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by Josh Bernstein
As we read articles and attend lectures on providing the best possible dental care to our patients, we learn about new materials, the best techniques, creature comforts, customer service, communication, attractive financing, etc. Conspicuously missing from much of our continuing education is the one thing that means the most to our patients — painless, comfortable dentistry. You can have the most gorgeous dental "spa" with all the latest equipment, providing the most up-to-date services, but if you really want to give your patients a "Wow" experience, don't hurt them!
Some may take exception to the suggestion that dentists are not painless here in the 21st century. After all, we would all like to think that the way we deliver our outstanding care is as comfortable as possible. We have effective topicals, great local anesthetics, high-speed handpieces, fabulous bonding materials, four-handed techniques, and ergonomic dental chairs, so we must be keeping our patients comfortable, right? We might even indulge in thinking that our notorious reputation as a profession is an anachronism; that the jokes, movies, and comedy routines are outdated. Yet, every day that new patients walk into our consultation rooms, they tell us stories about experiences with contemporary dentists that range from pain, to gagging, to manhandling. Sadly, we also hear about the indifference and lack of compassion associated with uncomfortable care. We hear that the previous dentist said, for example:
"We're almost done," as the drilling continues long after the anesthetic has worn off.
"This will pinch a little" or "You're going to feel a little mosquito bite," right before a painful injection.
"Your whole head must be numb after all the Novocain we've given you," when the dentist repeatedly misses a block.
"Nonsense, there's nothing to worry about," to a phobic patient who describes the sheer terror at the prospect of the most minor dental procedure.
The reality is, as they say in The Music Man, "There's trouble in River City, my friends." With honest introspection we find that we commonly don't do as good a job as we could in the area of pain control and overall comfort. It's not just the "other" dentist who is perpetuating our unfortunate reputation — it could be you.
If you are not completely insulted by what you just read, and you are still reading this article, congratulations. You are a highly motivated dentist who wants to be part of the solution, not part of the problem. We know that it is possible to perform completely comfortable, painless dentistry, because many of us have actually experienced it. In fact, that is why I became a dentist. My family dentist when I was growing up was a fantastic dentist, Dr. Allan Hyman, who never, ever hurt me. I never saw — or felt — an injection, and I certainly never felt any pain.
The fundamentals, revisited
If every dentist took the time to revisit some of the basic principles of comfortable dentistry, our reputation as a profession could outgrow the stigma of the sadistic dentist. If every dentist then took it one step further and learned about all the latest equipment, materials, and techniques for comfortable dentistry, we could set ourselves apart as the one health-care field that patients identify as comfortable. If you think that sounds far-fetched, just remember how the Japanese transformed their reputation for quality control. After World War II, "Made in Japan" was a phrase that was laughed at, because the product bearing this label was flimsy and of poor quality. Now, Japanese products are world renowned for the highest standards in quality control and reliability. Clearly, it can be done.
First, let's discuss the single most essential element of a comfortable experience — a painless injection. Never underestimate the importance of a painless injection. In the patient's mind, the measure of a good dentist is in whether or not the dentist can give a painless injection. Patients won't remember if your crown margins are perfect or if your endo fill is precisely to the apex. In fact, they probably don't even know the objective measurements of quality dentistry. But they will always remember if you gave them a painless injection. If you can truly overcome this single obstacle, you will elevate your reputation in your community to the point where you will always be as busy as you want to be. Unfortunately, the opposite is also true. If you hurt the patient during the injection, nothing else matters, because you may never get a chance to complete the dentistry the patient needs.
Steps to total patient comfort
Step one in a painless injection — or in comfortable dentistry in general — is compassion. Somewhere along the line, many of us become a little too detached from the patient's pain. Maybe we're always in a hurry with a hectic schedule or maybe we become desensitized. We simply don't relate to it anymore. It's an expedient defense mechanism because as dentists, we frequently see patients with painful problems such as abscesses, fractures, and trauma. It's a convenient way to avoid bearing the burden of every patient's pain. However, for the benefit of the patient, it is enormously helpful to rekindle some of the compassion within you. If you do, it will not only help you in your painless injection technique, it will help you in your relationships with your patients. Remind yourself to be compassionate by placing a blanket over each patient (unless they walk in sweaty on a hot day!). Don't ask them if they want a blanket — just cover them with it. You'll be surprised by how much patients appreciate this small gesture. Blankets are enormously comforting and speak volumes about your thoughtfulness.
Step 2 in a painless injection is to place a great topical on dry tissue and leave it there for at least five minutes. There are many outstanding topicals on the market, from EMLA to Hurricaine to Cetacaine to Ultracaine to custom concoctions made by compounding pharmacies. But they can't work if you don't allow enough time. Dry off the injection site with a cotton roll or 2 x 2, then place your topical with a cotton-tipped applicator and leave it for at least a full five minutes. Set the timer to be sure you're giving your topical enough time to really work.
Step 3 is to give your initial injection. It is very important to approach the patient gently because they know what's about to happen, and they have been dreading it for a long time — long before they ever walked into your office. Handle your patient like a newborn baby with a broken leg — very gingerly. A soft touch does wonders for building trust for the injection and the treatment that is coming. A slow approach, rather than the dentist bursting hurriedly into the operatory, also helps. Stop and take a deep breath. Calming words such as, "We're going to take this nice and easy to make this as comfortable as possible for you" go a long way, especially when spoken in a soft voice.
A warm carpule of Citanest Plain or Carbocaine for the initial injection is much kinder to the tissue than anything with epinephrine, and increases your chances of getting an "A+" from your patient on the comfort of your injection. Use your no-epi injection just at the injection site and inject just barely under the mucous membrane, because that's what the topical numbed. Your initial injection may not last through your entire procedure; it's just to make the follow-up injection easier. The idea is to make that initial injection completely painless. You will further increase your chances of a painless injection by using The Wand or one of the other automatic anesthetic delivery devices. The Wand takes the human error out of giving a slow injection and, when it comes to comfort, slow is definitely better.
After the initial injection, wait. A minute or two now will make a big difference when you proceed with your follow-up injection using Septocaine, lidocaine, or Marcaine (bupivacaine), all of which have epi. Ask patients if they felt anything or ask them to grade you "A" through "F" on your anesthetic technique. If they didn't feel that first injection, they will relax for the follow up. Take your sweet time as you give your follow-up injection, allowing the bolus of anesthetic to numb the tissue ahead of the needle, just as we all learned in dental school. A painless injection can take minutes, rather than seconds. Patients won't care that much if you have the syringe or The Wand in their mouth for a couple minutes, as long as it doesn't hurt.
Step 4 is to wait until the anesthetic has had time to work. Blocks can take five to 10 minutes. Local infiltration also takes time to work. The anesthesia process is not a procedure to hurry through. There is also a psychological component to waiting. Patients need to take a few minutes to mentally adjust to the fact that they are thoroughly numb.
If at first you don't succeed —
If you begin the procedure and the patient is not profoundly numb, there are several measures you can take.
- Do an inter-dental injection. With the bevel of the needle pointed down toward the bone, inject a quarter carpule of Septocaine into the papillae mesial and distal to the tooth. Most of the time this works really well.
- Do a PDL injection. Slowly inject a quarter of a carpule of Septocaine into the PDL mesial, distal, and buccal to the tooth. It is interesting to note here that Milestone Scientific has developed a new version of The Wand, called STA (Single Tooth Anesthesia) that is specifically designed for doing PDL injections. STA is a great idea for getting one tooth completely numb and for patients who don't like that numb feeling in their whole face.
- If the tooth is still sensitive after an interdental and a PDL injection, do an intraosseous injection. Using the X-tip, this will get even the most difficult tooth profoundly numb.
While discussing comfortable delivery of every type of dental procedure is beyond the scope of this article, it is important to mention cavity preps and crown preps. There are a few basics that will help your patients.
First, consider using a rubber dam or an Isolite dryfield illuminator. You may have bad memories of placing rubber dams in dental school, but think like an endodontist rather than a state board examiner. If you can isolate the tooth, you will save time, which is important. When it comes to using a high-speed handpiece, speed with control is the right idea. Again, approach the patient very slowly, gently, and calmly. But, get in, get the job done, and get out. Patients hate the "drill" about as much as they hate the "shot." In an effort to do an outstanding job, some dentists take too much time prepping teeth. If you develop a systematic method for prepping teeth, most preps should not take more than a few minutes, especially if you use a brand-new bur, which is why I like disposable NeoBurs and NeoDiamonds from Microcopy. Axis, Brasseler, and many other companies also make excellent burs, but do yourself and your patients a favor and make sure that the burs you use are new.
Prepping is the part of the procedure that should be expeditious, not the injection, and a lot of us get this backwards. When it comes to prepping, patients hate the sound, they hate the vibration, and they hate the smell. They worry about debris going down their throat. They worry about iatrogenic damage to their tongue, cheek, and lip. They are afraid of possible pain. And they're afraid you're going to "hit the nerve."
Take your time with injections, make sure your patients are profoundly numb, and practice systematically doing beautiful preps in just a few minutes. Your patients will appreciate it. There are so many topics to cover in the area of patient comfort, but the most important things are basic. If you can deliver painless, comfortable dentistry without hurting your patients, you will develop an outstanding reputation in your community that will give you a deep sense of professional achievement along with success in your practice.
For more information on providing your patients with the most comfortable experience, please contact Dr. Bernstein regarding the Dental Comfort Academy (DCA), Dental Professionals Dedicated to Patient Comfort.
Dr. Bernstein maintains a private solo practice in Piedmont, Calif., emphasizing cosmetic dentistry, sedation, and TMD in an atmosphere of outstanding service. He is a Clinical Instructor at The Las Vegas Institute for Advanced Dental Studies, and is the Founder and President of the Dental Comfort Academy. Reach Dr. Bernstein at www.comfortacademy.org, www.allnewsmiles.com, or [email protected].