superstition Springs Endodontics, we have been using active irrigation for years, starting with ultrasonic and now currently using sonic activation on every case.  We have found that with adequate irrigation time, sonic activation and removal of the smear layer (using EDTA), we are finding and filling more and more lateral canals, accessory canals, apical deltas.  (The use of radiopaque sealers also increases the visibility) In my opinion, its difficult to say how much of this is attributed to the removal of the smear layer - but I expect that it is a combination of the active irrigation and removal of smear layer.

Here are a few of the cases demonstrating the benefits of active, sonic irrigation and smear layer removal.




So as you can see, the proper cleaning, shaping, active irrigation and removal of smear layer of the canals allows for us to open the lateral, accessory and apical deltas that we know exist in the complex canal anatomy.

Whether this changes the outcomes or success rate of the endodontic procedure is unknown, but it sure looks pretty!


Related Articles:
Passive ultrasonic irrigation in root canal: systematic review and meta-analysis.
Endodontic irrigants: Different methods to improve efficacy and related problems
Effectiveness of ultrasonically activated irrigation on root canal disinfection: a systematic review of in vitro studies.
The Use of Lasers in Disinfection and Cleanliness of Root Canals: a Review


    

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