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30 Years of Dentistry: Lessons Learned
Lesson #3 Painless Dentistry - Part 1 Joe Steven Jr., DDS

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Lesson #3 is a no-brainer: Painless Dentistry. How many times do we forget that though? I used to get a lot of compliments from my patients like, “Wow, I didn’t feel that shot at all!” Well, guess what folks; I have to admit that I don’t hear that as much as I used to, and I know it’s just because I am more rushed than I used to be when I first started out. I realize that is a poor excuse, but I know it to be true with many other dentists out there as well.

I still try to take my time and do a great job, but sometimes I don’t. That’s one advantage of practicing in a state where hygienists are allowed to give anesthetic, which they do for me many times throughout the day. Just the other day, I went in to work on a patient whom Ashlie, my newest hygienist, previously numbed up. This patient has been coming to me for many years and when I finished treatment on him, he said, “Joe, you need to talk to that gal of yours who gave me those shots.” At first I was slightly afraid of what he was going to say, but then he went on to say, “I tell you what, those were the best shots I have ever gotten! She needs to teach you how to give shots. Whatever you do, you better not ever get rid of her.”

I know there is no excuse for not giving a painless injection, but too many of us simply do not take the extended amount of time to do so. Along those lines, sometimes we doctors don’t take the extra measures to provide painless dentistry in all of our procedures. I have talked about this before and only about five percent of dentists do what I do and that is to seat crowns with anesthetic. Just the other day, I gave anesthetic to a patient to reseat a crown on tooth number 19 and he was fidgeting because he felt some discomfort so I gave him a little more. I told him, “You know, most offices don’t even give anesthetic for putting crowns on, and he said, “Well, I’ll be damned if I’ll be going to those offices!” I thought that was very interesting. Twenty years ago I made the decision to routinely give anesthetic when cementing crowns – even on endo teeth. I told a patient that we just finished a crown on the right side of her mouth and that we needed to make an appointment to start the crown on the other side. She said to me, “Joe, I think I’ll wait, crowns hurt!” That’s when I made the decision to give anesthetic on every patient when we are seating crowns. It allows us to do this procedure totally pain free, and our assistants will have a much easier job of thoroughly removing excess cement.

We should always make every procedure as comfortable as possible. We all know why patients hate dentists, so let’s really look at our own practices and find out just how well we are doing in this area. We have to avoid the “sometimes it hurts, sometimes it doesn’t” scenarios in our practices that create “white-knuckled patients.” Painless dentistry has always been the number-one best practice builder, and it all begins with our various anesthetic techniques. In this issue and the next one, I want to share with you some of the analgesic protocols I’ve learned over the years that may help your practice provide more comfortable dentistry. Managing painless anesthesia in an efficient manner is essential for a successful practice, which results with less stressful patients and a less stressful dental team.

Nitrous Oxide
I’ve had nitrous oxide units plumbed into my treatment rooms for the last 31 years and wouldn’t practice without it. Occasionally, I’ll even let the patients breathe it also! Seriously though, nitrous oxide sedation has been responsible for countless patient referrals simply because we have it available for those who chose it. We have converted many true dental phobics into excellent, relaxed patients who undergo comprehensive dentistry over a period of time. With children under 10 years of age, many times we don’t even need a local anesthetic to restore small cavities. I’ve even done vital pulpotomies on primary teeth without a local on some of our “good little astronauts.” We usually introduce the “happy gas” to our children patients by asking them if they want to play astronaut and wear a mask and float around. It’s a great way to introduce dentistry to young apprehensive children.

Many doctors express a concern about having to work around the hoses and the nosepiece. Sure, it can be a hassle sometimes, but not really when you consider the alternative many times is working around a gyrating head and thrashing arms and legs. So, I really consider the extra hardware to be more of a benefit than an inconvenience. Portable nitrous units are OK, but they fall into the same category as a single intraoral camera system or an air abrasion unit on a cart. If it’s not readily available in every room, you just won’t be inclined to use it as much.

A common question that usually comes up when I discuss this topic at seminars is about what to charge for it. I’ve never charged a fee for nitrous oxide for any situation. I’ve heard of dentists who charge anywhere from $25 to $50 per appointment. Heck, with some patients, I’d pay them $25 if they let me gas ’em up! We only spend about $400 per month for our nitrous oxide and oxygen refills. That’s the best money an office can spend to market their practice while taking care of apprehensive patients and eliminating a lot of stress within the office. If you charge a fee, most patients will not use nitrous and therefore will not benefit from it; neither will you.

Topical Anesthetic
I’m aware that some dentists get excellent results without the use of a topical anesthetic. They take the time to explain to their patients that it’s really not necessary, etc., etc. They then proceed to give a painless injection. I still depend on topical anesthetics if for nothing else at least for the placebo effect. Plus, our patients are comfortable with it and understand it, and I would just as soon not have to re-train them to a new protocol that they may have doubts about anyway. So, we continue to use topical anesthetics. It’s always best to be sure and dry the tissue with gauze and let the topical soak in for a good 30-60 seconds to get optimum results.

Some dentists regard EMLA cream by Astra to be the best topical anesthetic we can use. It’s available at any pharmacy but costs about five times as much as our conventional topicals. If you are using EMLA and you have a prescription card, use it to lower the cost since it requires a written prescription. By the way, the instructions say not to use it on mucosa, but thousands of dentists are doing just that without any complications.

A comparable topical to EMLA is Profound which does not require a prescription and is also stronger than the regular fruit-flavored topicals. It is available through Stevens Pharmacy (no relation) in California (www.stevensrx.com or 714-540-8911).

Vibraject
I’ve been using Vibraject motors on our syringes for the last seven years or so. These little vibrating units attach to a conventional syringe and vibrates the needle and syringe while administering anesthetic. It works off the Gate Theory of pain management. Most of us have used that principle when we vigorously shake the patient’s lip as we insert the needle. We have a Vibraject unit in each of our nine treatment rooms and love them, and so do most of our patients.

I will be very honest with you and tell you that some patients don’t notice any difference. That group will complain about anything. But, the majority of patients report a more comfortable injection with many saying they didn’t feel a thing. I simply tell the patient that I’m using a new vibrating syringe that will make it more comfortable for them – no long explanation. Many dentists don’t even use topical anesthetic when they use the Vibraject. I still do simply because I think it helps and my patients expect it.

Another benefit with using the Vibraject is that it’s another way to really impress our patients by showing them that we are always on the cutting edge. It’s a rather inexpensive high tech adjunct that patients truly appreciate. Give Vibraject a try! You’ll love it, and more importantly, your patients will love it also.

In Part II next month, I will share with you more information including successful mandibular blocks, the Gow Gates injection, interligament injections, and the most comfortable palatal injection possible. I hope you stay tuned!
Author’s Bio
Dr. Joe Steven graduated from Creighton Dental School in 1978 and has been in solo practice in Wichita, Kansas up until June 2007 at which time his daughter, Dr. Jasmin Rupp, joined him. He is president of KISCO, a dental products marketing company, providing “new ideas for dentistry,” and is the editor of the KISCO Perspective Newsletter. Dr. Steven along with Dr. Mark Troilo present “The $1,000,000 Staff" & the “Team Dynamics” seminars. Dr. Steven also presents three other seminars: “Efficient-dentistry,” “Efficient-prosthetics” and “Efficient-endo.” Dr. Steven also provides the KISCO Select Consulting Program to dentists in the form of a monthly audio cd recording. (Contact info: jsteven@kiscodental.com, 800-325-8649, www.kiscodental.com)

This story, originally published in the KISCO Perspective Newsletter, is reprinted with permission.
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