Mastering the ability to achieve rapid, profound, predictable anesthesia can have a major impact on your life, not only from an economic standpoint but also from the perspective of your own personal sense of well being. It is anesthesia that really allows us to practice. Without it we would not be able to perform most of our procedures.
Dentists who have been able to effectively manage pain and anxiety among their patient base have been able to enjoy a significant competitive edge. This is true even if their colleagues possess superior diagnostic and technical skills. In general, patients are frequently unable to discern differences in technical quality, but have no trouble at all in discerning pain inflicted on them. If we want to succeed in our practices, and if we want to have a sense of well-being during our day, we need to have great expertise in the administration of anesthesia. We need to be able to practice with confidence and give anesthesia with confidence. This is critical in scheduling our day so that we can meet our obligations to the patient in terms of time they will spend in our office. They, too, are scheduling their day, and have made obligations to other people that will have to be broken if we are not able to be reasonably punctual. The doctor’s awareness of the preciousness of patient time is an enhancement to the perception of your office as being the right place to be.
We need to be very careful and purposeful whenever we administer anesthesia because anesthesia is so critical to the way we, and the services we render, are perceived by our patients. Delays in the onset of profound anesthesia lead to extremely stressful situations, ie, running behind with the patient you are working on as well as running behind on the patient who is coming next. Beginning treatment when the patient is not completely anesthetized has an extremely negative impact on the patient and your practice. For one thing they will have bad memories of you, and they won’t be in a mood to refer. Worst of all they may not come back. Imagine the things they must say after a bad experience in your practice. “That doctor practically killed me! I thought I was going to die! He pushed that drill in my tooth, and it felt like a lightening bolt shot through my head!” These are comments we want to avoid at all costs.
Here are the three techniques I use every day that help me anesthetize patients in a rapid, profound, and predictable way.
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| Figure 1. Individual Septocaine cartridges. Caution: Always reduce volume when using Septocaine. You must not use as many carpules of Septocaine as you do of Lidocaine. You must be vigilant in your calculations of maximum dosage. |
NO. 1: PALATAL ANESTHESIA
In dental school, I was taught that if you administer palatal anesthesia, give it quickly and get it over with. The theory being, if you are going to deal out excruciating pain, you might as well get it over with quickly. In other words, just stick the needle in and inject and get out.
I would have to say that using that method is one of the most intense, eye-popping experiences that you could ever give a patient. What are the most common signs that a patient exhibits when receiving palatal anesthesia? White knuckles, sucking in a deep breath while hyperventilating, eyeballs about to pop out of the head, sweat beading up on the upper lip, whimpers, moans, screams. All of the most dramatic signs of intense suffering are seen with most palatal injections. No wonder we don’t like to give palatal anesthesia. The patients hate it. I’ll never forget the time when I was a 19-year-old who had come back from college to have my wisdom teeth removed. Some old guy with a mirror on his head whipped in and gave me a couple of shots in the roof of my mouth, which caused tears to shoot out my eyeballs. Man, did that hurt! The guy didn’t say a thing; he whipped right out as fast as he whipped in. I don’t know who he was, but I knew I didn’t like him. I still don’t like him. He hurt me.
Therefore, in the past I would avoid giving palatal anesthesia as much as I could. Occasionally I would give it as a last resort. Or, I would try the unpredictable technique of “walking” the anesthesia around the tooth. I would often repeat the mistake of injecting into the interdental papilla with the belief that it was probably numb from the buccal infiltration. Wrong. At least half the time when you try this, the patient will feel a sharp pain—when you “walk” the anesthesia around, you repeatedly stick them and they feel every bit of it. It is a nasty experience for the patient, and none too pleasant for you. I have never found this technique to be predictable. Besides not being predictable, it is horribly inefficient. How many times have you made a patient “tough it out” while you packed cord around a tooth on the palatal aspect, and the patient was wincing the whole time?
One of my dental school instructors told me that topical anesthetic doesn’t work in the palatal area. I have to agree. I have used as many approaches as I could think of in applying topical anesthesia to the palate before an injection, including re-application every minute for up to 5 minutes, in the hopes that the patient’s tissue would get numb so that I could give a painless palatal. Nothing worked, or if it ever did, it wasn’t predictable. Finally, after reading an article about the Gate theory of anesthesia, I decided to give palatal anesthesia another try. It worked incredibly well. I’ve been using it ever since.
Here is the technique I have used to great effect. I press the end of a mirror handle firmly into the palate until the tissue blanches. Then I slide the needle on the end of my syringe down the mirror handle until it penetrates the tissue down to bone. I lift the mirror handle from the palate. I still have not injected anything into the palate. Then I ever so slowly begin to inject. I always check with my patient to see what their comfort level is. If the patient gives me any kind of indication that they are feeling pain, I stop injecting and check on them. I then slow the injection down. I will inject from 30 seconds to 2 minutes depending on the patient’s comfort level.
The palatal injection results in a very rapid onset of anesthesia. The anesthesia is almost always profound. Using this method, you can proceed with confidence, and your patient is very comfortable. Today, I almost never work on a maxillary tooth without palatal anesthesia.
NO. 2: SEPTOCAINE USING THE INTRALIGAMENTARY TECHNIQUE
We have a new weapon in dentistry: articaine hydrochloride. This local anesthetic was developed in Germany 24 years ago, and has been available in Europe for a very long time. It has been available for use in the United States since the FDA approved it in April 2000.
Septocaine from Septodont is the form of articaine that is available in the United States (Figures 1 and 2). Septocaine has very rapidly replaced lidocaine in my local anesthesia armamentarium. In my personal experience, Septocaine seems to have a more rapid onset of anesthesia. It seems to penetrate deeper, and the depth of anesthesia seems to be deeper. I am not alone in my assessment of this new drug. Many others have reported similar findings.
In patients with thin bone, using this anesthetic agent you can give a buccal infiltration and usually anesthetize a tooth. I’ve had patients who got a numb lip just from a buccal infiltration. When you are giving block anesthesia, a block you would have missed with lidocaine will frequently be effective with Septocaine. Septocaine used with an intraligamentary technique is capable of anesthetizing a single tooth very rapidly. This is a technique I like to use on lower teeth. By the time you have finished injecting a quarter of a carpule over a period of a minute or so, you can usually pick up your handpiece and start preparing a tooth. I use the N-TRALIG from Miltex. (Caution: Always reduce volume when using Septocaine. You must not use as many carpules of Septocaine as you do of Lidocaine. You must be vigilant in your calculations of maximum dosage. On the other hand, you can re-inject with Septocaine in a shorter period of time because of Septocaine’s shorter half-life.)
If you take no other advice from this article other than using Septocaine in place of your traditional anesthesia, you will experience a significant impact on your dental practice as a result of quicker, deeper, more profound anesthesia.
NO. 3: INTRAOSSEOUS ANESTHESIA
Intraosseous anesthesia may be relied upon as a method that will succeed when others have failed, as well as a method of first choice. It bypasses the pesky cortical plate so that your anesthesia can go directly to the tooth you want to anesthetize. For endodontics, intraosseous cuts to the chase, and you can rely on this technique more than any other for very profound anesthesia.
This technique requires a commitment of time and energy to master. Once mastered, your life and your patients’ lives are going to be a lot easier. It is a humane and efficient way to anesthetize a patient. How humane is an anesthesia procedure that is predictable only 75% of the time? With 75% predictability, you are going to make one out of four of your patients experience a nasty shock of pain when you sink your carbide bur into their dentin. And that’s just for starters. Have you ever had to inject a patient multiple times, repeatedly “zinging” them over and over? Great practice builder, right? And how about running the whole day’s schedule behind because you are taking so long trying to get anesthesia? How do you feel after a day like that? Refreshed and satisfied?
I believe that every dentist should master this technique because of the tremendous benefits to patient and doctor. You must make a bold commitment if you are to succeed in becoming versed in this technique. I suggest that for 1 month you use the intraosseous technique for every injection you give. It is only from repetition that you are going to get good at this technique. Following are a few helpful hints to get you off to a good start when using the intraosseous technique.
First, begin by inserting the needle of a traditional syringe into the mucosa at a shallow angle until you slip under the periosteum in the area where you want to make your penetration with an intraosseous needle. Inject very slowly, raising a small blister. You only need about a tenth of a carpule. When you finish, withdraw the needle. My favorite intraosseous needle is the X-Tip from X-Tip technologies. Using the X-Tip in a low-speed handpiece with an rpm of about 20,000, push the stiff needle through the mucosa and into the alveolar bone. The bone has no nerves, and because you have injected beneath the periosteum, the tissue has been anesthetized very rapidly, so you don’t have to worry about hurting the patient.
Use a series of strong pecking motions in order to make your penetration. I have a low speed that has an air/water spray, which keeps the bone from heating up too much. You don’t want to create too much friction with resulting heat. Sometimes the bone is too thick and you have to give up. In that case, move to another spot, making sure that you have anesthetized the buccal tissue beforehand. You can make the penetration through attached gingiva or alveolar mucosa. Always view a preoperative radiograph in order to find an area of bone that is wide enough to receive an X-Tip. You may make your penetration distal or mesial to the tooth you are treating. I have even gone between the roots of a molar tooth that had adequate root divergence and proper root trunk distance. Root trunk distance is the distance between the CEJ and the point where the roots start to bifurcate. If this distance is too long it would be difficult to make a penetration because the bone you encounter that far apically is frequently too dense to penetrate. I also will make a penetration through the retromolar pad behind a second molar if the pad is not too thick. The important thing with this technique is to get through the cortical plate so that the anesthesia can flow directly to the nerves entering the apices of the tooth you are working on.
Under no circumstances should you use the X-Tip for more than one complete penetration. Over-aggressive use can fatigue the tip and result in shearing of the tip.
After you penetrate the bone with the X-Tip, pull the handpiece back. The X-Tip sleeve remains in the bone. You now have a path to guide your needle into the bone. Using the same syringe that you made your blister injection with, insert the needle into the X-Tip and begin to inject very slowly. If the patient begins to feel it, simply stop and then inject more slowly. Even though there are no nerve endings in the cancellous bone, there are nerve trunks coursing through it. If you inject too quickly, you will create intraosseous pressure that will be perceived as discomfort by the patient. Never use 1/100 k epi. I like to use Marcaine which has 1/200 k epi. Higher concentrations of epinephrine can cause heart palpitations and resulting panic that we all are familiar with. Only a quarter to a third of a carpule is usually necessary. The tooth becomes anesthetized very rapidly.
I know of no other technique that approaches the efficacy of intraosseous anesthesia in terms of profoundness.
ECONOMIC ANALYSIS
The average dentist will spend, on average, 3 years of his or her practice life waiting for anesthesia to take effect during a 35-year practice career. Using eight injections per day, 4 days a week, and 5 minutes per injection, that’s 192.5 days during a practice life. That figure goes up if you consider that about 20% of all mandibular blocks are missed or not completely effective. If you work 4 days a week, that translates to a minimum of 1 year of your career just waiting for anesthesia to take effect. You can save 6 months of time over your practice career by incorporating the three techniques that have been presented. In addition, you do not have to leave the operatory while anesthesia takes effect. Leaving the operatory is wasted motion, which costs you time and money. Instead, using the three techniques, you may start treatment almost immediately after you finish your injection.
Remember, the sooner the patient’s tooth is anesthetized, the sooner you can start treatment. The sooner you can start treatment, the sooner you will be through with treatment. The shorter the overall treatment times, the more treatments you can perform. The more treatments you perform, the more people you help. The more people you help, the more financially rewarded you are. In addition, the more predictable and profound the anesthesia, the fewer interruptions there will be in the procedure. Again, the fewer the interruptions, the sooner the procedure will be finished.
CONCLUSION
The problems we encounter with administering anesthesia—delay in the onset of anesthesia, lack of profound anesthesia, pain to the patient when administering anesthesia, effects from too much epinephrine, and interruption of the schedule when anesthesia is delayed—are largely overcome by use of the three techniques I have described.
Dr. Perkins lectures and writes on efficiency systems in practice management and developed a software package for the diagnosis and management of periodontal disease. He maintains a private practice in Houston, and can be contacted at (713) 658-8636 or sperkins@neosoft.com.
For a PowerPoint Presentation that more thoroughly describes the three techniques presented in this article (especially the intraosseous technique), including high-resolution digital photos and graphics, call (713) 658-1708 or order from Dr. Perkins’ e-commerce site, scottperkinsdds.com. Rapid Anesthesia CD/ROM. Price: $59. One hour AGD/CERP credit available.
Disclosure: The author has no financial interest in any of the products or companies mentioned in this article.
