Cozy and numb

Sept. 22, 2016
Timothy M. Bizga, DDS, FAGD, talks about how buffered anesthesia gives patients a more comfortable injection, more profound numbness, less anesthetic needed for the procedure, and more rapid onset leading to shorter time in the chair.  

Timothy M. Bizga, DDS, FAGD

Can you imagine what any sort of tooth issue must have been like before we had the comfort of dental anesthetics? We do know that the earliest signs of dental surgery were between 3000 and 2500 BC and usually involved drilling out cavities or pulling teeth without any way of numbing the patient. Ouch! It might be hard to imagine having your teeth drilled without the comfort provided by anesthetic shots and/or laughing gas, but by 1550 BC Egyptians managed to develop prescriptions for dental pain and related injuries.

Ancient Greek dentists struggled to manage and cure cavities as well. Their methods involved linen soaked in medicine and packed into suspect holes in teeth in an attempt to relieve tooth pain. Cloth in the tooth prevented food from entering and festering in the affected area. The ancient Greeks prided themselves in their strength and ability to handle pain. So, when cavities were found in the teeth, they would often deal with the pain rather than have the tooth pulled. Losing a tooth was considered a great loss, and the dental pain associated with toughing it out was a small price to pay.

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Flash forward to more recent history. In the Old West, for instance, when people had to have a tooth pulled, it meant a trip to the local barber. There, the barber would use a few rudimentary tools to yank the tooth out of the patient's mouth. If the patient was lucky, he or she would get a few shots of whiskey to help "numb" the pain. Antibiotics to fight off any infection that might have occurred were totally unheard of. The idea of getting a tooth extraction back then was often worse than the pain associated with a diseased tooth. It is no wonder that just 200 years ago tooth abscesses were among the leading causes of death.1

The invention of dental anesthetics vastly improved our ability to manage dental pain. Since the introduction of lidocaine in 1948, modern-day dentists have enjoyed the luxury of a more humane and comfort-driven approach to dental pain and treatment. Today, some studies suggest that each individual dentist uses an average of 1,800 cartridges of dental anesthetic per year.2 Yet, despite the widespread use of dental anesthetics and their assistance in dental pain management, numerous challenges exist in our day-to-day application of these modern miracle drugs.

The challenges arise from the fact that local anesthetics are innately acidic. This acidity may contribute to lengthy waiting periods and cause the "bee-sting effect," or burning and stinging during the injection. Most widely used dental anesthetics are formulated and have a pH near that of lemon juice (anesthetics range from 2-4 pH; lemon juice has a pH in the range of 2). In this pH range, less than 0.1% of the anesthetic is in the deionized or active form. This acidity may delay or even negate onset, contributing to injection pain and ultimately slowing down the efficiency and workflow of day-to-day dental operations.

Practice dentistry long enough and one is bound to have one of "those days" where no one seems to get numb, IAN (inferior alveolar nerve) blocks do not work, productivity is low, tensions are high, and frustrations become unfathomable. It is days like this when one thinks: Is there something that can remedy or curb this issue we all experience from time to time? Cue alkalinizing or buffering of dental anesthetics.

Long practiced and recommended in medicine, buffering is still a relatively new concept in dentistry. One reason has been that our presealed, single-use anesthetic cartridges are not easily alkalinized. Thanks to clever innovation, that is no longer the case. The alkalinization armamentarium manufactured by OraPharma allows the dental practitioner to alkalinize (buffer) a cartridge of lidocaine with epinephrine chairside immediately before loading the syringe and delivering the injection. The benefit of the OraPharma Onset system is that it allows the clinician to conveniently buffer without disrupting the routine delivery method to which dentists are most accustomed.

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Buffering the anesthetic solutions before injections immediately increases the active form of the drug, thus facilitating more rapid diffusion of the anesthetic through interstitial tissues and decreasing common latency periods associated with the patient's own physiology, anatomy, and kinetics toward the anesthetic solution. In addition, buffering also raises the inherent pH of the local anesthetic toward physiologic pH, reducing the discomfort often associated with dental injections.3

Translation: In most cases, you can unholster your handpiece sooner because you no longer have to wait five to 10 minutes, as one may have to using conventional methods of local anesthetic delivery. Furthermore, your patients most likely will experience less pain during injection.

Today, some studies suggest that each individual dentist uses an average of 1,800 cartridges of dental anesthetic per year.

In terms of dental therapy, we have come a long way since 3000 BC. Today, local anesthetics play a central role in the typical dental office setting and may be the safest and most effective drugs for the prevention and management of dental pain.3 Many have found success for years with traditional anesthetics and may not find anesthesia a problem. Still, one cannot deny the plethora of evidence-based research supporting the fact that buffered anesthetics may be more predictable, comfortable, and convenient, as well as allow for greater flexibility on the part of the clinician.

In today's practice, a manner that goes beyond satisfying our customers and moves into delighting them creates immeasurable clinical value. Patients expect to be satisfied. It is the unexpected positive experiences-or delights-that grab their attention. The ability to buffer an anesthetic may offer the patient a more comfortable injection, more profound numbness, less anesthetic needed for the procedure, and more rapid onset leading to shorter time in the chair. For the dentist, this can lead to more predictable procedure times, greater reliability, less stress, increased productivity, and the lasting value created by the delight from a better-than-good patient visit.


1. Clarke JH. Toothaches and death. J Hist Dent. 1999; 47(1):11-3.

2. Haas DA. An update on local anesthetics in dentistry. J Can Dent Assoc. 2002;68(9):546-551.

3. Malamed SF, Tavana S, Falkel M. Faster onset and more comfortable injection with alkalinized 2% lidocaine with epinephrine 1:100,000. Compend Contin Educ Dent. 2013;34(1):10-20.

Timothy M. Bizga, DDS, FAGD, is a general dentist practicing in Cleveland, Ohio. Dr. Bizga's practice focuses on comprehensive care with special interests in implants, cosmetics, and facial esthetics. He is a certified John Maxwell speaker, trainer, and coach, a certified DiSC profile trainer, and a member of Catapult Elite. A fellow in the Academy of General Dentistry, Dr. Bizga gives back to the community via dental missions around the world.

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