• Archives
  • Products
  • Operative Dentistry
  • Dental Team Communication
  • Practice Management
  • News
  • Research
  • Dental Debates

DentalBuzz: a jolt of current

trends, innovations, and quirks of dentistry

  • Home – Latest Buzz
  • Bloglist
  • Indie Dental Showcase
  • Free Dental Timer
  • Practice printables
  • Podcasts

Should dental hygienists give shots?

March 15, 2017 By Trish Walraven 13 Comments

healthyteeth212

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.

cottonrollssyringe

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.

redstates

 

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.

Filed Under: Dental Debates, Featured, News, Operative Dentistry Tagged With: dental anesthesia, TDA, Texas dental hygienists

Best ways to get numb at the dentist

February 3, 2017 By DentalBuzz Staff 8 Comments

nopain

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.

Dentistkicklegs

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.

breathe1

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/

Spray2

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.

 

 

DrMSmileAbout 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.

Filed Under: Operative Dentistry, Products Tagged With: air abrasion, dental anesthesia, DentalVibe, Kovanaze, laughing gas, nitrous oxide, topical anesthetic, VibraJect

Were these third molars aborted?

May 22, 2013 By Trish Walraven Leave a Comment

It looks like wisdom teeth can be preventable.

Now that you’ve found yourself a little incensed at the inflammatory title of this blog post (sometimes it takes alarm words to grab people’s eyeballs these days!) you’ll realize that the word ABORT actually does apply in this case.

Last month Tufts University School of Dental Medicine announced that there was a correlation between the injection of local anesthesia given to children between the ages of two and six and evidence of missing lower wisdom teeth. In other words, if a child had an IAN block at this age, they were over 4 times more likely to have missing third molar buds when radiographs were taken at least three years later.

At this young age, the cells that will become the third molar are not much larger than the anesthetic needle itself, and the developing tooth bud is quite vulnerable to injury. Dr. Anthony Silvestri, a clinical professor at Tufts University and an author of this study, has also published research to support the trauma theory of wisdom tooth prevention, showing that both diode lasers and electrosurgical energy can stop third molars from developing in rats.

Interestingly enough, I might have been affected by this phenomenon. As a kid I had my share of mandibular blocks as soon as my permanent molars started popping in with occlusal decay, and never developed my lower wisdom teeth. Thank you, Dr. Big-Scary-Hands-But-Really-Nice-Dentist Tom Watson DDS! Thank you for excusing my future visit to the oral surgeon.

You know, if the science behind this prophylactic de-nucleation of third molars gains any momentum, think about the consequences. In the next thirty years out-of-work oral surgeons will be lining up in protest of the loss of their bread and butter business. They’ll be picketing general dentists who perform these euphemisms and call them names like wizzie abortionists or bud killers.

Don’t take a side just yet. At this point the ethics of new research itself are even in question, but if there is a way to inoculate kids against the inconvenience of such minor diseases as chicken pox and shingles, why shouldn’t we at least explore the idea of making third molar extraction an option instead of an inevitability for most people?

And as a hygienist trying to hit production goals, I say, well, there goes my fourth qualifying tooth for quadrant scaling and root planing.

DBSmile1

 

 

Thanks to these articles for all their information:

TuftsNow: Dental Anesthesia May Interrupt Development of Wisdom Teeth in Children
Nerve Blocks in Children May Destroy Future Molars
Dimensions of Dental Hygiene: Local Anesthesia and Wisdom Teeth Development

Filed Under: News, Operative Dentistry Tagged With: bilateral aplasia, dental anesthesia, missing teeth, partial anodontia, school of dental medicine, third molars, Tufts University, wisdom teeth

About

DentalBuzz explores rising trends in dentistry with its own slant. The speed at which new products and ideas enter the dental field can often outpace our ability to understand just exactly the direction in which we are heading. But somehow, by being a little less serious about dentistry and dental care, we might get closer to making sense of it all.

So yeah, a tongue-in-cheek pun would fit really nicely here, but that would be in bad taste. Never mind, it just happened anyways. Stop reading sidebars already and click on some content instead.

Email Subscription

Still in the sidebar, huh? You must be really bored. Or a fan, which is awesome! Please fill out the form below to know whenever DentalBuzz is updated. We'll send out new posts as they happen, directly to your mailbox.
Loading

Recent Posts

  • It’s not OK for your dental practice to use free cloud-based communication
  • Patients ask, “Is it safe to go back to the dentist?”
  • Free “return to work guide” from the American Dental Association
  • Why COVID-19 increases your need for contactless payments
  • A virtual care package from worried dental hygienists
  • Lead Aprons feel so good! Here’s why.
  • What is this $&!% on my toothbrush?
  • The Prophy Jet Challenge
  • How to trick kids into brushing their teeth
  • These identical twins can both be your dentist
  • Why dental insurance makes good people do bad things
  • Amabrush (and all other mouthpiece toothbrushes) do NOT clean your teeth in ten seconds

Article Archives

Contact Us

Guest columnists are welcome to submit edgy stories that cover new ground (no regurgitations, please!) , or if there's a topic that you'd like to see explored please punch in your best stuff here and see if it ends up sticking to the website.

Follow DentalBuzz on Social Media

  • Facebook
  • Twitter

DentalBuzz Copyright ©2008-2021 • bluenotesoftware.com • All Rights Reserved