Th 108143

PAINLESS DENTISTRY: oxymoron… or reality?

Oct. 1, 2002
A pain-free experience for your patients is no longer optional ? it's required! Today's products offer dentists a myriad of options for achieving profound anesthesia.

by J. Mel Hawkins, DDS

A pain-free experience for your patients is no longer optional — it's required! Today's products offer dentists a myriad of options for achieving profound anesthesia.

The moment a new patient walks into your office, the quest for pain-free dentistry begins. A warm smile and a friendly welcome form the first nonpharmacological building blocks toward mutual confidence and respect between the dental health team and the patient.

When I graduated from dental school almost 30 years ago, patients actually expected dentistry to hurt occasionally! Pain is, after all, a consequence of many medical procedures ... why not dentistry? But expectations change. Twenty-first century dental patients are no longer willing to accept this insult to their nervous systems; they are determined to seek a dentist who will not hurt them. Their ideal dentist will display superior compassion, knowledge, and provide painless delivery of dental services.

Fig. 1 — The Treatment Triangle
Click here to enlarge image


Perceptions about the advancements toward painless dentistry differ understandably. The three key elements are the patient [PA], the dentist [D], and the procedure [PRO]. Take away any one of these elements, and we literally will not have dentistry (Figure 1).

Dental case delivery

Here are a number of suggestions to help achieve success:

  • TLC — Compassion, trust, and confidence are the foundation for introducing pain-control procedures. The team approach to allay the patient's apprehension may include important props such as :
  • Warm blanket per operatory
  • Headphones
  • Warm face cloth postop
  • Giving your home phone number (they'll never use it, but it is great for public relations!)
  • Follow-up phone call to see how patient is doing (same night or next day)

•Hypnosis — This is effective for some, but requires a controlled, quiet environment; skill; inter-patient/practitioner trust; time; and conditioning. Sometimes, an outside hypnotherapist can come to your office. This is not for everyone. Hypnotherapy can be enhanced in combination with nitrous oxide/oxygen, or conscious sedation.

•Electronic Dental Anesthesia (EDA) — The documentation of EDA is well-known, although the therapeutic results are reportedly varied.

•Needleless Local Anesthesia — More than 30 years ago, Mada Equipment Company, Inc. developed a revolutionary "no needle" technology that successfully captured a portion of the dental local anesthesia market. Based on a piston/pressure expulsion principle, the system offered demonstrable patient acceptance of "no invasiveness" and is a very effective soft-tissue anesthetic.

•Computer-controlled injections — There are currently a number of computer controlled injection devices available:

  • The Wand™ (Milestone Scientific Inc.) — The Wand represents the first computer controlled dental anesthetic delivery system. Product promotion and training have inundated the profession with suggestions that slow, controlled injections could be an "efficient practice-builder and time saver." The lightweight and easily manipulated handpiece is a significant asset.
  • Comfort Control Syringe (CCS) (Midwest Dentsply) — This preprogrammed local anesthesia delivery system offers a selectable choice of rate of administration by technique.

•Conscious sedation — Increasingly popular in the 21st century, conscious sedation most commonly employs the oral (O) or intravenous routes (I.V.) of administration. We must remember three essentials:

  • Depth of sedation is not synonymous with route of delivery.
  • Depending on sedation does not compensate for poor local anesthetic performance.
  • Benzodiazepines form the back bone of our conscious sedatives (along with N20/02). The "benzos" have no analgesic action.

•Nitrous Oxide/Oxygen (N20) —This gaseous agent, discovered by Dr. Horace Wells in 1844, has had variable success. It is extremely safe and readily reversible. In concentrations of 10 percent to 70 percent N20 (thus 90 percent to 30 percent oxygen concurrently), some analgesia may be obtained.

  • Topical anesthesia — Topical anesthesia comes in various formulations, such as sprays, creams, gels, and ointments. Other agents may be applied topically, but drug formulations used topically seem to be effective in providing anesthesia at the mucosal nerve endings. Depending on intraoral location, topical anesthesia diminishes the pain of needle insertion.

    The "big five" checkpoints in successful topical results include the following:

    • Isolating the area
    • Drying the mucous membrane and keeping it dry — eg., cotton and salivary gland isolation.
    • Reapplying to areas of high mucous/serous secretions every few seconds (palate).
    • Selecting an agent that tastes good to the patient (more important than it sounds!)
    • Being patient — give it a full 90 seconds

    •Local anesthetic solutions: The secret of ph chemistry. The fact is that the more concentrated the vasoconstrictor included inside the cartridge, the more acidic the solution being deposited in situ.

    As a generalization, the plain solutions of 3 percent mepivicaine and 4 percent prilocaine, although still acidic, are the least acidic compounds and exist closest to physiological ph and, therefore, hurt less.

    •Scope of local injections:

    • Infiltration anesthesia
    • Field-block anesthesia
    • Nerve-block anesthesia

    •Advanced nerve-block techniques:

    • Maxillary nerve block
    • Inferior alveolar nerve block
    • Akinosi Closed Mouth mand-ibular nerve block
    • Gow-Gates mandibular nerve block

    •Supplemental injections

    • Periodontal ligament injection
    • Intraosseous Anesthesia
    • Stabident
    • X-Tip Technologies

    •Education, training, and confidence — Until Dr. James Dower Jr., a colleague and friend from the University of Pacific in San Francisco, published A Survey of Local Anesthesia Course Directors, I was suspicious that our North American dental schools offered too few curriculum hours for these vital modalities. He noted that the mean number of didactic undergrad instruction hours was 15, followed by a mean number of five hours of total clinical practice time. (Author's note: This is not a criticism of directors of undergraduate local anesthesia programs. On the contrary, it is a compliment that they (we) are able to do so well with the students considering the odds of minimal curriculum time!)

    I had suspected this since I had codirected undergraduate local anesthesia courses as a member of the University of Toronto dentistry faculty for nine years. Then, I shifted my focus to the continuing-education and professional-development level. I found that hundreds of dentists have been taking hands-on local anesthesia courses (dentist-on-dentist format) over the past 20 years — an obvious statement that the practice of local anesthesia needs continual reinforcement and enhancement. Confidence becomes the bottom line. In fact, another article by Dr. Dower that was published in Quintessence 1993 reports that in a survey of 711 dentists, 19 percent disliked giving a "shot" and were especially apprehensive about block anesthesia. Fear of failure bothered some practitioners — 6 percent — so much that, from time to time, they actually reconsidered dentistry as a career! We know how to help rectify this dilemma, but nothing is 100 percent failsafe. We must reassess the treatment triangle of dentist/patient/procedure interactions. We must ask these questions:

    • Can we live and practice local anesthesia under our current means?
    • Are we willing to invest time and money to advance our knowledge and technique base?
    • Are we able to "know when to hold 'em and when to fold 'em" by recognizing the odds of success or failure and referring those problems that can make practicing miserable?

    Great strides in implantology, microabrasion, adhesive and cosmetic dentistry, and, in fact, all areas of dentistry, will shape the technical prognosis for the 21st century. Dentistry enjoys a state-of-the-art status, and local anesthesia should be no exception.

    Patient factors:

    • Calm patient
    • Nervous patient
    • Substance abuser
    • Local anesthetic may or may not work
    • Patients with metabolic problems
    • Patients with anatomical variations
    • Misc. patients
    • Mechanism not well-understood.

    Dentist factors:

    • Can give anesthetic to either calm or apprehensive patient who may not get numb.
    • Well-trained
    • Good self-image
    • CE is current
    • Poorly trained
    • Little or no CE
    • Gives anesthetic to all types of patients who usually will not get numb.

    Procedural factors:

    Restorative procedures:

    • Easier procedures = easier to numb
    • Difficult procedures = harder to anesthetize

    Dr. J. Mel Hawkins will speak at the 2003 Thomas P. Hinman dental meeting. He will discuss the current state of local anesthesia techniques and will direct the hands-on local anesthesia course on Saturday at Fort MacPherson Military base located close to the Hinman meeting site. This participation course has "retrained" more than 1,000 dentists in the use of successful techniques, especially in the mandible. Note: There are no out-of-state licensing restrictions since the course is given on federal territory. All dentists — regardless of state license — are welcome to register.

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