Operative Dentistry

Off-Label and Totally Legal: What the FDA Won’t Say About Fluoride Varnish & SDF

May 29, 2025 By Trish Walraven Leave a Comment

Fluoride Varnish and Silver Diamine Fluoride (SDF)

Let’s play a little game. Imagine your fluoride varnish brush could talk. You pick it up, ready to slather it across the facial and lingual surfaces of your patient’s teeth, and it whispers:

Psst… I’m only here for sensitivity.”

Excuse me? We both know that’s not the real reason you’re using it. You’re using it to prevent cavities. So why the double life?

Not-So-Secret Agents: Fluoride Varnish & SDF

If you work in dentistry, you know there are two magical fluids we love using to fight decay without breaking out the drill: fluoride varnish and silver diamine fluoride (SDF).

But here’s the kicker: neither is FDA-approved for the thing we all use them for – you know, the actual preventing or arresting of cavities. They’ve got their little badges that say, “I’m here to reduce sensitivity,” and that’s it. It’s like hiring a security guard to scare off pigeons and they stop a bank robbery instead. Not exactly their “official” job, but they’re killing it nonetheless.

So… Are We Doing Dentistry Wrong?

Not at all. This is what the grown-up version of medicine looks like: off-label use. That means we, as clinicians, are allowed to use products in ways that aren’t specifically written on the packaging, as long as there’s good science behind it and we’re not just winging it with snake oil and hope.

Fluoride varnish has been used off-label for decades to prevent caries. Every major dental organization (ADA, AAPD, CDC) backs it. It’s reimbursed by Medicaid for that purpose in many states. Even pediatricians – outside of a dental setting – are authorized to apply fluoride to children’s teeth under certain medical guidelines. But the label? Still just for hypersensitivity.

Silver diamine fluoride (SDF) – same deal. It got FDA clearance in 2014 for sensitivity. But its real superpower is stopping decay in its tracks. You paint it on a mushy lesion and – bam! – it freezes like Elsa just sang at it. Black, hard, ugly-but-healthy decay. Not glamorous, but incredibly effective, especially for kiddos, elders, and patients who can’t tolerate traditional treatment.

Why Not Just Change the Label?

Here’s the not-so-fun part: getting a new FDA indication is expensive. Like, “we could build a small dental school for this money” expensive. Most of the companies that make fluoride varnish and SDF are not Big Pharma. They’re more like Little-To-Medium-Sized Dental Supply. If their product is already being widely used and endorsed for the off-label thing? Why spend millions for a gold sticker that says “Approved”?

Also, if it ain’t broke (and no one’s getting sued), they’re not fixing it.

The Ethics and the Eyebrow Raises

Now, I’m not saying you shouldn’t know what’s on-label and what’s not. It matters. Patients deserve transparency, and we owe it to them to explain why their kid’s teeth are turning black (SDF, looking at you) or why we’re applying fluoride varnish after a cleaning even though they don’t have “sensitive teeth.”

The next time you brush on that fluoride varnish or dab a bit of SDF, give a little nod to its secret identity. Off-label? Definitely. Totally legal? You bet. Cavity-fighting? That’s the plot twist they didn’t print on the package.

TL;DR for Your Patients (and Curious Colleagues)

Fluoride varnish: FDA says it’s for sensitivity. We use it for cavities.
SDF: FDA says it’s for sensitivity. We use it to stop decay cold.
Both are off-label for caries, but not off-limits.
Science is on our side.
No one’s getting arrested. (Except maybe the cavities.)

What’s your take? Are we stretching the label, or just catching up to the science? Will this be one more talking point for those on the anti-fluoride side? Share your thoughts in the comments.

References

FDA 510(k) Summary for Advantage Arrest (SDF): FDA Clearance Database
ADA Clinical Practice Guidelines for SDF: ADA.org
ADA Topical Fluoride Guidelines: ADA.org
CDC’s Take on Fluoride Varnish: CDC.gov
AAPD Policy on Fluoride Therapy: AAPD.org

The Prophy Jet Challenge

May 28, 2019 By Trish Walraven 4 Comments

Why you should improve proficiency at air polishing

No, we’re not daring you to eat your Prophy Jet. Read on.

What has changed little over the past 50 years and is the most performed yet overvalued service provided in dental practices? If you guessed rubber cup polishing, you’d be correct.

Overvalued? Sure—from a health perspective, polishing is more or less a cosmetic procedure. Then why do most patients still get their teeth polished with prophy cups and paste? It’s certainly not because it’s the most thorough way to remove plaque and stain; if it were, we wouldn’t have the need for adjunct cleaning methods. Often, the bulk of plaque and stain is removed with curettes, ultrasonic scalers and lavage, and the polishing paste is merely the finishing touch—the smoothing out that makes everything feel nice again after a major prophy jam session.

No, the reason that rubber cup polishing is the method used on probably 90% of patients in the United States is because it’s less technique-sensitive and equipment-sensitive. Not because it’s better. It’s also because of tradition. We find that prophy polishing is the standard of care because of what we experienced as patients in our childhood and also how we were taught to polish in school. You do it not because it’s right, but because it’s easier.

Rubber cup polishing is good enough … well, at least until it isn’t. Nowhere is the incompleteness of a prophy cup polish more evident than when trying to perform one on an orthodontic patient in full brackets and wires. Only then do you switch up your routine and reach for an adjunctive polishing system. Why? Because you’re relatively inexperienced using alternatives like air polishing on a regular basis, which translates into a messy melee for you and the patient, so the trade-off needs to seem “worth it.”

The only way to combat inexperience, though, is with experience, which you won’t get unless you start using your prophy jet on a regular basis. This means you’re being challenged to replace your prophy angle with the air polisher—yes, even on patients without a lot of stain or without orthodontia! But first, let’s dispel some of the biggest myths about air polishing that may have already caused you to dismiss the thought of making this change.

Myth #1: Air polishing is too messy.

It can be, but only during the learning phase or if you’re using poorer-quality equipment.

After air-polishing my patients almost exclusively for more than 10 years, I’ve found that the Dentsply Prophy Jet and Cavitron Jet Plus machines are unmatched for not only longevity and quality but also the ability to minimize overspray. Some lesser brands may not mix the water and powder into a slurry properly, so you end up with excessive powder all over the patient’s shoulders afterward. If you learn how to adjust the powder control, better angulation, correct working distances between the jet nozzle and the tooth, suction management and even patient positioning, over time you will realize that air polishing is no more of a cleanup disaster than prophy paste.

Myth #2: Patients hate the taste of baking soda.

What’s worse when you go to the beach on a windy day: tasting salt spray or biting into a sandy hot dog? I’d much rather taste the ocean. Why? Because it’s expected. You expect to taste salt water when you splash in the waves. The same can be true for your patients if you prepare them before you blast: Let them know exactly what to expect before you use the air polisher on their teeth for the first time. Explain why you’re using it instead of pumice, and you may be surprised at how many patients are agreeable about trying something new, especially if it benefits them. Try to use a powder that has flavoring as well, because this reduces patients’ perception that they’re being scrubbed down with household cleaning agents.

Myth #3: Air polishing doesn’t clean as well or feel as clean as prophy paste.

These should probably each be their own myths, but since they’re related we’ll keep them together. While prophy paste spins around in circles and does smooth the teeth nicely, guess what? Polishing paste also has a way of exaggerating the feeling that the mouth is dirty. Maybe your patient experiences this:

Prepolish:“My teeth feel normal—a little grimy, but nothing I can’t handle.”
Midpolish: “I have a mouth full of soul-crushing tiny rocks and sand that will kill me if I swallow.”
Postpolish: “Wow, smooth teeth! What a relief that’s over. Much better than grit!”

It’s interesting how perception can be shaped by going to extremes. This same contrast is what makes people think that black charcoal toothpaste makes their teeth whiter. There’s not much of a “midpolish” grit with air polishing if you’re using sodium bicarbonate, however, because it has low abrasiveness—especially compared with pumice. Also, because it can be directed into pits, fissures and interproximal spaces, air polishing cleans at least 30% more of the tooth surfaces than rubber cup polishing. Be honest: How well do you polish the occlusals of molars with a prophy angle? You may be surprised at how often you’ve been neglecting certain areas of your patients’ teeth after you’ve switched to air polishing for a while.

Myth #4: Air polishing will make sensitive teeth more sensitive.

The opposite is more likely, actually. Every once in a while, I’ve encountered a patient whose roots were too sensitive for the air polisher, but the vast majority of patients with sensitive teeth do better than expected. This is likely because bicarbonate crystals are capable of blocking the openings of the dentinal tubules. Just be cautious not to hover over individual root surfaces for very long and you should be fine.

As an alternative to the Prophy Jet, there are air polishers that utilize glycine powder or erythritol. These newer powders are not only friendly to sensitive root surfaces, but they are also gentle enough to use for subgingival biofilm management.

Myth #5: The aerosol created by air polishing creates excessive contamination.

That’s why preprocedural rinsing is recommended as a universal precaution to reduce airborne bacteria—not just for air polishing, but also for ultrasonic scaling and even for prophy cup polishing. While it is true that jet polishing creates more aerosol than prophy angles, there’s not a significant difference in bacterial overspray caused by jet polishers versus ultrasonic scalers.

Myth # 6: Air polishing is more expensive.

Economics is certainly a consideration when it comes to implementing any technology. The initial setup cost for a quality jet polishing system, including an adequate number of inserts to maintain proper sterilization, can be daunting. However, once the equipment is in place, there’s much less waste compared to disposable prophy angles and single-serve prophy paste cups. The polishing powder is the only recurring expense once the system is in place, and you’ll find that the cost of it can be significantly less than polishing paste. My favorite sodium bicarbonate powder is supplied in simple tear packets by Young Dental and has excellent consistency and flavor, in addition to being affordable.

Probably the best reason to implement air polishing, however, is because in the long run it’s going to be less expensive for the practice in terms of efficiency. A patient with moderate staining takes less time to polish with an air polisher than a patient with light staining and a prophy cup. This means less operator fatigue, especially if you begin mixing up your routine and becoming flexible as to when you polish during a prophy. It doesn’t need to be at the end to be thorough, or even to gain patient acceptance.

The challenge

Even if you often still reach for the rubber cup at the end of an appointment, you will find that having strong air-polishing skills will help you better tailor the care you provide to meet each patient’s needs, instead of feeling like you’re running each mouth through the exact same routine, all day, every day. I didn’t even go into depth about the newer types of air-polishing systems available out there for you to try! But that’s because the first step you need to make is the step away from your prophy angle. Do it for a week, especially if you already have a neglected air polisher somewhere in your office. Dust it off, be patient, and rise to the challenge that you’ve made to yourself to change this one thing for a bit. You will be a better clinician for it.

Trish Walraven RDH, BS is a dental hygienist who lives in the suburbs of Dallas/Fort Worth. She was very reluctant to move all of her patients to jet polishing when her co-hygienist first suggested the change, but is very grateful to her and to all the patients over the years whose encouragement and feedback helped her realize that there was no going back to prophy cup polishes.

Ready to roll? Here’s a video tutorial from Dentsply to get you started:

Should dental hygienists give shots?

March 15, 2017 By Trish Walraven 13 Comments

When people talk about what they hate most about going to the dentist, they’re usually talking about the needle. I mean, who in their right mind would ever consent to allowing another person to give a shot in a place that has as many nerve endings as our tongues, lips and cheeks? Shots in the mouth are pretty dang scary. And when you’re trying to calm down and prepare yourself for an injection, it’s almost worse than trying to relax for the air-burst thingy they do at the optometrist’s office when you’re getting your eye pressure checked.

And yet, anyone who has had significant dental treatment performed has allowed someone to inject their mouth with a needle, right? We’ve all accepted the fact that shots are so much better than the actual thing that we hate about going to the dentist.

Pain. Pain is what we really hate.

And shots? They make pain go bye-bye. No shot? You’re all-knowing (in a very bad way) about every little thing that is getting fixed in your mouth.

But you already realize this unpleasant truth. What you might not know is that there’s a stink in Texas right now about who can give shots at the dentist’s office and who can’t. Here’s a little backstory: Dentists go to college for 6-8 years to learn all the things they need to do in order to be dentists. Dental hygienists are in college for 2-4 years to learn everything they need to learn in order to be dental hygienists. In states that allow dental hygienists to give shots, their anesthesia education follows the same curriculum as dentists. These states also test dentists and hygienists to make sure that they are qualified to give shots before granting their licenses.

In Texas and five other states, this is not true. A dental hygienist’s education in regards to anesthetic delivery is considered inferior, and therefore, allowing hygienists to stick a needle in a patient’s mouth allegedly places the public in unnecessary danger.

On this map, you’ll see red states, with years next to their abbreviations. These are the states that allow hygienists to give shots, along with the dates when administration and licensing first became available. [edit: See image at update at the bottom of this article – this was amended to 47 states in 2023]

Do I think that Texas should allow dental hygienists to give shots just because “everyone else is doing it?” No. We tried being our own country once, and if we still were our own country we wouldn’t care one tiddly bit what was going on in the US.

The reason that Texas should allow dental hygienists to give shots is simple:

We are tired of hurting people.

The alternative is to ask the dentists we work with to leave a hole in their schedule so they can come give a shot for us. And come anesthetize again if the first time didn’t work. And again if our patient is still in pain.

Here in Texas, hygienists learn to say “I’m Sorry” a lot to our patients, instead of continuing to interrupt our dentists.

Thankfully, most of our patients don’t need shots. Those who come regularly have healthy mouths and their visits with the dental hygienist are preventive in nature, comfortable, maybe even relaxing. But take a person who has been scared to go to the dentist for a while and they’ve noticed that their gums bleed when they brush. There are sores in their gums, and guess what? The treatment it takes to heal up those sores can hurt! Hygienists in all states are highly trained to provide this deeper therapy – it’s what we “really” do. And if there are obstacles to providing this treatment painlessly, well, it’s either not going to be painless, or else the treatment won’t be as thorough as it would have been if it would have been if the patient had gotten completely numb.

Last week’s hearing of the Texas Senate Committee on Health and Human services highlighted the stances of those both in favor and against granting dental hygienists the permission to deliver local anesthesia, in other words “give shots.” The original video was 2 1/2 hours – I’ve shortened it down to a little under 40 minutes of testimony only about this bill, edited out all the procedural or repetitive bits, and left the juiciest parts behind.

Full video of the archived meeting: http://tlcsenate.granicus.com/MediaPlayer.php?view_id=42&clip_id=11813

Here are my bullet points, yes… •Bullet •Points for this committee meeting:

• The map handed out in the chamber is the same one you see in this article (feel free to scroll up and follow along).

• The bill is permissive, not mandatory. If a dentist does not want to allow a hygienist in their office to give shots, they can’t. Furthermore, dentists must be present in the office for hygienists to administer anesthetics.

• No evidence of harm is presented in any testimony. Scroll to 18:45 where you’ll see Dr. Scott Dowell testifying for the Texas Society of Periodontists against this bill. His admission of the relative danger of local anesthesia is…interesting.

• The Texas Dental Association states that they opposed to this bill due to patient safety because they feel that it lowers the education standard and it’s only about expanding dental hygienist’s scope of practice, possibly to open the door to independent practice by hygienists.

• Dr. Matthew Roberts, who represented the Texas Dental Association, seemed surprised to learn that physicians are legally allowed to delegate the duty of administering anesthesia shots to even medical assistants in their practice when this is brought up in the meeting.

• There are 9000 members of the Texas Dental Association, but in a poll, 53% of the members were actually in favor of hygienists giving shots.

• The amount of training dentists receive to legally put patients “to sleep” is less than the training hygienists receive in order to be legal to give shots.

If you’re not convinced by this video, then you didn’t actually watch it (my opinion, sheesh!). But if you did watch it and still feel like hygienists are unqualified to give shots, your voice is very important to us right now. Maybe there are more problems with hygienists using needles, maybe there are negative reports that haven’t been correlated properly. Do you have concerns? Post them here in the comments below. I’m serious – if there is a compelling reason that is being hidden from the public and even from hygienists, we all deserve to know the truth.

At this point, though, if the day ever comes when I’ll be able to give my patients shots, it will be like someone trusted me with the most delicate equipment available in the Compassion Toolbox. It is a precious gift to be able to deliver painless dental care, and for those in the caring business (which most of medicine is, if you think about it) sometimes it’s the best gift we can give to others.

Yuck, ick, too late, the mush landed. Bottom line? Please don’t hate me if I ever get to stick you with a needle.

Trish Walraven RDH, BSDH is a dental hygienist who lives in the suburbs of Dallas/Fort Worth. She longs for the day when she can drop a couple grand of her own money and leave her family to take a week-long college course, just so she can sit for an anxiety-provoking board exam that will grant her the license to poke a shot in places that no one wants poked. Goals, man. Goals.

UPDATE 4/5/2017: The April newsletter from the TSBDE states that SB 430, which would authorize dental hygienists to administer local anesthetic was heard in the Senate Health and Human Services Committee on March 8, 2017. The committee considered testimony both for and against the legislation. The bill was voted out of the Health and Human Services Committee on April 5, 2017 with some changes. The change is that only infiltration administration would be permitted. The bill is now waiting to be scheduled to be heard by the full Senate.

UPDATE 5/25/2023:

It’s been six years since the original article above was posted; however, today I received the following information:

“After almost a year of collaboration between TDHA [Texas Dental Hygienists’ Association] and TDA [Texas Dental Association], legislation passed today through the Texas Senate that would allow Texas dental hygienists to administer local infiltration anesthesia.

The last step is for Governor Abbott to approve and sign the bill which would then become law. After the legislation is signed by the Governor, the Texas State Board of Dental Examiners will be tasked to write specific rules and educational requirements that will align with the intent of the legislation. This is a lengthy process that can take up to a year. The rules will then need final approval from the Governor’s Office.

Please note – this legislation allows dental hygienists to administer local anesthesia under the direct supervision of a dentist via infiltration only to patients who are over the age of 18.”

Here’s the thing: this was also the biggest bone of contention even in the 80’s and 90’s for the majority of Texas dental hygienists. For over 30 years we have been arguing for this option! That’s pretty much the scope of an entire career. Enough said – all you 50+ year olds who’ve been waiting for this day? See y’all back in college soon!

Best ways to get numb at the dentist

February 3, 2017 By DentalBuzz Staff 8 Comments

Why “Painless Dentistry” Doesn’t Have to Be An Oxymoron

Dentistry has got a bad reputation!

“No offense doc but I hate dentists.” …said everyone who ever came to see me.
“I was in Vietnam and I’d rather be shot at than come see you.” …said one of my veteran patients.
“My last dentist put his foot on my chest and pulled a tooth out while I wasn’t numb!” …said most people who ever had a tooth extracted.

Why so much hate? In my personal experience, most of the people who hate dentists have had really bad experiences in the past. They’ve got legitimate reasons to be fearful. As a profession, we dentists, especially in years past, haven’t done a great job with pain and anxiety management. Uncontrolled pain and anxiety creates lifelong dental phobics.

So here’s the secret… While dentistry isn’t ever something that will be fun, it doesn’t have to be the traumatic experience that many people expect. Dentists have a huge number of different tools at their disposal to make dentistry as painless and easy as possible. For the most part, all it takes is a willingness to listen to a patient’s fears and address them with whatever tool is most appropriate.

What?!? We have more options than just “Open wide”, “It’ll only pinch a bit” and “Suck it up”? Yes! I’m going to cover all your options here, from techniques that have been around forever, to the latest advances in painless dentistry.

If you’re a dentist who thinks all dental phobics are over-dramatic and that the previous statements are appropriate, this article may not be for you. You should probably go hang up your drill and find a job that doesn’t require contact with the public. I hear dental insurance companies are always looking for cranky dentists to deny claims. Everyone else, let’s get working on ways to make dentistry better for our patients!

Old School

Let’s start with some options that have been around for a long time. Just because these options are technically “old school” doesn’t mean they shouldn’t be used. It’s my opinion they should be used far more often than they currently are today.

Laughing Gas / Nitrous Oxide
Laughing gas is almost synonymous with going to the dentist but somehow many dentists don’t offer this at all. I’ve heard from many that they find it to be too much hassle. I’ve had the exact opposite experience in my practice. The benefits of laughing gas include decreased anxiety, increased pain tolerance, quick acting effects, and an almost perfect safety profile compared to any other type of sedation. The downsides… ummm…. occasionally people don’t like how it feels and we have to stop using it. So why aren’t more dentists using laughing gas? Beats me. It is the absolute easiest and quickest way to make a dental appointment easier. I often give it away free because it makes the appointment easier for me and the patient. Easier for me + Easier for the patient = A good day!

Sedation
Sedation can range from taking an oral medication before a dental appointment (with or without nitrous oxide) all the way up to IV sedation or general anesthesia. Of all the techniques we go over here, this is by far the most challenging to get trained in and implement due to safety and liability issues with sedation. It is also the most effective option for treating patients who are truly terrified of any type of dental experience. If you’re able to offer this safely and effectively, you’ll really set yourself apart. One option for sedation if you don’t want to go through training is to look for a traveling anesthesiologist who comes to your office and does sedation while you do the dental work. This is a fantastic option where you can focus exclusively on treating your patient instead of worrying about anesthesia at the same time. There are more and more anesthesiologists who offer services like this today. If you’re especially lucky, you might even find a dental anesthesiologist who understands the special challenges that come along with sedating a patient for dental work (dental work is essentially an anesthesiologists worst nightmare).

Air Abrasion
Air abrasion uses a high pressured jet of abrasive particles to conservatively remove smaller to medium sized decay in teeth. As it doesn’t generate any vibrations, pressure, or heat most people don’t need any shots of anesthetic (yay!) to have the procedure done. Many people think air abrasion is a new technique in dentistry. It actually has been around over 60 years! Early on, it wasn’t something that was typically used because the bonding materials needed to do minimally invasive dentistry weren’t invented yet. Now that we’ve got all these great bonding techniques, somehow air abrasion still isn’t routinely used. Very few dentists own an air abrasion device and even less use it routinely. It can be especially useful on children as it is far less “scary” than a dental drill and doesn’t require a shot! Kids who have good dental experiences are far less likely to become dental phobics in the future.

This article by Dr. Gordon Christensen goes into a bit more detail about air abrasion and why he thinks it should be used far more often… http://www.dentaleconomics.com/articles/print/volume-100/issue-6/columns/ask-dr-christensen.html

New-Fangled Stuff

Distractions
I spent about $400,000 several years ago to build a brand new office. You know what makes the biggest impression on our patients? It sure isn’t the $50k panoramic machine, several thousand dollar chairs, or amazingly efficient layout. It is the $300 television mounted on the ceiling that they can watch during treatment while wearing a pair of noise canceling headphones. OK, OK so televisions aren’t exactly new to the scene. CHEAP flat screen televisions sure are though. I just saw a 37 inch TV at Best Buy the other day for about $150. This is what most dentists charge for a single filling. Considering the benefits, calling it an affordable investment is an understatement. I’ve found it to be equally effective for both adults and children.

Vibraject™ / DentalVibe™
The Vibraject™ and DentalVibe™ play off our overall distraction theme. These devices vibrate a patient’s lip while the injection is being given in order to distract them from the sensation. They’ve been proven to be quite effective and many dentists say they wouldn’t want to give injections without them anymore. If you’re talented you can pull off this trick yourself without the device. Just vibrate a patient’s cheek quickly while giving the injection. Dentists have used this technique successfully for a long time. That is about the only thing I remember about the dentist from when I was a child.

For more information on these devices visit https://www.physicsforceps.com/vibraJect-comfort-solution or https://www.dentalvibe.com/.

Compounded Topical Anesthetic
Topical anesthetic has been used for a long time to reduce the pain associated with the needle stick. Unfortunately the only topical anesthetic that is widely available is 20% benzocaine. This works OK but there are a lot better options out there. The downside… you have to get them specially compounded at a pharmacy. It’s unbelievable that none of the big dental companies have come up with a better topical anesthetic (OK I do actually know why… The FDA approval process is a bureaucratic nightmare and costs a fortune for approval of a new formulation). If anyone in dental product R&D is reading this, I’D BUY A BETTER TOPICAL IN A HEARTBEAT! Get working on it!

My favorite formulation is a compounded gel with 10% lidocaine, 10% prilocaine, and 4% tetracaine. A SMALL dab of this a couple of minutes before an injection does wonders to almost entirely eliminate the pinch of the needle stick.

There are a good number of other formulations but most are some variation of these anesthetics. Some compounding pharmacies offer to add 2% phenylephrine to the gel to prevent but I do not recommend this. Any of these gels with phenylephrine seems to cause high incidence of tissue sloughing in the area where the gel was applied. I’ve only rarely seen minor tissue sloughing with the plain mixture of anesthetics. Once you use compounded topical you’ll never want to go back to plain benzocaine again!

Buffered Anesthetics
Even if the needle stick during a shot is totally painless, the shot can still hurt. Why is this? Most anesthetics used in dentistry are quite acidic. When they are injected they cause quite a burning sensation. This sensation can be minimized by injecting very slowly but people will still occasionally feel it. A couple of years ago a system known as Onset™ was introduced that buffered the anesthetic with sodium bicarbonate in order to bring it up to a more neutral pH level. Buffering solutions is commonly done in medicine but really hasn’t been used in dentistry up to this point. When anesthetic is injected with a pH close to physiologic levels, the burning sensation is almost entirely eliminated. In addition to reducing the burning it also dramatically increases the speed that the anesthetic takes effect. Mandibular blocks are fully complete within a minute and a half. You don’t even have to leave the room before getting started. There are a couple of other buffering systems that have come out since then but Onset™ remains the standard.

Stanley Malamed (You know, the guy who basically wrote the book on dental anesthesia) is a big fan. You should be too!

For more information on Onset™ visit http://www.orapharma.com/products

The Wand™
The Wand™ is a computerized anesthesia device that injects anesthetic at a controlled rate. As we discussed with buffered anesthetics, the rate at which anesthetic is delivered determines whether that uncomfortable burning sensation is felt. The Wand™ keeps this from happening by injecting at an extremely slow and controlled rate that is controlled by a computer, instead of your hand. Interestingly enough, the slow injection rate also provides higher success rates of getting people numb. One additional benefit to The Wand™ is that it looks far less scary than a typical dental syringe. Perception counts for a lot in how pain is experienced. The Wand simply looks like it will hurt less.

For more information on The Wand™ visit their website at http://www.thewand.com/.

Lasers
Lasers are very slowly making headway into dental offices. They can be used to remove tooth structure, oftentimes without any need for an injection. Due to how the laser pulses it actually induces some analgesia in the nerve of the tooth. It is truly needle free dentistry. There are some major downsides with lasers at this point. They can’t remove all types of materials from a tooth like a dental drill can, there is a huge learning curve, major magnification is required, and lastly the units still are wildly expensive (think $100kish). When the price comes down, I think they’ll start showing up in more dental offices but I don’t expect them to replace dental drills anytime soon.

For more information on dental hard tissue lasers you can visit http://www.Biolase.com, http://www.convergentdental.com/solea/, or https://www.lanap.com/laser-dentistry/periolase-mvp-7/

Kovanaze™
Kovanaze™ is the first needle free anesthetic option that I know of. Kovanaze™ was approved in the summer of 2016 by the FDA for use as a dental anesthetic and became available for purchase towards the end of the year. Kovanaze™ is a combination of the anesthetic tetracaine and oxymetazoline. This solution is sprayed up the nostril and provides anesthesia from the premolars to central incisor on the same side. Second premolars have a success rate around 64% while the first premolar through central incisor have a success rate of 96%. For major anterior work, such as veneers, this is a game changer. I know that I personally hate giving injections for the maxillary anterior teeth due to the sensitivity of the tissues in this area, especially around the centrals. Going from multiple painful injections to several painless nasal sprays makes these procedures far easier and essentially painless for patients.

The big downside at this point is cost. As of the time of this writing it costs approximately $600 for 30 sprays (or 15 doses as each dose requires two sprays). This is cost prohibitive for routine use by most dentists. Hopefully the price will start to come down and it will come into more routine use in practice. This would be a huge win for patients in general. Injections don’t bother me that much and I’d still pay extra just to have this type of anesthesia. My guess is that I’m not the only one.

As cool as needle free anesthesia is, the real story I’d like to hear is how the inventor originally came up with the idea of nasal spray anesthesia. Also, who was the unlucky person to be the original test subject?!?

For more information on Kovanaze™ you can visit their website at http://www.Kovanaze.com

There are so many different options out there for making dental care easier for patients. Not all of them have to be difficult or expensive. I’d highly recommend that you pick just one of these tools to implement well in practice and see what a difference it can make. Even better, pick several that you don’t currently offer and put them in place. I believe that comfortable patients will be happier, trust us more, and follow through with treatment which is ultimately a win-win for everyone.

About the Author:
I’m Dr. M, a regular dentist with aspirations of being a tooth saving superhero. My website, The Healthy Mouth Project is dedicated to educating and equipping patients to take control of their oral health.

How do you floss under a retainer?

March 14, 2016 By Trish Walraven 17 Comments

It used to be such a dread, seeing patients with fixed lingual retainers. I mean, they’re great because they keep your teeth from shifting after you’ve had braces, but GAWRSH, do they have to be so difficult to floss around?

Not any more.

Thanks to the talented hygienists over at Hygiene Edge we now can share this super-easy secret with patients as well!

Here’s how you do it:

It’s embarrassing to say this, but it took me over 20 years as a dental hygienist to find out about this trick, so now I’m thrilled to see lingual retainers on patients because it gives me a chance to share this newfound secret. That’s why I’m sharing it here, too. And as for you poor folks whose retainers are glued to each and every front tooth? I’m sorry, this trick doesn’t work. You’ll just have to stick it to ’em instead:

Remember, it’s all about friction. Whatever gets in there is good by me.

A blogger since 1997, Trish Walraven, RDH, BSDH is a mom and practicing dental hygienist in the suburbs of Dallas, Texas. Her mission with DentalBuzz is to offer a fresh podium of discourse for those involved in dentistry and to expose fun in our professional lives.