Cementation: To numb or not to numb?

April 1, 2006
My dad is a big influence on the way I practice dentistry today. After I graduated from dental school, we practiced together for three years.

My dad is a big influence on the way I practice dentistry today. After I graduated from dental school, we practiced together for three years. I learned some great real-world tips from him. He did not like to numb patients for crown seats, and would tell people that the 30 to 60 seconds of sensitivity they would experience were not worth four hours of local anesthesia.

During the last couple of weeks that we practiced together, I performed two lower crowns on him. When it was time to cement the crowns, no one could find him in the office. Turns out he was in the restroom giving himself a lower block because he was too embarrassed to ask for one after not having numbed patients for all those years!

From the patient’s point of view, having a lower block to just cement a crown on tooth No. 19 may seem like overkill. Patients hate to have half of their jaw numb for four hours for just one tooth. I always prefer to anesthetize patients for this procedure, and know that they will not experience any pain. I also know I can do a better job of keeping the tooth isolated. This helps prevent salivary contamination of the cement.

So, years ago, I began searching for a way to satisfy my requirement that all crown seats be numbed. But I wanted to do it in a manner that was doctor-friendly as well as patient-friendly. First, this means no lower blocks could be used since they are not really patient-friendly. Whether it is having to take the needle through the two pterygoid muscles, or that the procedure incapacitates half of the patient’s lower lip and tongue - which makes talking and eating difficult - the lower block is not a patient favorite. I began to look for a method to anesthetize mandibular teeth individually, without all the soft tissue involvement of a block.

The first step was to find a strong topical anesthetic. The topical I found, Profound, is sold by Steven’s Pharmacy in Costa Mesa, Calif. The pharmacy’s telephone number is (714) 540-8911. Steven’s nationwide toll-free number is (800) 352-DRUG. The product comes in a 30-gram tube and a 10-gram syringe for direct subgingival placement for hygiene use, packing cord, etc. Profound works well because it is a combination of prilocaine, lidocaine, and tetracaine. It is unlike most topicals, which are just benzocaine. The first time I used Profound, I placed some above teeth Nos. 8 and 9 and left it on for a few minutes. To my amazement, I had pulpal anesthesia on these two teeth - just by the use of this topical!

Since then, I have learned that I can get mild pulpal anesthesia with Profound anywhere the cortical plate of bone is thin. This includes maxillary and mandibular incisors but not the cuspids. If you do need a local anesthetic, the injection site has been completely anesthetized with this topical, and is ready for a painless injection of anesthetic based on your duration requirements. For crown seats, I typically like to use a local anesthetic with high absorption through bone and shorter duration. Septocaine does just that. The absorption of Septocaine is so high that - in addition to using it for maxillary infiltrations - it works quite well for mandibular infiltrations, including bicuspids.

This leaves us with the molars, the teeth most likely to require crowns. In order to anesthetize these teeth without the soft tissue, PDL injections in the furcation are quite effective. I use Profound in the syringe with an 18-gauge disposable Endo-Eze tip from Ultradent to place the topical anesthetic into the sulcus and over the furcation. After letting the topical absorb for 60 seconds, I can give a painless injection from a standard syringe with a 30-gauge extra-short needle. This results in pulpal anesthesia without any of the unwanted soft-tissue effects.

The use of an exceptionally strong topical allows you to painlessly regain moisture control at the crown seat appointment. Then, when necessary, Septocaine is an excellent local anesthetic with high absorption and shorter duration for these quick procedures. If anesthetizing crown seats in a patient-friendly and patient-acceptable manner allows you to maintain ideal moisture control as well as increase the longevity of crowns, then you have created a great “win-win” situation for restorative dentistry.

Dr. Michael DiTolla is the Director of Clinical Research and Education at Glidewell Laboratories in Newport Beach, Calif. He lectures nationwide on both restorative and cosmetic dentistry. He also teaches hands-on courses on digital photography and digital image-editing for the entire team. Dr. DiTolla has several clinical programs available on DVD through Glidewell. For more information on this article, or to receive a free copy of one of Dr. DiTolla’s clinical DVDs, e-mail him at [email protected].

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