No pain. Plenty to gain.

March 21, 2012
Stan Goff
Issue 6

Local anesthetics have allowed you to perform dentistry for more than 100 years. And those needles you’ve bee n using have scared patients for just as long.

Local anesthetics have allowed you to perform dentistry for more than 100 years. And those needles you’ve bee n using have scared patients for just as long.

Great strides have been made in topical anesthetics, local anesthetics, delivery systems and needles, and even in relaxation and comfort measures, not to mention sedation. But a replacement for the needle needed to administer local anesthetics hasn’t yet been developed, and many a patient continues to be frightened by the sight of the needle and the noise of the drill. So it’s critical for your practice’s success and for your patients’ comfort that you know how to deliver pain-free dentistry the best ways possible, and that you and your entire staff know how to handle that phobic patient before you lose him or her and everyone that patient talks to along the way.

Dr. Stanley F. Malamed, author, lecturer and Dentist Anesthesiologist at the Herman Ostrow School of Dentistry of USC, often refers to an article written by practice management consultant Jennifer de St. Georges whenever anyone questions just how important pain is to the dental patient.

The 2004 article on how patients select their dentists presented a top 10 list of things that patients look for. It includes a high degree of sterility, prompt appointments, and having upbeat people who work in the office. But the No. 2 and No. 1 most important things are, respectively, a dentist who doesn’t hurt, and the ability to give an injection painlessly.

“The two most important things in the patients’ mind deal with pain, and that’s because people out there think of the dental profession as a painful profession,” Dr. Malamed said. “So that’s who we’re dealing with to start with. And the answer to that is dentistry can be painless.”

That’s a good thing. Dr. J. Mel Hawkins, a lecturer who conducts courses on anesthesia and sedation and who runs Anesthesia Services for Dentistry in Toronto, said patients today are no longer tolerant of a dentist who hurts them.

“Patients are no longer willing to put up with that. Also, they’re not faithful anymore. They’re more willing to change dentists almost instantly,” Dr. Hawkins said. “It’s so important for the dentist (to deliver painless care)…the competition in dentistry especially in the large centers needs the dentist to rise above perhaps his colleagues in any ways he or she can do that.”

The last thing you want is for your patients to tell everyone how much you hurt them.

“Word gets around,” Dr. Hawkins said. “Word doesn’t follow the most beautiful filling in the world. Word follows pain and no pain. That’s what people talk about.”

In this month’s Exclusive Survey experts including Drs. Malamed, Hawkins and Kenneth L. Reed, the vice president of the American Dental Society for Anesthesiology, will help discuss the latest products and techniques designed to allow you to make sure your patients feel the least amount of pain and have you and your staff best prepared to handle those phobic patients who may need a little extra TLC to get through treatment.

Our May 2011 Anesthesia Survey results indicate that 12 percent of you report that more than one-fourth of your patients regularly require pain and/or anxiety control beyond what they consider standard protocol. Of those of you who responded to the survey, 8.3 percent indicate that between one-quarter and one-half of your patients  require such care.

On the bright side, there are many options available today to help you care for these anxious patients.

Local anesthetics

The bad news may be that the “dreaded” needle is required to properly numb patients for dental care. But the good news is twofold-the drugs do indeed work well when properly administered, and topical anesthetics and innovative delivery systems have come along that allow the injections to be painless.

“Local anesthetics are the safest and the most effective drugs we have in medicine for pain control. They work,” Dr. Malamed said. “The only problem that we have is you need a needle to get it in. That’s really what scares our patients. It’s not the drug. It’s not the syringe…it’s the needle. The fact that you have to stick that needle in their mouth and it’s scary.”

Today, however, dentists can consistently give injections painlessly and the drugs, once they’re in, work. There are even products on the market now that can help make the drugs work faster, better and be more comfortable. These products include OraVerse, now available from Septodont Inc., and OnPharma’s Onset, which was officially launched at the Chicago Midwinter Meeting in February.

Additionally, a number of delivery innovations over the years have hit the market in an effort to allow the injection pain to be reduced and/or to relieve the pain associated with the administration of the anesthetic itself. These include the STA (single tooth anesthesia) system from Milestone Scientific, IntraFlow (formerly available through Pro-Dex Micromotors) and Bing Innovations’ DentalVibe.

While attempts have been made to come up with a method of dental analgesia that doesn’t require a needle, the science and research has yet to develop a worthy alternative.

“Over the years we tried a whole bunch of stuff and nothing works as well as putting that needle in. Nothing works as well as putting the needle in and injecting, unfortunately,” Dr. Malamed said.

“I keep on saying to my students I have textbooks on local anesthesia dating back 100 years. We look at what they did 100 years ago and we say how barbaric that was. I have a feeling if we were 100 years in the future and they look back at the state-of-the-art today they would look and say, ‘My God look at what they were doing. They were sticking needles in people.’  “Probably over the next 100 years there will be some advances made so that we don’t need to do this anymore but right now the state-of-the-art is still the injections.”

In terms of the drugs themselves, lidocaine and articaine are the two biggies in the industry. Articaine only has been available in the United States for a little more than a decade, but Dr. Malamed said its effectiveness has made it a popular choice. “Articaine is the No. 2 most used local anesthetic in the United States used in dentistry,” he said. “If we speak again in 3-4 years it may be No. 1. It’s that good a drug.”

Dr. Hawkins adds, “Until 2006 the profession didn’t really know if there was one local anesthetic solution that was better than any other local anesthetic.”

But at that point in time a researcher named Kanaa MD did a double blind crossover study to compare 2% lidocaine 1:100K to 4% articaine 1:100K in efficacy. It was statistically significant that articaine was the more effective solution in anesthetizing the nerve(s). This study was actually done on University of Washington dental students in 2006 and the results were published in the Journal of Endodontics the same year.

The study’s conclusion was that articaine was more efficacious than lidocaine and this is probably because of its chemical structure rendering the product very lipid soluble..i.e. …sulphur added to form a thiophene ring, while all other local anesthetics have a benzene ring.

Articaine, according to the sales team at Septodont (the manufacturers of Septocaine), has a significant market share since it was launched in April 2000 in the U.S., said Dr. Hawkins. Surveys that have been done suggest that it’s about 35 percent in each of Canada and the U.S. Zorcaine by Eastman Kodak (now known as Carestream Health Services), as well as others have now entered the sales market as generics and have had a lower market impact. Articaine has been available since 1976 in Europe, especially in Germany and France, where it has an estimated 90 percent of the market and in Canada since 1983, where it approached 30-40 percent of the market at various times, Dr. Hawkins said.

At the California Dental Association’s  CDA Presents The Art and Science of Dentistry meeting in May, the Italian company Pierrel Research International AG launched Orabloc, a new “purer” formulation of articaine, for oral surgery and routine dental procedures. The  product is available exclusively through Patterson Dental.

Injection techniques 

Getting a patient numb is something dentists do several times a day and something they most likely mastered long before graduating dental school. But that’s not to say injections go perfectly well every time. Some patients just don’t react to local anesthetics like others and some injections-namely in the mandible of adult patients-can be tricky at times.

“Giving injections is something dentists learn in school and it’s something they do every day. They do it every day 10-15 times,” Dr. Malamed said. “Obviously there are some doctors who are more proficient than others. The problem is that not all of our patients are wired the same way. You can put a needle in the same place on 1,000 people and the nerve isn’t going to be in the same place in all 1,000 people.

“It can be tough at times, especially when you’re working with the lower jaw, the mandible. That’s where the biggest problems come. It’s a bad injection in terms of failure rate.”

Most dentists who graduate from school are comfortable with infiltration injections (upper injections) and mandibular block injections, Dr. Malamed said. But at times the docs can suffer a “slump” in terms of getting the patients properly anesthetized in the mandible.

“That’s why, when I get these phone calls from dentists who are frustrated saying ‘I can’t get my patient numb’ it’s always in the mandible, always,” he said. “If infiltrations worked in the mandible then we wouldn’t have this kind of problem. But the bone in the mandible in an adult patient is very thick and infiltrations don’t work. They’re literally stuck with this mandibular block, which is a frustrating injection.”

Sometimes this frustration can lead to a slump. “In their lifetime every dentist goes through in their practice what I call a mandibular slump,” he said. “There are certain weeks where you go in and give patients injections and it works every time. You bring the same group of patients in now and you can’t hit the broad side of a barn and again it’s always in the mandible.

“The doctor always seems to blame the drug, saying ‘I got a bad batch of local.’ Well there’s no such thing as a bad batch of local. If the local anesthetic is put on a nerve you have anesthesia. If you can’t find a nerve then you don’t get anesthesia and that’s where the problem comes in.”

“The contemporary challenge in dentistry is the apprehensive patient who frequently suffers from extreme anxiety associated with a dental  visit,” added Dr. Hawkins, noting that it’s both the injection and the effectiveness of the analgesia that frightens many patients. “They often break their appointments or just don’t go to the dentist period.“Patients tend to be primarily afraid of the needle and it’s potential not to  work, and secondarily, especially if the local anesthetic hasn’t effectively blocked nerve impulses to the brain, the drill.”

Dr. Hawkins reiterates Dr. Malamed’s claims that the drugs themselves do work just fine. “All the commercial local anesthetics perform well. Otherwise, they wouldn’t be on the market and wouldn’t be approved by the FDA or accepted by the patient and dentist population,” he said.

Topical anesthetics

The large majority of survey respondents use topical anesthesia prior to injection (77 percent), and there are a wide array of products available to choose from, including Premier Dental’s Topicale Topical,  Sultan Healthcare’s Topex, Colgate Orabase paste, Beutlich LP Pharmaceuticals’ HurriCaine, Crosstex’ GumNumb, DMG America’s Kolorz Topical Anesthetic Gel, and a wide range of private label pain medications offered by Henry Schein.

Dr. Hawkins suggests dentists make sure to follow directions when applying topicals to get the best results.

“Painless administration of local anesthesia systems depends on a number of factors,” he said. “The first area of action would be the application of a topical anesthetic on the mucosa to alleviate the sensation of discomfort from needle penetration. It’s essential to dry the tissue, isolate the area and leave the topical on for a suitable period of time. Dentists can be impatient and generally want everything in dentistry to work virtually instantaneously. It has been shown that a predictable and  successful effect requires 1½-to- 2-minutes.”

DENTSPLY’s Oraqix (lidocaine and prilocaine periodontal gel) 2.5%/2.5% is a subgingival locally applied anesthetic gel that dispenses as a liquid and sets as a gel in the periodontal pocket. It provides safe and effective pain relief during scaling and/or root planing procedures without a needle.

“Oraqix is a relatively new topical anesthetic that has proven to be very effective. Unlike the 20%  benzocaine topicals, which are esters, this topical is an amide combination of two local anesthetics and it appears when these  two local anesthetics (2.5% prilocaine, 2.5% lidocaine) are combined it shows a shorter clinical onset time and actually  exhibits penetration and diffusion into the submucosal tissue layers.”

Fighting the fright

It seems that patients always have been afraid to go to the dentist. Many things have been done over the years to improve their overall experiences in the office, but the needle and the noise of the buzzing handpiece still scare off many.

These are patients that may be candidates for sedation, but at the very least they’re ones who require extra awareness and attention from the entire staff.

“There’s a fear factor if somebody’s scared. Even if you have profound anesthesia you’ll have vibration and sound,” Dr. Malamed said.

“There are a lot of things that our patients respond to. Even a slowspeed drill can feel like a jackhammer. The noise and the vibration…if you’re a scared patient you might not feel anything but just the vibration is scary.”

This is where staff awareness can intercept a potentially scary situation and allow the practice to handle the phobic patient with the necessary TLC.

“No. 1 the entire staff should be trained to recognize fear,” Dr. Malamed said. “That starts out in the waiting room…when the patient walks over to the receptionist and says, ‘Does the doctor give good shots?’ What that patient is saying is I’m afraid of getting an injection. The message has got to get back to the doctor before they draw out a syringe and the patient faints.”

He said a similar scenario might occur in a conversation between two patients. The receptionist overhearing two patients talking in the waiting room, and one of them is going to have root canal work and the other one says “Oh I feel so sorry for you because root canal work is so painful.” Dr. Malamed said that type of message also has to get back to the doctor before he or she begins to do anything because you can explain root canal work in a way that makes it not scary. Tell the patient you’re going to clean out the tooth, shape the tooth and fill the tooth.

“So getting the message back to the doctor if anybody in the office recognizes that a patient may be fearful then confronting them, asking them about it,” he suggested. “And then being able to do something about it.

“Whether it’s oral, sedation, pills, nitrous oxide sedation, even hypnosis, or how about a head set with music? In other words, anything a doctor can do to distract. Sedation simply is distracting a patient. Taking their mind away from what you’re doing while they’re in the chair. Obviously my bias is drugs, because that’s what I do for a living, but hypnosis or anything that can make that patient relax is good.”

According to our latest survey, a number of you are taking advantage of some of these methods to comfort and care for potentially frightened patients. About 7 in 10 use inhalation sedative (nitrous oxide) and the same number of respondents report using pre-procedure oral sedatives in their practice..

In terms of non-pharmaceutical methods offered in the practice, 70 percent use headphones for audio, 56 percent use video/DVD viewing and 12 percent use massage in their practice to manage patient anxiety.

Dr. Hawkins concurs with the need to offer these types of services in your practice. But he adds that dentists wanting to get more involved in sedation should take advantage of some of the quality CE now available in that field.

“Tender loving care goes a long way and it is the staff that are the first team members the patients are exposed to,” he said. “However pharmacological adjuncts in the field of sedation and patient management offer choices in dentistry both in local anesthesia advanced success enhancing technique courses, and in the administration of nitrous oxide/oxygen, oral and IV sedation for the appropriately trained dentist.”

These courses range from about 60 to 100 hours and because of the ever increasing demand from both the public and by the dental profession these programs tend to be very sought after. In Canada and in Ohio they comprise about 95 hours in total and are given on two separate weekends (includes ACLS) with a third session of one week for patient treatment.

Sedation

The use of oral sedation has become extremely popular in dentistry. Nitrous oxide always has been around and is probably still the best technique available for dentists.

“There’s more and more interest among dentists in using other techniques like intravenous sedation,” Dr. Malamed said. “We’re giving more courses in that, and I think there is more of an awareness. For the doctor out there that’s treating scared patients, No. 1 it’s not fun for the doctor, and No. 2 it’s more dangerous.  More problems happen.

"Take away that patient’s fear, and everything becomes a lot easier to do. It makes dentistry more fun for the doctor, too, because he’s no longer fighting with his patient.”

Dr. Reed said sedation techniques need to be learned by dentists and adds that the education is easily accessible. “Sedation is their friend. Nitrous oxide is a wonderful drug and is a technique in which all dentists have been trained,” said Dr. Reed, who is an Attending in Anesthesia, Arizona Region, for the Lutheran Medical Center in Brooklyn, N.Y. “Minimal sedation from an oral route also takes very little training to learn to do it properly and safely. IV sedation takes a bit more time and effort to learn, it is roughly a 100 hour CE course, but will offer a huge transformation to most dental offices.”

Dr. Reed added that in most states, general anesthesia is readily available by bringing in a dentist anesthesiologist. For those with an interest, a dental anesthesia residency is available; it is a 24-36 month full-time residency.

When we asked our readers if they had completed CE courses in the past two years, 42 percent said Yes they had done so in dental analgesia, while 21 percent said Yes to completing CE in conscious sedation.

Dr. Reed suggests you shop around to make sure you sign up for quality courses.

“Primarily, look at the faculty of the course you are planning to attend. Also look at the motivation of those faculty,” he said.

“As an example, there are organizations that exist solely to make a profit and other organizations that exist as a non-profit entity with their reason for existence only to provide continuing education in anesthesia and sedation. Some courses have extremely well qualified faculty educators while faculty at other courses really don’t have the background and training to be providing the courses they do. Simply, I suggest doctors do their homework prior to signing up for continuing education courses so they maximize the return on their investment.”

Of the survey respondents, just more than 71 percent offer inhalation sedatives (nitrous oxide), while 68 percent offer oral sedatives. Ten percent of you offer injectable pre-procedure sedatives.

Innovative agents

While we haven’t progressed to the point where needles are no longer needed, there have been substantial breakthroughs in other areas that have helped both the doctor and the patient.

Topical anesthetics have gotten much better, while products like OraVerse and Onset have become available and are designed to provide benefits to both the patient and the dentist.

OraVerse is a reversal agent designed to significantly reduce the time a patient remains numb following dental procedures. It came onto market about four years ago from Novalar Pharmaceuticals based in San Diego, and was subsequently acquired by Septodont.

“It showed promise in its ability to  reverse the local anesthetic numbness effect only, without reversing the actual anesthetic effect itself,” Dr. Hawkins explained. “Oraverse is a vasodilator and this factor is responsible for the faster absorption of the local anesthetic from the injection site into the blood stream.”

OraVerse theoretically can be given soon  after the local anesthetic is given at the beginning of the appointment in  a one to one volume ratio and it can begin to eliminate this numbness during and shortly after the appointment, Dr. Hawkins said. The local anesthetic will be ongoing and the dentist can work until the actual local anesthetic effect disappears, which is predicted to occur after the operation or when the dentistry is finished.

“This has many applications including, for example, the business man or woman who is going back to work, cessation of drooling and return of self confidence, important meetings, lunches,  dinners, telemarketers, children, news casters and just about everyone in the preceding related situations,” Dr. Hawkins said. “It would have relatively few drawbacks-reversal of an endodontic or  surgical case might not be desirable.”

Statistics on this show that OraVerse cuts the numbing effect time in about half. The average maxillary time to  return to normal sensation was accelerated by 83 minutes and the  average mandibular time was accelerated by 85 minutes, he said, adding that it isn’t recommended for children younger than 6 years or weighing less than 33 pounds.

“The OraVerse solution is required to be injected at the very site that the local anesthetic was delivered in an equal volume to an oral maximum of two cartridges. The other disadvantage with that is if the area is numb, for instance in the block, there is a risk of trismus (locked jaw or sore jaw with reduced opening), which won’t be realized until post-op and the rare potential for paresthesia (mechanical damage of the nerve via a second injection through an already numb area).”

But those risks are slight, and Dr. Malamed admits he’s been a big fan of the concept since the product’s inception.

“Some of us were like ‘Oh my god this is a fantastic thing, you can un-numb a patient,’ ” he said. “Usually the patient leaves the office and is still numb for another 3-5 hours. This product, injected at the end of the procedure, makes it go away within an hour or two. From a patient’s perspective it’s great.”

Dr. Malamed said he expects Septodont to help get the product into more practices. Until now, he said, some practices may not have considered just how strong OraVerse’s benefits could be to the patient; rather they assumed their main priority was delivering comfortable care while the patient was still in the chair.

“Here’s the problem with the dentist... the dentist’s goal is to provide pain-free dentistry and with the local anesthetics we have we can do it virtually all the time,” he said. “But think like a doctor now. I did my job. I didn’t hurt the patient. The fact that this patient is numb for another 3 or 4 hours doesn’t really affect me.”

He did say that high-end practices with numerous large treatment plans have successfully implemented regular use of OraVerse for their patients.

“They’re doing a treatment plan for $30,000…if you need IV sedation or if you need reversal of local anesthesia they’re not going to charge you the $10 cost for it. Those are the ones who’ve used it and the ones who love it.”

Onpharma Inc. has created a simple system for buffering local anesthetic cartridges to physiologic pH to reduce the “bee sting effect” that can occur when standard local anesthetic is injected at its off-the-shelf pH, which is about the pH of lemon juice. 

The Onset system buffers the standard cartridge of lidocaine with epinephrine, immediately before the dentist loads the cartridge into the syringe and gives the injection. The dentist retains his or her injection technique and armamentarium. The buffering process can be done by the dental assistant at chairside, in less than 10 seconds.

Raising the pH makes the injection more comfortable and it speeds up the onset of the anesthetic, allowing dentists to start and complete care sooner.

“Onset is something you do to the anesthetic cartridge before you give the injection to make it work a lot faster. It makes it work a lot better and it makes it more comfortable,” Dr. Malamed said. “That’s going to be popular because the dentist is going to see the benefit. Patients are going to like the injection because it doesn’t hurt.

The doctor can get started a lot faster and it works better, which means you’re number. You’re less likely to feel anything. That’s why it’s gonna work. I would be shocked if a year from now I’m not saying to you that this thing is a hit. If the dentist sees the advantage of it, and it is a tremendous advantage to the doctor, it’s going to sell.”

Dr. Hawkins elaborated on the product’s potential by explaining just how it works. “The local anesthetic stinging is directly related to the pH (acidity) of the solution. All locals are dissolved in hydrochloric acid for stability and that acid concentration is causative when discussing the stinging aspect. Sodium bicarbonate, a buffering agent added to acidic solutions (in this case local anesthetic’s HCl cartridge contents) to render them more basic (i.e. closer to physiologic pH), has been available since the 1950s.

“However until now, it could not be harnessed and adapted into a delivery system for dentistry. Onpharma developed a delivery system where a portion of the local anesthetic in the cartridge can be exchanged for an equal volume of the bicarbonate. This action may be applied to any local anesthetic product. Technically, 0.18 mL of local is withdrawn and replaced by 0.18 mL of sodium bicarbonate. The favorable change in pH results in a faster onset and it doesn’t sting during the injection process.”

Dr. Hawkins refers to a study  (Malamed SM, Falkel M, Draft Public.  2011) conducted by Dr. Malamed in discussing the effectiveness of Onset. “The data reports that 44% of buffered patents experienced zero injection pain compared to only 6% of the anesthetic control group experiencing zero pain on injection of the conventional unbuffered solution,” he said.

Although the local anesthetic must be packaged as a hydrochloric acid (if a vasoconstrictor is added it decreases the pH or increases the acidity), by buffering it’s better tolerated by the patient, is gentler to the patient’s tissue and shortens the time of onset significantly, Dr. Hawkins said. “Seventy-two percent of patients in the same study group preferred the injection of the buffered solution,” he said.

The average onset time for local anesthetic when scientifically researched was approximately 5½ minutes averaging all the different techniques for injections, Dr. Hawkins said. With Onset the average time to complete IA nerve blockade was about 1 1/2 minutes. “This is significant. Especially for the busy practice or for the patient and dentist/hygienist who wishes to proceed virtually immediately and not be delayed,” he said.

Dr. Reed said these types of products may be well-suited for some younger patients and some patients with special needs, although OraVerse isn’t to be used with very young children.

“They have application. But the numbness will not be reversed before the patient leaves the office,” Dr. Reed said. “The local anesthetic ‘reversal’ agent will be administered before the patient leaves the office but it takes some time to become effective; it is not instantaneous.

“I see the greatest benefit to pediatrics, where we don’t want patients numb for a long time after the procedure. The local anesthetic ‘reversal’ agent does not significantly increase blood levels of the local anesthetics so in addition to being effective, it also is very safe. Keep in mind that this ‘reversal’ agent is absolutely NOT indicated in case of a local anesthetic overdose. Local anesthetic reversal agents also benefit patients with special needs, for similar reasons as the benefits to pediatric dental patients. Also, their use should be considered for the diabetic patient because we do want them to be able to eat after the dental procedure and take in nutrition that elevates their blood sugar. And of course local anesthetic reversal agents benefit those that go right back to work after their dental appointment and have to speak, either on the phone or in person, to others so not being anesthetized would be a benefit in those situations.”

STA System/new devices

Dr. Malamed stands behind Milestone Scientific’s STA system’s claims that it delivers pain-free injections. In fact, he believes more dental practices should use the product and that in doing so their patients’ positive experiences would help attract new patients. According to our survey results, 10 percent of our readers use computer-controlled injection administration systems.

“The concept is computer-controlled local anesthetic delivery, CCLAD, and there are other machines, many all over the world, on the market,” he said.

“The concept is great…you can give an injection anywhere in the body as it’s also used in medicine. You can give an injection of local anesthetic anywhere in the mouth painlessly…that includes the palate, which is obviously the test right there.

“In the eyes of patients giving an injection in the palate is the most painful thing we do. You can give it painlessly with this device. I won’t say there’s a negative to this but it’s $2,000. In my lectures I say to the doctor, ‘How much is it worth to you to be able to guarantee painless injections anywhere in the mouth? Is it worth $1,000 dollars to you? Is it worth $2,000? Is it worth $10,000? If the No. 1 thing patients use in selecting their dentist is painless injections, then this thing is priceless. I got involved over the years with gadgets…people come to me with all sorts of things. But the Wand (STA), and these computerized devices are not a gadget. Onset is not a gadget. OraVerse is not a gadget. They work. They actually work.”

Hygienist Renee Cultrara, clinical products specialist for Milestone Scientific, said the product actually can do some injections the old fashioned needle can’t.

“It is used for all injections that you can currently do with the hand syringe and then some,” she said. “There are additional injections that can be done with our instrument that can not necessarily be done with the hand syringe because of the design of the hand syringe and the design of our Wand handpiece needle. That’s why these additional injections can be done.”

The computer slows down the administration of the anesthetic and this eliminates the pain usually caused by the swelling of  tissue. “It gives a comfortable injection to the patient and the reason we can honestly say that is our instrument is a computer. We have a controlled flow rate; the instrument itself controls the flow of anesthesia. Something that can’t be replicated or done with the hand syringe,” Cultrara  said.

She added that the  instrument’s design also is less intimidating. “If you have a needle phobic patient…if you look at the traditional hand syringe, the syringe or the metal or the plastic part itself with the needle attached to it…versus our Wand, it’s not threatening to needle-phobic patients,” she said.

Joyce Freeman, who works in marketing for Milestone Scientific, said the STA system and its Wand handpiece is a practice builder because of its ability to deliver pain-free dentistry.

“We have people who call here who are with dentists who currently use the Wand who might be moving to another area and they call or go on our website and ask, ‘Where can I find a doctor with this product in a new location?’ It is a very big practice builder,” Freeman said.

Dr. Hawkins elaborates on just how the acid in the injection cartridges causes a stinging sensation and why the STA device works so well in eliminating this sting.

“A second aspect of a painless injection involves the acidity of solution itself,” he said. “Being acidic inside the cartridge for its stability, it frequently elicits a stinging sensation, which some patients interpret as pain. If that pH could be at least somewhat neutralized, that is altered to be closer to physiological pH of 7.4, then according to the Henderson-Hasselbalch equation, there would be less or no stinging and the onset time might be reduced to one-fourth the time of a standard local anesthetic that had not been buffered.”

The speed of the injection, therefore, plays a role in how much stinging a patient may feel.

“Pain can be directly related for any of the products, to the speed of injection,”  Dr. Hawkins added. “This is where the STA system has a great advantage. What the STA system does is it slows the dentist’s administration of the anesthetic and choosing from a 1-minute delivery of 1 cartridge or carpule to the maximum time of 4 minutes to deliver the anesthetic. It controls the speed of the solution entering and  spreading the tissue. This has been shown to be painless, especially in tight tissue spaces and computerizes the injection, most importantly by time but also by location of the chosen technique.”

Dr. Hawkins had AMSA (anterior middle superior anesthesia) palatal blocks performed on him by one of the inventors and “can truly state that it is a painless technique.”

Other advantages of the STA system include a lightweight and  streamlined, non-intimidating handpiece, a floor placed reostat as  opposed to a thumb driven injection, automatic aspiration feature and the capability of administering a second cartridge, for example, without removing the needle and without doing an additional needle insertion. Minor drawbacks, Dr. Hawkins said, include the 4-foot tubing through which the  local anesthetic must pass (0.4 mL is wasted to initially purge this tubing) and a handpiece that is only compatible with medical/dental luer lock needles, inexpensive, but sold separately.

As previously mentioned, other systems including the DentalVibe and the intraosseous IntraFlow also provide effective methods of delivering pain-free injections.

The IntraFlow (originally available from Pro-Dex) intraosseous one-step handpiece system has been available for more than 5 years. It consists of a handpiece with a mounted local anesthetic cartridge secured to that handpiece and rendering the need for only one perforation having the perforator and  needle portion combined as one unit. Dr. Hawkins said there’s a cost for the disposable type cannula, what’s called the transfusor and for the perforator-needle.

“It is foot activated and it has an extremely sharp needle perforator-needle and seems to be inserted painlessly, only requiring topical anesthetic at the site or no pre-anesthetizing,” he said. “There is less discomfort than an injection of an infiltrative local anesthetic.”

Additionally, the cannula-perforator system is unbreakable. It simply flexes, a tremendous advance over the other intraosseous two-step systems of needles and perforators, which occasionally can break at the hub.

Dr. Steven G. Goldberg, inventor of Bing Innovations’ DentalVibe Injection Comfort System, first recognized the challenges of delivering painless injections while a student at New York University Dental School in the 1980s.  Upon entering private practice in Boca Raton, Fla., Dr. Goldberg said, “I realized that to be considered the top dentist around, I needed to be one that was painless, because patients just do not want to feel any pain.” According to WorldDental.org, 50 percent of the population avoids going to the dentist because of the fear of pain, most often the fear of injection pain.  “Once your patient is numb, you’re a painless dentist for the remainder of the procedure.  It’s the act of getting your patient numb that hurts and herein lies the problem,” he said. 

Dr. Goldberg also noted that painless dentistry can convince patients to return for the treatment they need and to schedule elective cosmetic procedures because they no longer have to fear the pain of injections. The incorporation of DentalVibe into mainstream practice can change the perception of dentistry from one of pain to pain-free, he added.

The DentalVibe is based on the Gate Control System and involves a relatively small investment on the part of the dentist, Dr. Hawkins said.

“It was launched recently and works via ultrasonic vibrations delivered to a retracted  corner of the mouth, “ he said. “It is based on Gate Control Theory. This theory states that if you have impulses getting to the brain and ‘blocking’ those pathways first, the pain impulse theoretically can’t get past the initial vibration impulse to the brain.

This system has been developed and is analogous to the forerunner H Wave and 3M machines that have electrode type patches placed on the skin adjacent to each side of the lower lip. It involves a relatively low investment.

The rechargeable kit is $359 and the second kit, the alternative if you’re doing less than 50 injections per week, is $289, Dr. Hawkins said .

It doesn’t stop here

Anesthetics and their delivery draw plenty of attention from dental manufacturers, lecturers and GPs looking to improve their techniques, not to mention from patients no longer as “accepting” of pain as they were in years past. Your patients now expect pain-free injections and pain-free procedures. Because of this it’s critical for your practice that you know just how to deliver such care.

The good thing is there have been plenty of great developments in recent years in terms of analgesia and patient comfort, and more may be just around the corner.

“This is a very exciting time right now for local anesthesia,” Dr. Malamed said. “There’s a lot happening. The additives, the Onset stuff, the reversal agent…there’s a lot of exciting things going on. Innovations make life more comfortable and then life becomes easier for the doctor.”

Dr. Hawkins said there’s research currently going on that may allow needle use to indeed go away-at least for certain areas of the mouth.

“In an experimental phase there is a mistometer delivery, no needle lidocaine local anesthetic nasal spray, tentatively referred to as AccuSpray, that could have a format much like an antihistamine or a cold remedy for congestion relief,” he said. “It theoretically could  be sprayed and inhaled through the nostrils (St. Renatus). Effective pulpal anesthesia is predicted to be performed on teeth No. 3 through and including No. 14. Once again no needles for any of those maxillary teeth. It seems non-applicable for the mandible but a no needle format may popularize it. It is currently in phase testing, and also is not advocated for tooth Nos. 15-16, and Nos. 1-2. Research and phase studies are ongoing and patent pending.”

Dr. Reed said there are other innovative possibilities down the road. “There are always developments,” he said. “A couple are in the works now. One involves obtaining pulpal anesthesia in certain situations without injecting the local anesthetic at all while another involves changing the physicochemical properties of the local anesthetic while chairside to allow more ideal clinical effects.”

So maybe some day the needles will be needed for far less dental cases than today. But the needle is still here today so you’d better know how to best use it without scaring or hurting your patients.