This page is under construction at the moment. Please check back for updates. This page reviews my evolution over 49 years to become “Painless Pete”, and is a supplement to all the other sources of information you may find.
PAINLESS PETE
They call me “Painless Pete” in my community, which I like. “Painless” is true because I understand how to do dentistry without pain, during or after, because I understand the inflammatory pathways of oral tissues. Secondly, I like being called “Pete”, because it indicates they like me, trust me, and find me approachable. At root I am driven to optimize the patient’s experience of their time in my office. I take full responsibility for delivering the highest quality of work. In almost all regards, this has meant casting aside conventional limitations and re-inventing routine procedures. longer restoration life, better appearance , wider application of materials, higher return, and fewer problems requiring follow-up appointments/re-treatment, which are profit and reputation-killing.
People do not trust you if your work fails quickly, looks bad, is perceived as very expensive or hurts. They also do not trust you if you are shifty-eyed, evasive, and always trying to up-sell them towards expensive treatment, implying that you do not recognize high costs or the sacrifices patients make to shoulder them.
This segment discusses the best ways to use local anesthetic. In my early years I tried transcutaneous stimulation and it was inconsistent and took a long period of induction, and was not particularly comfortable in its own right. It took years to develop my present technique and I pass it on as a way to open the door to excellent dentistry, which begins with high patient comfort .
LOCAL ANESTHETIC
TOPICAL: PAINLESS NEEDLE INSERTION:
Topical benzocaine ointment is widely used in dentistry, but it needs several minutes to take effect. In observing dentists operating in live study clubs, I see many dentists rush to inject, losing its full benefit. Therefore I place it as soon as possible in the appointment, while chatting and connecting to the patient to distract them and get them relaxed. The chat flows to the subjects necessary to organize the assistant and other aspects in the first two minutes. Then we proceed to place the injection, in two steps:
- initial shallow perfusion
- wait one minute
- second injection to depth
SHALLOW INITIAL PERFUSION, SHORT WAIT, FINAL INJECTION, MAXILLARY FACIAL SUPERPERIOSTIAL
For maxillary supraperiostal injections, I stretch the tissues tight to make a controlled and easy insertion. Tension or a slight tug on the lip generates proprioception to distract from the penetration.
In a series of injections I like to make the central incisor the last site to receive full volume. The central incisor is the most sensuous of the anterior facial areas, which makes sense with its role in intimacy.
The piercing depth is 3mm or less and placed nearest to the area’s major nerve innervation and perfused with minimal fluid volume and pressure. Multiple injections in the same area do not increase postoperative pain unless one carelessly balloons the tissues with excess anesthetic. Although seemingly inefficient, the guiding principle is the patient’s experience. The aim of diviiding the placement into two steps with an intervening soak time is to work with the patient’s apprehension level and be aware of their experience. Once we have done the initial light perfusion we return to place superperiostially to the root lengths involved, and the patient has had time to relax over the initial normal apprehension.
Throughout these steps the grip on the syringe is light. Clenching the operating hand destroys the ability to feel resistance and subtle tactile cues.
INJECTION, PALATAL
The first question is whether a palatal injection is necessary. Often, for rubber dam clamp comfort, Oraqix is perfectly satisfactory. See ORAQIX
For many restorations on the occlusal surface and even some simple extractions, there is enough bleed-through anesthesia from the superperiostal injection to be perfectly comfortable, even with a rubber dam clamp, unless tissue is impinged upon by forceps or clamp.
Topical benzocaine is seldom enough for palatal injection comfort. Firm pressure adjacent to the site, however,is very beneficial,using a mirror handle for example.
It is worthwhile to warn the patient that slight pain may be coming… and asking them to let you know if so….Again, a shallow insertion and slow perfusion is the most comfortable. Never go full depth to bone with the first insertion. Don’t continue for more than a few seconds if its painful… watch for the usual signs of patient discomfort – body tightening, gripping the arms of the chair, breath holding, furrowed brow. If evident, relate to it, acknowledge its discomfort,continue only long enough to gain some perfusion. If possible, make a joke about it that reduces the emotional alienation that may otherwise begin. Once the patient has recovered, a second injection can be placed because by then you will have at least partial anesthesia from the first injection.
WARMING ANESTHETIC CARPULES?
In the 70s to the 90s it was common to warm carpules to body temperature to reduce initial shock. This applied to lidocaine in particular because it was acidic and that effect, superimposed on thermal shock, was painful.
With Articaine, which is not acidic, it seems no longer necessary.
That said, if the syringe and carpule are cold to the touch, it is more pleasant to run the syringe with carpule in it under the hot water tap briefly.
THE ANESTHETIC AGENT
Articaine 2% has been a revolution in dentistry, bringing 100% comfort withi range, along with faster onset and lower volumes in many cases. Better transosseus perfusion makes mandibular superperiosteal injections effective, including, as a wonderful boon, mandibular pedodontic restorations without the panic-inducing use of mandibular block on young children.
It is recognized that total number of injections is lower than lidocaine, due to a higher inherent toxicity, but that threshold in beyond normal dental situations.
Page under construction notes:
epi-free carbocaine and marcaine
needle
, supplier,
length,
guage,
hub,
bending the needle
the syringe ,
aspiration,
safe recapping,
disposal,