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Stop hurting your Patients!

by partica

Nothing builds a practice more quickly and surely than a dentist who can predictably and PAinleSSly anesthetize teeth. And nothing destroys a practice more quickly and surely than one who can’t! (A “rough” hygienist would be second.)

But you’re a painless dentist, right??? Painless all the time, every time, right??? What about palatial injections? Still stabbing foramen and apologizing? How about numbing 8 and 9 without your patient feeling discomfort, even for extractions? Can you anesthetize lower molars painlessly?

I won’t be guilty of burying the lead. If you want to offer completely comfortable care (a significant level above painless) to even the most terrified patient – the one who screams and/or faints when topical is applied – use N2O and a drug like valium, an oldie but still my favorite. This modality allows even the clumsy and inept practitioner to appear to be a savant, and working on relaxed, comfortable patients will allow one to offer his or her highest quality of care, while tremendously reducing stress for everyone in the operatory. Long-term cost is minimal (Nothing for valium, a portable N2O setup can be had for around $3,000, and the aggregate gasses came to less than $100 per month in my practice), both are billable, and the remuneration is generous for doing no more than setting a nosepiece in place and saying “breathe through this,” (bubble-gum favored nasal hoods are a big help here, especially with kids); or saying “please swallow this.” To the true dental phobic, you will seem godlike, they will finally be able to tolerate long delayed dental care with equanimity, and I’m aware of no better way to create missionaries – zealots – for your practice than by employing this modality.

But for those foolish enough to ignore this suggestion, which can almost immediately revolutionize your practice and life (sadly and incomprehensively, this will be the great majority of our oft benighted and tremulous profession), allow me to concisely explain how to give completely painless injections.

MAXILLARY POSTERIOR TEETH

1. As you walk into the operatory, have your assistant place topical gel. (If you don’t believe these work, place a bit on the buccal tissue adjacent to your own #5, then look in the mirror and infiltrate around both 5 and 12. Debate over! If you wish to work ahead and jump to the advance course, inject one side quickly—5 seconds–the other slowly—60 seconds. Such a learning experience is referred to as epiphanic.)

2. Lift the lip, position the needle tip, then shake the tissue briskly and bring the tissue to the needle.

Keep wiggling while you inject, but less vigorously.

3. INJECT SLOWLY! Take 60 seconds or the fluid flow will damage tissue and cause discomfort. You have to wait at least that long to begin care under any circumstance, so invest one minute in demonstrating compassion for a fellow mortal.

4. If you need palatial anesthetic, a) Use a ligaject to inject the mesial and distal papilla’s. Press until you (or assistant) see palatial blanching. b) Put a few drops in the palatal SULCUS (leave the foreman’s along…they hurt). Once this is done, you can extract or begin endodontics almost immediately.

MAXILLARY ANTERIOR TEETH

1. Infiltrate as above over 6 or 11, with the needle tip angled toward the midline.

2. Inject over the midline of 7 or 10, also canting the needle’s apex toward the midline.

3. For extractions, return to ligaject and numb mesial and distal papillas, then place a drop or two of anesthetic in the palatal sulcus. Six through eleven can now be extracted painlessly.

4. Always have suction when injecting in papillas or sulcus, as anesthetic solutions taste vile!

5. If there is any pain for any injection on a maxillary tooth, you screwed up (see one minute injections, as going too fast is usually the cause of discomfort).

It’s helpful during any shot to maintain a flow of conversation as a distraction. Also, anyone still using lidocaine instead of septocaine, to be kind, isn’t paying attention. Prometheus stole fire from the god’s to benefit mankind; due to its enhanced dispersion, articaine is almost as profound a gift for dentists, and has about a fifty-year track record of efficacy and safety.

MANDIBULAR ARCH

For twenty through twenty-nine, numb exactly as Maxillary teeth, infiltrating for operative; and employing the ligaject for extractions and endodontics. (The ligaject also significantly reduces post-extraction hemorrhage.)

For lower molars on the hypersensitive (i.e. Patients on whom you’d rather get the block than give it):

1. Infiltrate on the buccal as above.

2. Use the ligaject on mesial, distal and midline with significant pressure (you must see blanching).

Before you do this, warn patients that this technique often causes the gum adjacent to the tooth to be sore for a day or two; but for needle phobics this is seldom a deterrent. This will give you 20-30 minutes of profound anesthesia, and is fine for operative or a single crown, but not endodontics or extractions, which require a block. The Gow Gates technique is vastly superior to a conventional block for about five different reasons. Go look it up.

I practiced for 40 years, and nothing stressed me more than even exiguous patient discomfort. No foolproof techniques exist, but if you follow these instructions, you and your staff will discover that grateful patients will thank you (bless you on occasion) and enthusiastically refer; and that dentistry isn’t quite so hard anymore.

WHILE I’M THINGING ABOUT IT

I called every patient I injected the evening of their care (I called, not an assistant; she didn’t give the shot, and her name is not on their check). The calls are quick, the patient impressed, and if there is trouble, it’s nice to know about it while you’re still in the office.

Having any trouble with new patient exam patients failing? I scheduled forty minutes for a new patient exam, and a hole in my book that large severely damaged my production (one failure costing me approximately 9% of my day), but this virtually never happened after I began having my staff place the record of every new patient who had scheduled an exam on my desk on the day that they’d called. I’d phone them that evening, introduce myself and ask if they had any questions; and I didn’t take “no” for an answer, as my goal was to establish a relationship. Every patient I talked with was VERY IMPRESSED that I’d called (no doctor has ever done this before), and because fear of dentists is where we almost always ended up, you must be able to confidently tell them you are painless, and why (topical, slow injections, N2O, valium, no shot in roof of mouth…ever, feather-gentle technique) because they heard the painless stuff from the last guy…who hurt them, and that’s why they are calling you. Make this effort and they will practically always show up. (I know this is inconvenient, especially so at day’s end, but success occurs to those willing to do the things unsuccessful people aren’t…like learning to give painless injections.)

Allow me two added injunctions:

1. QUIT PROVIDING CARE YOU WOULDN’T DO ON YOURSELF OR A LOVED ONE. The data varies, but the average life of a crown is around seven years.

You not only take patients’ money by unnecessarily cutting down teeth so severely, but you rob them of the very thing we are sworn to protect: Their longterm oral health.

2. Learn to do an onlay. It’s MUCH EASIER to prepare and impress than a crown, thus quicker (I scheduled 20 minutes for the prep), and if at some point it fails, you still have options that will allow you to retain the tooth.

Dentistry was difficult for me, even in year forty, but I learned very early in my career that the key to excelling isn’t possessing the newest product, gadget, advertisement or website; but adopting old fashioned virtues (there are compelling reasons why these are considered ageless), such as honesty, empathy and compassion for our fellow man.

I wish you the best.

Dr. John A. Wilde has published six dental books including A Dentist’s Guide to Financial Freedom, which is still available through the TPD website, and he has had over two hundred articles appear in print.

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