Anesthetizing

[saydental]

Hi,

Do all dentists give anesthetics when doing any type of filling? I know you definitely numb the patient when doing a root canal in US but then I heard that in other countries the patient can tell you if you have gone to the nerve (like they can kinda feel) so do they not give anesthetics?

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[Mauricio45]

Depends on the patient and filling. Vast majority yes require local anesthesia. But if filling is small enough, you can get away without numbing. Pt's love having to go without freezing.

 

[CharlieAF]

I’m in the US and I do anesthesia for probably 90% of fillings. The only time I don’t is if I think it’s going to be very small or if the patient requests not to be numb.

For most people, drilling into the dentin hurts. And they can’t really give you an accurate idea of how close to the pulp you are. So there’s not really a good reason not to numb.

 

[Sublimazing]

I do everything without local, the trick is to hold them down and convince them it’s just pressure.

 

[OMSDoc]

The only person who knows how good a dentist you are is another dentist.

Your success as a dentist depends on two things:
1. How well you relate to people
2. How well you can provide pain-free dental care

After 35 years, I think is is important to strive for both of these from the beginning of treatment with each patient.

50 percent of the US population does not see the dentist (whether they have money or not), and this is mostly due to fear.

Don't be part of that problem.

You should not have the attitude of: "I am going to try this (i.e., restorative dentistry without local anesthesia), and if that doesn't work, I will try that." CharlieAF is correct, there is no good reason not to obtain profound local anesthesia.

The key is to administer the local anesthetic as painlessly as possible.

I use a 30 gauge needle for all initial local anesthetic administrations. Just before I insert the needle and while I inject, I shake the cheek adjacent to the injection site with my other hand.

There is a theory called the "Gate Control Theory." There are different nerve fibers for pain and temperature vs. touch and pressure. The touch and pressure fibers are larger in diameter, and the nerve impulse travels faster on these fibers than impulses on the pain and temperature fibers.

The Gate Control Theory postulates that only one of these can traverse the first synapse at a time (in the substantia gelatinosa in the spinal cord).

Shaking the cheek stimulates touch-and-pressure nerve fibers and "closes the gate" to the pain and temperature fibers in the substantia gelatinosa. This makes it possible to give a virtual pain-free injection. By the way, the painful part of an injection is not the pin prick, but the fluid expanding in the tissue.

Do all you can to learn how to obtain profound local anesthesia, my friend.

 

[Mauricio45]

I use warmed 4% Citanest Plain as the initial injection, they hardly feel anything. Follow it up with either Lido or Septo and they won't feel the 2nd injection. Received lots of compliments about painless injections. I have the cartridge oven in each OP.

 

[CharlieAF]

When patients come in with several sets of dentures and show you where they adjusted them with a tool at home. Then, they want you to make a max and mand denture for them.

I use warmed 4% Citanest Plain as the initial injection, they hardly feel anything. Follow it up with either Lido or Septo and they won't feel the 2nd injection. Received lots of compliments about painless injections. I have the cartridge oven in each OP.

I use the same method, except without the warmed cut.

I inject just a couple drops. Then wait a couple of minutes before injecting the rest. It’s not super time efficient but patients love it. It especially works well with kids.

 

[Alpha Centauri]

Read the Malamed anesthesia textbook. Worth it 100%

 

[dentalstudentprospect2]

The only person who knows how good a dentist you are is another dentist.

Your success as a dentist depends on two things:
1. How well you relate to people
2. How well you can provide pain-free dental care

After 35 years, I think is is important to strive for both of these from the beginning of treatment with each patient.

50 percent of the US population does not see the dentist (whether they have money or not), and this is mostly due to fear.

Don't be part of that problem.

You should not have the attitude of: "I am going to try this (i.e., restorative dentistry without local anesthesia), and if that doesn't work, I will try that." CharlieAF is correct, there is no good reason not to obtain profound local anesthesia.

The key is to administer the local anesthetic as painlessly as possible.

I use a 30 gauge needle for all initial local anesthetic administrations. Just before I insert the needle and while I inject, I shake the cheek adjacent to the injection site with my other hand.

There is a theory called the "Gate Control Theory." There are different nerve fibers for pain and temperature vs. touch and pressure. The touch and pressure fibers are larger in diameter, and the nerve impulse travels faster on these fibers than impulses on the pain and temperature fibers.

The Gate Control Theory postulates that only one of these can traverse the first synapse at a time (in the substantia gelatinosa in the spinal cord).

Shaking the cheek stimulates touch-and-pressure nerve fibers and "closes the gate" to the pain and temperature fibers in the substantia gelatinosa. This makes it possible to give a virtual pain-free injection. By the way, the painful part of an injection is not the pin prick, but the fluid expanding in the tissue.

Do all you can to learn how to obtain profound local anesthesia, my friend.

Aren’t teeth and mucosal structures of the mouth innervated by cranial nerves?

 

[OMSDoc]

Aren’t teeth and mucosal structures of the mouth innervated by cranial nerves?

Yes, the fifth...the substantial gelatinosa of which I speak might be in the midbrain or the pons. I honestly haven’t thought about that in a while.

Maybe an SDN dental student could look it up and get back to us on that?

 

[TanMan]

On the flipside, if there's a patient you never want to see again, painful injections will often do the trick.

Seriously though, pain is subjective and we can try our best to make the anesthetic as painless as possible. However, this depends on the patient's previous experiences, pain threshold, phobia of the dentist/pain, and clinical presentation.

When I say clinical presentation, there are some instances that are harder to numb than others. One is a very hot tooth (SIP/AAP) on a mandibular molar. Unfortunately, there are some teeth that can only be calmed down with an intrapulpal injection and those are never fun (for the patient). Many times, you can get them numb enough just to access the pulp chamber (via septocaine-marcaine IA/infilitration/PDL/mylohyoid) then hit the tooth with a septocaine intrapulpal injection.

Edit: There are rare instances where even an intrapulpal won't do the trick, even into the canals. What I find works well is using an Er:YAG laser (or you can use other activation devices) along with a carpule of septocaine to irrigate the canal system/fins/accessory innervation. That is the absolute last resort and hasn't failed me yet.

However, what's more important than a painless injection is a painless procedure. When a patient asks if it's gonna hurt, I always say just the anesthetic, but not the procedure.

 

[dentalstudentprospect2]

Yes, the fifth...the substantial gelatinosa of which I speak might be in the midbrain or the pons. I honestly haven’t thought about that in a while.

Maybe an SDN dental student could look it up and get back to us on that?

Lol I’m just being pedantic. The SG basically becomes the spinal nucleus in the medulla where afferent fibers synapse and thus may be modulated by gate control.

 

[OMSDoc]

Thanks buddy...ur the man. Again, I have not thought about this for 35 years. I can go look this up myself if it was clinically significant for me. But thanks for that.

As an aside, I learned this initially from a great neuro-anatomy professor, who was one of my greatest mentors. I did research for him the summer after my freshman year of dental school on temporomandibular joint anatomy and elastin, which ended up being published in Acta Anatomica, so that was great.

I asked him once after a neuroanatomy lecture if he had a hard time remembering that about which he lectured, and he said, “In a word, I have a hard time remembering it, even though I lecture about it every year.”

10 years later, I was practicing in my hometown with my father and I received a call in the evening from my answering service stating that this professor (!!!) was on the line and wanted to talk to me. He was in town with his teenage son for a wrestling meet, and his son had taken a punch to the face, and he had split his oral commissure wide-open...a through-and-through laceration. Could I see them now?

I met them at my office (maybe 10 PM), and he and I (he assisted me !!! ... he had both a PhD in anatomy and a DMD dental degree) sutured up his son (who was maybe 14 years old). While I was working, I said that the most important thing was to suture the perioral muscles first before performing a mucosal and skin closure.

Ever the professor and teacher, he then asked me, “What is that confluence of the muscles of facial expression that meet at the oral commissure?“

Fortunately, I was able to immediately come up with the answer.

“Modiolus.”

Silence.

By then, I was a board-certified oral and maxillofacial surgeon, trained at the Mayo Clinic, and the great thing about getting older is that you feel comfortable giving good-natured grief to your betters.

So I stopped, looked at him, and I said, “Be honest...if I had gotten that wrong, would you have gotten him up and left?“

We all had a good laugh on that.

 

[saydental]

Does anesthetizing correctly have a learning curve? How often do dentists miss the nerve they are trying to numb?

 

[OMSDoc]

Does anesthetizing correctly have a learning curve? How often do dentists miss the nerve they are trying to numb?

There is a learning curve to everything we do, but if you do not obtain profound local anesthesia after a standard technique, you must also consider two things: anatomic variations and the presence of infection.

For example of the former, my cadaver in dental school had a common trunk for the facial and lingual arteries coming off the external carotid artery, and this bifurcated into the respective arteries after 1 cm.

The same applies to nerve anatomy. This is most troublesome with inferior alveolar block anesthesia. For example, the nerve to mylohyoid occasionally will send a branch up to the incisors. For anterior teeth, I will infiltrate on the lingual aspect of the incisors. For posterior teeth, I will give additional anesthetic inferiorly in the retromolar trigone to where I normally do. For mandibular second and third molars, the root apices will sometimes come through the lingual cortical plate, and I will infiltrated in retromylohyoid fossa. If this doesn't work, I will give an intraosseous block, akin to a PDL injection.

Secondly, odontogenic infections tend to make the surrounding tissue acidic, and due to the pka of the local anesthetic, it will not diffuse through the cell wall of the nerve (see the Henderson-Hasselback equation). In these cases, it doesn't matter how much local the patient receives. Profound local anesthesia will not be possible.

As an oral and maxillofacial surgeon, I am blessed to be able to administer a general anesthetic.

It is important also to remember maximum doses (mg/kg), especially in children, of each local anesthetic that you use. I have an Excel spreadsheet in each operating room showing the maximum allowable amounts based on weight, with it broken down into the number of carpules based on weight. There have been some case reports in the literature of deaths in children in dental offices due to local anesthetic overdoses.

 

[Mauricio45]

Anyone here buffer their anesthetic? I hear it's really effective in getting a fast onset, hardly pinches and it really helps with acidic conditions (infection). But it does seem a bit of a pain to set up. I've never done it.

 

[OMSDoc]

Anyone here buffer their anesthetic? I hear it's really effective in getting a fast onset, hardly pinches and it really helps with acidic conditions (infection). But it does seem a bit of a pain to set up. I've never done it.

I do not do this in my clinic practice today, but the hospital pharmacists in my residency would make up plain 1% lidocaine, mixed with sodium bicarbonate, to inject subcutaneously when we started IVs. This would allow a virtually pain-free infiltration, and then the patient would not feel the 14-gauge IV line going in. I wouldn't do it because it is labor intensive and has a short shelf-life.

 

[Alpha Centauri]

Anyone here buffer their anesthetic? I hear it's really effective in getting a fast onset, hardly pinches and it really helps with acidic conditions (infection). But it does seem a bit of a pain to set up. I've never done it.

Just use carbocaine / citanest. Just because there is no epi doesn't mean it doesn't work effectively

 

[schmoob]

Just use carbocaine / citanest. Just because there is no epi doesn't mean it doesn't work effectively

Yep. If it’s a little warmed up it’s more comfortable too. You can then add lidocaine if necessary which they won’t feel and can really achieve profound anesthesia. I see this is mentioned earlier.

If I have a tough time anesthetizing, I’ll grab an X-tip for intraosseous delivery. The relief is instantaneous.