Pain Management

By Laura Thill

Improved technology and delivery systems have made it easier for dentists to keep patients comfortable and calm

The dreaded needle! For most patients about to receive an anesthetic, it’s their biggest nightmare. And, the last thing dentists want is for their patients to be uneasy in the chair. But contrary to what many patients believe, the needle isn’t their greatest source of their pain; the majority of the pain comes from the anesthetic itself, according to experts.

Pain: A major concern
For most patients, receiving an injection is the most “fear-inducing” aspect of a dental visit, says Stanley Malamed, D.D.S., Emeritus Professor of Dentistry, Ostrow School of Dentistry, University of Southern California, Los Angeles, CA. In fact, it is estimated that some 30 to 40 million persons in the United States avoid seeking dental treatment because of their fear of pain and needles.

Malamed – a consultant for St. Renatus – believes that “pain control is the most important aspect of dentistry, as most dental treatment cannot be performed without adequate pain control.”

Not only do most patients fear the pain associated with an injection, many dentists are equally frustrated by their inability to successfully – and consistently – manage their patients’ pain, Malamed points out. Making matters worse, some needle-phobic patients have been known to faint (syncopy) – the most common medical emergency in dentistry, he notes. This – together with concern that the use of a syringe and needle can lead to inadvertent needlesticks and potential transmission of such diseases as Hepatitis C and HIV – have led some doctors to explore a needleless alternative. “Kovanaze – a nasal spray consisting of 3 percent tetracaine and 0.05 percent oxymetazoline – effectively provides anesthesia to maxillary non-molar teeth via a nasal spray,” he explains. “No needles are involved.

“Most dentists dislike administering palatal injections because, in their mind, they hurt,” Malamed continues. “The same is the case for their patients. Offering a new technology that provides profound anesthesia without the need for injection should be well received by both doctors and patients. Further, there is no anesthesia extra-orally, so the upper lip does not get numb or droop.” This is a “significant advantage in some esthetic dentistry procedures,” he adds, as it won’t impair the patient’s ability to eat, drink or speak.

In addition, the availability of a relatively new drug called OraVerse – a local anesthesia reversal agent introduced to the market in 2008 – helps reduce the amount of time a patient is numb.

Needle: Addressing misconceptions
While more dentists are incorporating Kovanaze in their practice, needle injections remain a common and efficient means for delivering anesthetics. By selecting the right needle size, dentists can provide injections safely and more comfortably, notes Matt Woolson, product manager, Septodont. However, sales reps may have to help clear up a few misconceptions for their dental customers.

“Many dentists hate giving injections as much as their patients hate getting them,” says Woolson. But that needn’t be the case. Features such as needle sharpness, length, bore size and quality all impact the injection delivery, he points out. “Most dentists don’t know what needle brand they use,” he notes. Yet, the manufacturing process and quality of materials can have a big impact on the efficacy of the needle.

Dental needles are typically available in three gauges (25-gauge, 27-gauge and 30-gauge), according to Woolson. The smaller the needle gauge, the larger the needle size. In addition, the 25-gauge and 27-gauge needles are available in two lengths (long and short), while the 30-gauge needle is available in short and extra-short. Dental schools encourage students to use a 25- or 27-gauge needle, and most commonly a 25-gauge long needle and a 27-gauge short needle is used. However, practicing dentists tend to favor the 30-gauge needle because it is the smallest size available, he notes. Indeed, many dentists have a misperception that a smaller needle size is associated with less pain for the patient. “This is absolutely wrong and, in some cases, dangerous,” he says.

“A 30-gauge needle is only available in short or extra-short,” Woolson continues. “Extra-short needles are designed for use with PDL injections, while short needles are designed for infiltrations. (Long needles are designed for block injections.) Some dentists use 30-gauge short needles for block injections, but that is ill-advised, he says. This particular needle is 25 mm long, he notes. If it is used for, say, an inferior alveolar nerve block injection, and the dentist needs to advance the needle 15–20 mm into the tissue, “that leaves very little room for error if the needle breaks.

“I met one dentist who used a 30-gauge extra-short needle for an inferior alveolar nerve block injection,” Woolson recalls. “An extra-short needle is only 10 mm long. That means this dentist not only advanced the needle to the hub, but had to compress the patient’s tissue enough to permit the needle to be injected even further. Imagine the discomfort for the patient!” And, if the dentist inadvertently breaks a short or extra-short needle during an inferior alveolar nerve block, he or she may need to surgically remove it. To do so would cause scarring on the patient’s neck, not to mention a lawsuit, he points out.

“Years of clinical research shows there is no perceptual difference between a 25-, 27- and 30-gauge needle when inserted into the oral tissues,” says Malamed. “Yet dentists persist in using 30-gauge short and ultra-short needles for all injections, including the inferior alveolar nerve block.” In fact, over half of all needles sold to dentists in the United States are 30-gauge, he points out. “I’d love to see them use 27-gauge long and short needles, but after 43 years of teaching and preaching, I’m running short on hope in this regard.”

Reaching out to customers
Reps can initiate a discussion about pain management by asking a few probing questions:

  • “Doctor, have you ever had a patient faint during an injection?”
  • “Do your patients ever ask you if you have to give them a shot in order to do a procedure? Do they ever confess that they hate getting shots, but once they are numb they’re okay? These patients are prime candidates for needleless nasal spray for their planned treatment involving maxillary non-molar teeth.”

The cost of new technology may be a factor to the dentist, but it shouldn’t be, says Malamed. “I am perplexed at how a dentist can quibble over the cost of new technologies that enable him or her to provide better quality pain control, more easily, more comfortably and with increased safety. Yet they do. Yet these very same doctors will spend many thousands of dollars buying lasers, intraoral TV cameras and other truly expensive technology that, in many cases, cannot be used without the dentist first achieving effective pain control.

“To paraphrase the old Mastercard advertisements: What is it worth to be able to provide your patients with pain-free dentistry using, for example, a needleless technology, when the two most important items in a patient’s shopping list for a ‘good dentist’ are, ‘I don’t want to be hurt’ and ‘a painless injection?’ It is truly priceless.”

Looking sharp

At Septodont, needles and pain management can mix – as long as the needles are high quality and designed with optimal patient comfort in mind. First and foremost, needle sharpness is key, notes Matt Woolson, product manager, Septodont. In addition, the company offers the Septoject Evolution needle – a uniquely designed needle featuring a beveled scalpel – and the Septoject XL, which features an oversized lumen or bore. “The Evolution needle is so sharp, it is only indicated for infiltrations and PDL injections,” he says. “There is too much risk using it on block injections, where it could damage a nerve.”

Buffered anesthetic

For many patients, the worst part of a dental procedure is the initial injection of the anesthetic. A fear of the needle – together with their concern that the numbness might not last and they’ll experience great pain – presents a challenge for dentists, whose goal is to provide an optimal patient experience.

Indeed, a common misconception among patients is that the stick of the needle is the biggest source of pain when, in fact, the bulk of pain comes from the anesthetic itself. “Local anesthetic is very acidic, with a pH level as high, if not higher than that of citric acid,” says Ryan Vet, vice president of marketing, Anutra Medical. Consider getting injected with lemon juice, he points out. “No wonder it burns!”

One solution is the Anutra Local Anesthetic Delivery System, notes Vet. “By utilizing buffered anesthetic from the Anutra Local Anesthetic Delivery System, practitioners are able to inject local anesthetic at an acidity level that mirrors that of the patient’s body,” he continues. Some patients have even commented that they were unaware of receiving the shot, he adds. Additionally, whereas only two-thirds of patients typically reach pulpal anesthesia after the first injection of anesthetic, with buffered anesthetic, “the majority of patients get numb the first time,” he says.

“Utilizing buffered anesthetic helps the anesthetic take effect – on hard-to-numb patients as well as during nerve blocks – in two minutes or less,” says Vet, providing dentists with as much as 15-20 minutes for each restorative procedure they perform. For dentists who perform as many as 20 or more cases each week, they may gain an extra hour or two in a typical day, he points out, offsetting the higher expense for dentists purchasing a premium anesthetic such as Anutra.

Buffered anesthetic is far more reliable than traditional anesthetic, says Vet. This means fewer bail-out shots. Anutra is also more predictable, making it possible to schedule shorter appointment times and schedule more efficiently. Buffered anesthetic is more profound than traditional local anesthetic, allowing dentists to use less volume than they traditionally would have. Additionally, with the multi-dose Anutra Syringe, dentists are able to deliver the precise amount of anesthetic required, eliminating waste. This means the dentist is no longer confined to a 1.8 mL carpule. Most importantly, Anutra helps ensure peace of mind for patients, making their experience in the chair a positive one.

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