And, painless, too! Promise!
I’ve learned a lot of tricks over the years, and the internet has been my go-to source. For at least 20 years, I’ve been an active participant in online forums. The ability to access the minds of hundreds and even thousands of my colleagues has proved invaluable throughout my career.
A friend of mine, Dr. Michael Nugent (aka the “Shooting Dentist“) from the Great State of Texas, has been cajoling me about writing this particular article for at least a year. He finally and unabashedly resorted to bribery by sending me a 40-round AR-15 Magpul magazine.
And, it worked. So… all my readers… take note! I can be bribed with gun goodies! 😉
I’m still feeling it!
One frustrating aspect of daily dental practice for many dentists is consistent and profound anesthesia for lower molars. We were taught to administer an inferior alveolar nerve block… aka “IANB.” And, many of us have run into situations where the patient exhibits the classic signs of anesthesia, yet they still feel pain. So, we give them another block. And, wait. And, then HOPE that we got it that time.
Mind you, administering a “painless” IANB is quite the challenge. It’s not a fun injection to receive.
There are other techniques such as Gow Gates and Akinosi techniques, sworn by some to be very effective. And, in their hands, I’m sure they are. I’ve never felt comfortable with either.
Years ago, I briefly tried the intra-osseous technique branded as the “X-tip.” With this gizmo, you actually punch a hole through the gingiva and cortical plate with the needle mounted on a slow-speed handpiece. It works, but it can be a bit scary / traumatic to both the patient and the dentist! You’ve got to make sure your aim is good and not running into a root. I had a couple of cases that ended up sloughing some tissue and bone post-operatively. I abandoned the technique shortly thereafter. I consider it more an issue of my own shortcomings, not the product or technique.
Another fall-back technique, after all else has failed, is the PDL (periodontal ligament) injection. For some reason, this has been long held as the technique of last resort. And, by the time you get to it (after trying multiple blocks), the patient is pretty weary and probably losing confidence. And, chances are that many dentists are not doing the PDL injection correctly.
Make your life easier and patients’ experience better with PDL (intraligamentary) injections.
Why not make it the PDL technique of FIRST resort? If it can work when all else fails, why not use it routinely… first? OMG! FIRST? Well, yeah… sorta. Read on.
Many years ago, there was a dentist on Dentaltown named, Dr. Scott Perkins. His “thing” was doing procedures efficiently. He managed to create some controversy with concepts like the “15-minute molar root canal.” I believe he even had a series of videos for sale. But, he shared a lot on the forum. One of his ideas was to use a PDL injection routinely for lower molars as the primary way to anesthetize the tooth. I gave it a try and was very surprised at how effective it was. Of course, I’m a typical dentist, and I ended up modifying the technique. But, it’s one of the best “pearls” I’ve learned in my career.
Nobody can get me numb!
I haven’t given an IANB injection for routine restorative (even endo) of lower molars in many, many years now. And, I don’t miss it. Neither do my patients. One of the best things I learned was the routine use of PDL injections. I now am absolutely confident that I can get lower molar profoundly numb, quickly and predictably. This is also a huge confidence builder for patients. Now when a patient says, “Nobody can get me numb,” instead of thinking, “oh great,” I smile and say, “I can and will get your tooth completely numb.” My assistant will usually be nodding, as well. It’s all about instilling confidence in our patients.
Profound anesthesia is a win-win. Patients can relax, knowing they will not feel a thing. We can do our best work when we’re not worried about hurting patients and the patient isn’t jumping or flinching.
So, how do we do it?
I will discuss my own variation of the technique. The entire experience for the patient is effectively painless. And, for the purpose of this article, let’s consider the case of a lower first molar.
First let’s discuss the armamentarium:
- Topical anesthetic.
- PDL syringe.
- Regular syringe.
- 30-guage short needle.
- 30-gauge extra-short needle.
This is actually very important. Use a good one, and use it properly. By “properly,” I mean a couple of things. First, DRY THE TISSUE (with 2X2″ gauze) in the buccal vestibule of the area being anesthetized. Then apply a liberal amount of topical on a cotton-tipped applicator and place it on the dried tissue. Now let it sit… for TWO MINUTES. Time it. Two minutes! This is the critical part, in my opinion. If you let it sit there for two minutes, it will actually work! My favorite topical is Ultradent’s Ultracare in the “Walterberry” flavor.
I tell my patients about the topical anesthetic as follows, “We’re going to place some gel on your gums to numb you before we numb you.” This is a way of letting them know they’re not going to feel the injection.
I like Septocaine (Articaine). Some dentists report that on patients with thin cortical bone, that merely infiltrating Septocaine next to a lower molar will provide adequate anesthesia. Supposedly Septocaine penetrates bone better than Lidocaine. I don’t know if that’s true. And, it really doesn’t matter. I do like the results I get with Septocaine.
So, for this lower first molar, after the topical has worked for two minutes, we’ll infiltrate with a full carpule of Septocaine, using a regular syringe and 30-guage short needle. I use my usual technique of a quick “jiggle” and shallow initial penetration of the needle. Express a little… pause… advance… express…. pause… advance. And, so on. Patients often tell me they didn’t feel it at all. Now we let that work a couple of minutes. It works quickly on the soft tissues.
PDL Syringe with 30-gauge extra-short needle:
This is also important! Do not try this with a conventional syringe, even though you may think you have the hand strength. You don’t. The PDL syringe gives you much better control and leverage. There is also a “pen-style” PDL syringe, but I have no experience with it. You MUST use a proper PDL syringe. They aren’t cheap ($160 – $280)! But, I’m telling you… this will make your daily practice SO much easier, predictable, and relaxed.
By now the local infiltration has anesthetized the tissues. Place a 30-guage extra short needle on the PDL syringe and load it with 4% Septocaine. I like to put a 45-degree bend in the needle right at the hub. Some of the PDL syringes have a tip / hub that is already angled at 45-degrees. Insert the needle, bevel facing out, firmly into where you would expect the buccal furcation of the molar to be. FIRMLY. I angle the needle parallel to the long axis of the tooth, so I can press straight down. The extra-short needle makes it less likely to bend or kink when pressing firmly. At this point, I will ask the patient, “Feel anything?” “Nope” is always the answer.
I let the patient know he / she will feel pressure and will hear some clicking. “You might feel some pressure, and you will hear some clicking sounds. The clicking is me, not you.”
I begin by slowly expressing the first “click” of anesthetic. I expect to feel some back-pressure, and I don’t want to see anesthetic leaking out through the gingival sulcus. If I get leakage, I may back out a bit and rotate the syringe / needle a few degrees one way or the other before firmly “re-seating” it into the bone. Then try again.
If I’m having trouble getting into the buccal furcation, I may try alternative locations like the mesial or distal buccal line angles of the tooth. Again, look for back-pressure and no leakage. Generally, I like to get 2 full “clicks” of anesthetic delivered. Each click is 0.2-ml of anesthetic. So, the actual volume of anesthetic is quite small.
“Did you feel anything?” Nope.
The truth of the matter is that the “PDL” injection isn’t a PDL injection. It’s an intraosseous injection infiltration.
Once you’ve delivered the anesthetic, you can go right to work. No waiting! Rock and roll, baby! Start preppin’! The patient will feel nothing! Win-win!
If your procedure goes long, and the patient reports feeling discomfort, you might have to supplement with another PDL injection. Use the same spot you used before. But, for most routine restorative, including a crown prep, the first round should provide profound anesthesia for the duration of the appointment…. and then some.
Patients love it. We use less anesthetic and they are more profoundly numb. Again, this is one of the best things I’ve ever implemented in my daily practice. And, I’ve been using it for more than 10 years. It greatly reduces stress when I know I can “go to town” and not worry about when the patient will be jumping. And, the patients relax, too! They know they aren’t going to feel a thing!
Try it! Chime in with your comments below. If I get around to making a video of this, I’ll edit this post to add it.