Painless Dentistry

Perfecting your local anesthesia technique can go a long way in building and maintaining a successful practice

Richard P. Gangwisch, DDS

Edgar R. R. Parker promised pain-free dentistry. The turn of the century dentist was so confident in his ability that he legally changed his first name to Painless. However, history tells us that Painless Parker's bravado was much greater than his ability to deliver on his guarantee. Painless dentistry may be impossible to promise in every case, but that doesn't mean that we shouldn't strive to come as close to this goal as possible. You can be the best salesperson on earth, but if you consistently hurt your patients, sooner or later, word will get out. To perform painless dentistry, you need to start with a good, painless local anesthesia technique.

The Right Approach

For scaling and root planing procedures, we use a topical anesthetic (eg, Oraqix^®, Dentsply Sirona; HurriCaine^®, Beutlich Pharmaceuticals; Kolorz^®, DMG America). The patients absolutely love the fact that they do not have to receive multiple injections, and for that matter, so do I. Regardless of how painless your injection technique is, no one wants to get stuck what seems like a hundred times.

When an injection is required, apply a potent topical anesthetic to the injection site and give it adequate time to work. Although the topical anesthetic's effects are only superficial, it will ease patients' minds enough that if there is a mild amount of discomfort, like with an inferior alveolar injection, they won't overreact. Slow is the way to go, especially in some of the touchier spots, such as in the upper anterior region or the palate, where you need to be excruciatingly slow. This requires patience, but the reward is in the potential to acquire new patients.

Type And Duration

The type of local anesthetic to be used can be important. The use of 2% lidocaine with 1:100,000 epinephrine is usually adequate for routine procedures. However, there are occasions where the use of the more potent 4% articaine HCL with 1:100,000 epinephrine is warranted. I find it helpful when working on the lower anterior and premolar areas when I want to avoid performing an inferior alveolar nerve block. In addition, it can be a useful aid when an initial lidocaine injection is not profound enough. I caution its use for inferior alveolar injections due to its potential to cause paresthesia. For lengthy procedures, bupivacaine is great because of its long duration.

Ensuring that you administer an adequate amount of anesthetic is also critical in the pursuit of pain-free dentistry. Due to the increase in managed care plans and the concomitant decrease in revenue, for many dentists, multi-chair dentistry is necessary in order to make ends meet. This means that patients may have to wait for an extended amount of time between injection and the start of the procedure. Having to reinject wastes time. Therefore, if there is any chance that it may be a while before you start, administer extra anesthetic during the initial injections. The cost of the extra local anesthetic is relatively low when compared with the potential cost of lost treatment time.

Advanced Techniques

Even with an appropriate anesthetic and an excellent technique, we cannot always obtain profound anesthesia after the first injection. Variable nerve pathways; less permeable, dense bone; and collateral innervations are among the culprits. With this in mind, we have to have a few additional tricks in our toolboxes. For example, numbing the mandibular arch, especially the molars, can be tricky at times. An inferior alveolar injection works most of the time, but not all of the time. In some of these situations, simply giving a booster injection will suffice. When that doesn't work, I will turn to the Vazirani-Akinosi block technique. Its goal is to anesthetize the inferior alveolar nerve, but it meets its mark higher up. This seems to block the nerve before it sprouts into collateral branches. To perform the technique, the zygomatic process is palpated with the patient's mouth closed, and the needle is inserted just inferior and posterior to that while the syringe is being held parallel to the upper arch. The needle is inserted almost to the hub.

When this doesn't work, I will infiltrate articaine both buccally and lingually in hope of blocking any collateral innervations. If that doesn't work and the patient is still jumping out of the chair, it's time for an intraligamentary injection. Placing an extra short, 30-gauge needle between the tooth and alveolar bone and injecting into the periodontal ligament space can be a very predictable way of obtaining anesthesia.

Once in a blue moon, all of these interventions can be used, and the patient still doesn't experience profound anesthesia. When this occurs, we reach back into our toolbox and out comes the intraosseous injection system. In this approach, a slow-speed handpiece is used to drill a tiny hole in the mandible just distal to the tooth that you wish to anesthetize, and then the anesthetic is injected into this space. The system that I use leaves a plastic guide behind after drilling, which makes it easier to find the hole for injection. It should be noted that when performing this technique, it is important to avoid pumping a vasoconstrictor into the marrow spaces.

Considering Sedation

Ninety-nine times out of a hundred, the aforementioned techniques will achieve a level of numbness that patients will characterize as painless. So, what do we do about the 1 in 100 who still believe that they are experiencing pain? More times than not, these patients are your nervous Nellies for whom all of the numbness in the world isn't going to change their perception of pain. Therefore, it is up to us to change their perception through sedation. Oftentimes, something as simple as breathing nitrous oxide allays these patients' fears enough that the level of anesthesia is sufficient. Oral sedation can also be an excellent adjunct to dental treatment. There are some medications available today that can safely relax a patient sufficiently enough to perform a sizable amount of painless treatment. And for those who do not respond well to oral sedation, IV sedation, or in drastic cases, general anesthesia, provide other options.

Word Will Spread

Although performing painless dentistry can be difficult in some cases, striving to do so can go a long way in building and maintaining a successful dental practice. The word about your efforts will be spread far and wide when your patients tell their families and friends about their pleasant experiences in your dental chair. They will be more likely to refer new patients to you for a pain-free experience. And when patients present with less fear and anxiety about pain, your job can become much easier and significantly less stressful.

About the Author

Richard P. Gangwisch, DDS, a master of the Academy of General Dentistry and a diplomate of the American Board of General Dentistry, is a clinical assistant professor at the Dental College of Georgia at Augusta University and practices in a Heartland Dental-supported office in Lilburn, Georgia.