Needle Free Dentistry
I get asked all the time if there is ANY possible way that dentistry can be done without giving shots! The shot is usually the most feared part of the whole procedure and I think most people would dread the dentist far less if that part could be done away with. So, is there any way that dentistry can be done without giving a shot? Let’s see what the current options are and what is possibly coming in the future.
Air abrasion
Air abrasion has actually been around for a long time in dentistry but is used infrequently in actual practice. Instead of using a drill, your dentist uses a special air abrasion unit that propels a fine stream of abrasive particles (usually aluminum oxide) at the tooth. There are a several benefits to using an air abrasion unit over a typical dental drill.
Pros:
- No need for numbing in most cases
- Can remove decayed tooth structure as well as old white fillings
- No high pitched whine
- Minimal pressure, vibration, and heat
- Less micro-damage to the enamel
- Better bonding of fillings to the tooth
Cons:
- Can’t be used to remove crowns, old amalgam fillings, or additional enamel
- Best used for small cavities, sealants, or preventative resin restorations (PRR’s) and not large cavities.
- Makes a mess!
Lasers
Compared to air abrasion, lasers that are able to cut teeth are a very new invention in dentistry. There are currently three main types of lasers used to cut teeth: ND-YAG, Erbium, and CO2.
Pros:
- It is rare to need to numb the tooth. The specific laser pulses deactivate the nerve fibers temporarily.
- No high pitched whine. Instead you hear typically hear a quiet “pop, pop” noise.
- Less micro-damage to the enamel.
Cons:
- Currently these laser units are very large and very expensive ($100,000+) putting them out of reach of most dentists.
- Can only cut certain materials.
- Requires better magnification and technical skills than with a dental drill.
Topical Anesthetics
For procedures that only involve the gum tissue and not the teeth, such as scaling and root planing or removal of a loose baby tooth, topical anesthetics can often be used just to numb the gum tissue. Typical topical anesthetics such as 20% benzocaine have been used for years in dentistry but aren’t terribly effective. Newer topical anesthetic preparations are much more effective than benzocaine, making such procedures more comfortable. The most well known topical anesthetic product used for scaling and root planing is known as Oraqix. It is a combination of lidocaine and prilocaine that can be placed gently under the gum tissue around teeth. It is very effective for 4-6 mm periodontal pockets but doesn’t do as well for more severe cases. Dentists have experimented for years with other topical combinations including EMLA, TAC, and other specially compounded anesthetics.
There are a couple of downsides and risks associated with topical anesthetics that generally aren’t present with injected anesthetics…
- Unknown dosage. Most topical anesthetics come as a gel and only a portion is absorbed into the body. This makes it difficult to calculate exactly how much you have received. Overdoses of anesthetics can be dangerous. Fortunately in dentistry this is extremely rare as we are usually working on small areas. Children are at the most risk.
- Many topical anesthetics contain ester type anesthetics. There are more allergy issues with these types of anesthetics than with the newer and more commonly used amide anesthetics. There is also a risk of a condition known as methemoglobinemia.
- Much more challenging to get good adequate numbness of the area.
Good topical anesthetics can also make the actual shot painless for the most part.
Coming Very Soon:
Better topical anesthetic. There have been rumors that a new, much more effective topical anesthetic for dentistry will be making it’s way onto the market shortly. Hopefully this will be even more effective than Oraqix and have more applications including painless shots in all locations of the mouth.
A nasal spray that can numb teeth numbers 4-13 (bicuspid to bicuspid). This was recently approved by the FDA for dental treatment and should be making its way into dental offices shortly.
Possibilities
One recent study published by a research group in Brazil shows some promise with using topical anesthetics applied with a small electric current (iontophoresis). The current helps the anesthetics to be absorbed at much higher rate than they would otherwise. The hope is that one day we can apply anesthetics topically that will be strong enough to numb the gum tissue as well as the teeth in the area. Other possibilities currently being studied are using chemicals or ultrasound to increase the absorption of the anesthetics as well.
What Kind of Pain Is Normal After A Root Canal?
Root canals are probably the most dreaded procedure in all of dentistry. Your tooth usually hurts prior to the root canal, the procedure is long and uncomfortable, and then afterwards you often have discomfort for several weeks or months. It’s this last part that most people aren’t aware of. Most people expect that once the root canal is completed, the tooth will immediately go back to normal. I wish this was the case, but unfortunately some amount of discomfort is normal and to be expected.
The first couple of days
Immediately following the root canal you can expect several types of soreness or pain. First, you’ll have some soreness of the gums around the tooth. This is the result of the small metal clamp that was used to hold the rubber dam in place. Second, you’ll have some pain from where the injections were done. Both of these will start to feel better within a couple of days. The third type of pain you’ll experience is a general soreness of the tooth itself. It can hurt when you bite, push the tooth with your tongue, or throb slightly on its own.
The next several weeks or months
In the several weeks to months following your root canal you will likely continue to have that same soreness and biting pressure with your tooth. This pain will slowly diminish over time until your tooth finally feels “normal” again.
Teeth where the nerve was still alive typically have less pain afterwards than teeth that were abscessed beforehand. You can ask your dentist or endodontist which was the case. Abscessed teeth in particular need quite a bit of healing to feel normal again. A root canal removes the source of the infection but can’t heal the damage that was already done. Only time takes care of this.
Continued Pain
In cases where the pain continues beyond about a month, you should have your dentist or endodontist re-check the tooth. Continued pain can be a result of your bite being off or a cracked tooth. If your bite is off a simple adjustment will usually help the pain to resolve very quickly. A cracked tooth after a root canal usually isn’t able to be saved. Root canals significantly weaken a tooth and unless a crown is put on them quickly there is a high risk of the tooth cracking.
What can you do to take care of the tooth and help relieve the pain?
- Over the counter painkillers such as Ibuprofen are the most effective painkillers for this type of pain. You can take 600-800 mg every 6 hours
- Avoid hard foods on that tooth. This will reduce your risk of cracking the tooth as well as allowing it to heal.
- Get the crown done as soon as possible
- Finish any prescriptions such as antibiotics that were prescribed
The Different Names For Sugar
Finding out where the sugar in your diet is coming from can be challenging! One of the big reasons why is that sugar in many products hides under different names. Here are some of the most common names you’ll see as part of the ingredients.
- Sugar
- High Fructose Corn Syrup
- Corn Syrup
- Honey
- Agave Nectar
- Pure Cane Sugar
- Syrup
- Cane Juice
- Glucose
- Sucrose
- Fructose
- Maltodextrin
- Sweet Sorghum
- Molasses
- Mannose
- Maltose
There are a lot of different variations even beyond these usually based on what source the sugar came from. Sure, some of these types of sugar have slightly more nutritional value than others (honey vs processed sugar for example) but overall, they all are highly concentrated versions of sugar that are added to many products.
Current recommendations are that you consume no more than 9 teaspoons (38 grams) of sugar if you are man and no more than 6 teaspoons of sugar if you are a woman. Many sugary drinks such as sodas or fruit juices contain more than this amount just in a single serving. Excess sugar consumption has been linked to a wide variety of health problems including diabetes, cancer, heart problems, and our favorite here, cavities!
Start reading those labels and avoid as much added sugar as possible.
Why Is Dentistry So Expensive?
Dentistry along with medicine has seen explosive growth in the cost to provide those services. For many people, the cost is more than they can reasonably afford. Why is this so? Does dentistry really have to be so expensive? Is it because dentists are greedy? How is dental care in other countries so much cheaper? I’m going to break it all down for you so you can truly understand what it costs to provide dental care.
USA Dental Care
Education – A dental education costs nearly $250,000 today. This only includes the cost of four years of dental school. If you add the other four years of undergraduate education most new dentists can easily be looking at debt in the range of $350,000 – $400,000. Over a ten year repayment period this works out to about $4000 a month just in student loan repayments.
Late Start on Earnings – Most dentists do a 1-2 year residency after dental school and at best start earning money around age 26-28. Missing out on those early years of earnings makes a big difference in how much money they have to earn to make up for it.
Dental Office Set-Up Costs – A typical dental office costs nearly $500,000 to purchase or a similar amount to build a new office. This ends up being nearly $5000 a month just in loan payments on the dental office.
Employee Salaries – Staffing is the biggest expense for a dental office. Typically, front office staff and assistants earn a minimum of $15/hr and hygienists earn double that around $30/hr. A typical office with 2 front office staff, 2 assistants, and 2 hygienists can easily pay about $25-30,000 a month just in salaries.
Business expenses – Business expenses for an office the size of the one described above usually run another $20,000 at a minimum. Taking all of the above into consideration, a typical office with 6 full time employees usually has expenses around $55-60,000 per month. Break that up over the course of about 20 days open per month and you’ve got an idea of how much money a dental office has to make in order to just pay the bills!
Self employment – Dentists who own their own offices are self employed. While it comes with certain perks, it also comes with more costs. Nobody provides health care and they pay more in social security and medicare taxes (currently 15.3%). Most employees don’t realize that they only pay half of that because their employer pays the other half. They also don’t realize that most health plans are subsidized significantly by their employer. An average family health plan costs over $1000 per month today!
Challenging job – Most people don’t realize it, but dentistry is an extremely delicate and challenging job. Dentists are universally hated (and hear about it every day), work in an extremely small space (your mouth), and often have to do so on patients who are somewhat uncooperative. The stress gets to many dentists. If it didn’t pay well, nobody would want to do this job.
Next time you’re at your dentist, try to remember that all that money you’re paying isn’t going directly into your dentists pocket. More than likely that money is going to pay the staff, loans, and business expenses more than anything else. If your dentist does make good money after all that, it’s likely because they sacrificed for a long time to finally get to that point.
Cheaper Dental Care in Other Countries
I’ve had several patients tell me that they simply can’t afford to have their work done in the United States. These are usually people who are originally from another country and need extensive dental work. In the United States their work would cost ten to twenty thousand dollars. They can get the work done in their home country for anywhere from a quarter to a half the price. How is this even possible?
School Costs – Dental education outside of the United States is much less expensive. As a result, dentists in other countries don’t have to make quite as much money in order to pay back the crushing burden of debt.
Less Regulation – The United States Government and State Dental Boards highly regulate the practice of dentistry. There are an incredible number of hoops to jump through as it relates to x-ray safety, office construction regulations, HIPAA compliance, OSHA compliance, and sterilization. Many other countries don’t have this same level of regulation.
Lower quality lab materials – Costs of lab materials for crowns, dentures, and implants can vary wildly based on the quality of those materials and where they were created. Generally, the materials used by United States dental labs are high quality and can be tracked and proven. Many dental labs outside of the United States in cheaper markets use lower quality materials and you can’t be quite sure where some of the materials are coming from.
Lower cost to run a dental office – Construction, equipment, and staff costs can all be significantly less expensive in certain countries.
Missing Permanent Teeth
Did you know that it is actually very common for people to be missing permanent adult teeth? Estimates are that about 20 % of people are missing at least one tooth. The majority of these are wisdom teeth but there are also some other teeth that are commonly missing as well. I’ll go over what teeth are commonly missing and what your options are long term.
Commonly Missing Teeth
Wisdom Teeth
Wisdom teeth are the most commonly missing teeth making up about three quarters of all teeth that are missing. They don’t replace any baby teeth and most people don’t even realize they’re missing them.
Second Premolars
Second premolars are the second most commonly missing teeth, only behind wisdom teeth. The second premolar teeth normally come in around age 12 and replace the furthest back baby molar teeth. This x-ray is actually of my son from a couple of years back. He is missing his second premolar teeth.
Lateral Incisors
Upper lateral incisors are the third most commonly missing teeth. Lateral incisors are the teeth right next to your two front teeth. Approximately 2% of people are missing these teeth. Missing lateral incisors pose the most significant challenges for replacement.
Other Teeth
Any other tooth can be missing but we don’t see them nearly as often as the ones previously discussed. I see children missing either lateral incisors or second premolars at least once a month. I see other missing teeth far less frequently.
Oligodontia
In rare cases, some people are missing more than six teeth. This is a condition known as oligodontia. It is often associated with a genetic mutation.
How Missing Teeth Are Treated
The treatment for missing teeth depends quite a bit on which teeth you are missing as well as other factors including crowding, spacing, age, the amount of bone available, and your finances. Treatment for missing teeth can be a time consuming and in depth process!
Wisdom Teeth
No treatment is needed for missing wisdom teeth. In fact, you should count yourself lucky if you don’t have them! In most cases, we take them out anyway because there isn’t enough room for them.
Lateral incisors
As I mentioned before, missing lateral incisors are one of the more challenging missing teeth to treat. The baby lateral incisors tend to be lost pretty early on, whether from the teeth on either side coming and helping push them out or them becoming loose as a result of being such a small tooth. Unlike second premolars, holding onto these baby teeth isn’t a great long term option. This picture is a good example of what happens if you let the baby teeth fall out and don’t do anything with the space. You end up with a space that is too small to do anything with.
For most kids, once the baby lateral incisors are lost, the space is held open either by a removable or permanent appliance until they are old enough for an implant (around age 18). A removable appliance can come in the form of either a flipper or retainer with a tooth attached to it. The most common permanent appliance is known as a Maryland Bridge. A Maryland bridge has a fake tooth with small “wings” that are cemented onto the teeth on either side.
An implant for a lateral incisor can be challenging as well. Because no teeth formed in that location there is typically far less bone in the area than normal. Sometimes a very small implant can be used and in other cases an oral surgeon will need to add bone in the area (bone grafting) in order to make enough space for an implant.
Before implants became a good option, many orthodontists would move the canine teeth into the space and then shave down the canines to look like lateral incisors. I personally don’t like this option because it tends to not look great and cause a good deal of damage to the canine teeth. Canine teeth are quite large and reshaping them enough to make them look like a lateral incisor runs the risk of creating a situation in which it needs a root canal.
Another option that was previously used quite a bit was a bridge. The biggest downside to a bridge is that you have to cut down the teeth on either side of the missing tooth. An implant is almost always a better solution.
Second Premolars
There are several different ways to approach missing second premolars.
For children with significant crowding of their permanent teeth, the primary baby molars are removed, and an orthodontist uses this extra space to align all the teeth properly.
For children who don’t need to have them removed, we usually leave the baby teeth in place and maintain them as long as possible. As long as cavities don’t develop on them and the roots remain intact, they can last an additional 30-40 years.
When the baby teeth are eventually lost an implant is the best option to replace it. Alternatives to implants include a bridge or a removable partial denture, especially if you are missing any additional teeth at that point.
Oligodontia
In cases where quite a few teeth are missing, treatment can be complex and challenging. It usually requires good coordination between a pediatric dentist, prosthodontist, and an oral surgeon. Make sure you’ve got a good team to help you deal with this.
Why You Should Replace Your Toothbrush Regularly
Did you know that it is recommended you replace your toothbrush every three months? Most people don’t. I’ve found that most of my patients only replace theirs when they come in for their 6 month check-up and get another free toothbrush from me. Hopefully after reading this I can convince you to spring for that one extra toothbrush every three months!
Reasons to Replace Your Toothbrush Every Three Months….
Bacteria and fungi can grow on your brush. Your mouth is home to an incredible number of microorganisms. Using your toothbrush to clean your teeth will transfer some of these organisms on to your toothbrush. Most aren’t harmful but some could be. These could possibly get you sick or transfer to someone else’s toothbrush if it is close by. Replacing your toothbrush every 3 months will help to avoid any possible spread of these organisms.
The bristles wear out. Over time the bristles on your brush will wear out and get frayed. When they are at the point that you can see this fraying, they have been cleaning less effectively for some time already. Try to replace your toothbrush before they get to this point. You can also try brushing more softly to reduce the wear on your toothbrush (and protect your gums). Hard brushing will fray your toothbrush extremely quickly.
There are also some situations in which you should immediately replace your toothbrush…
- After you’ve recovered from the stomach bug. Your toothbrush can harbor the virus which can get someone else sick. It takes as few as 10 of these viral particles to get someone else sick!
- After strep throat. Same reason as the stomach bug.
- Someone else used your toothbrush. Microorganisms can easily spread by sharing toothbrushes.
- You cleaned the toilet with it.
Tips for cleaning and storing your toothbrush
Storing and cleaning your toothbrush properly will also help extend it’s life.
- Rinse your toothbrush off after each use.
- Store upright to allow it to dry most effectively.
- Store away from other toothbrushes (not touching).
- Don’t put it in a closed container. Damp, moist environments favor the growth of mold.
- There is limited evidence that putting it in an antibacterial solution or UV light chamber may help kill some of those microorganisms. After you’ve done this, take it out and let is dry in the open like normal.
Six Reasons Why You Can’t Get Numb At The Dentist
Genetics
Did you know that simply being redheaded makes it so that you require more anesthetic for dental procedures? The same gene that helps produce your red hair also has some effects on the pain receptors in your body. Your pain tolerance is usually lower than other people and you are more resistant to anesthetics than other people. One study showed that people with red hair required a full 20% more anesthetic for general anesthesia than other patients. It is the same with dental anesthetics where you require more anesthetic to get fully numb. If your dentist isn’t aware of this link, make sure they know so that they give you more anesthetic to start.
It is also very likely that there are other genes that affect pain tolerance and the effect of anesthetics. Red hair is an easy one because it is so easy to spot. Others will be much more difficult to find by scientists. If you know that you have difficulty getting numb at the dentist, let your current dentist know so that they can give you more anesthetic or use different techniques.
Your Anatomy
Everyone’s teeth, bones, nerves, and blood vessels are in slightly different locations. Some people also have different nerves that supply different areas of their body. I might put anesthetic in the same specific area for ten different patients and only nine out of ten will get numb. Usually this is because the nerves are in a different place or there is an extra nerve that needs to be numb. You can also have long roots on certain teeth. If your dentist doesn’t know quite how long they are (which can be difficult to estimate based on x-rays) they won’t be able to put the anesthetic in the correct spot.
Anxiety
If your anxiety level with dentistry is really high, it can affect your ability both to get numb as well as tolerate any slight amount of discomfort. Many anxious patients move during the injection which can make it very difficult to place the anesthetic in the correct location. You might also interpret pressure or a light touch as pain. I’ve had plenty of patients who have extreme dental anxiety who will jerk their heads, grimace, or move all over before I’ve even touched anything. If you feel like your dental anxiety affects your cooperation for dental treatment you should ask about laughing gas or a medication to take before your appointment. This will make things much easier for you and your dentist. A light level of sedation also reduces the amount of anesthetic you need.
Infection
Did you know that an area that is infected doesn’t get numb nearly as well as a similar area that isn’t infected? Infected areas create a very acidic environment. For dental anesthetics to work effectively, they need to be close to a neutral pH. The low pH, infected areas make it so that only small amounts of the anesthetic are in their active state. This is one reason why some dentists will give you an antibiotic to reduce an abscess prior to a root canal or extraction. Another way to get around an infected area is to use a nerve block instead of local infiltration of anesthetic. A nerve block numbs the nerve further up, usually away from the source of the infection, and this allows it to block pain signals effectively. If a nerve block isn’t in an option in a specific spot, you may require quite a bit more anesthetic to get adequately numb.
Anesthetic
There are a couple of different ways that the anesthetic can affect how you get numb.
Expired – Anesthetic that is too old or has been stored improperly can break down and will be less effective. The biggest problem with anesthetic is when it is stored in temperatures that are too hot. The epinephrine is especially unstable and tends to break down quickly under these conditions. Some dentists will store the carpules of anesthetic in a warmer in order to make the injection more comfortable (temperature of the solution closer to your body temperature). This is a good idea but can definitely cause the epinephrine to break down if stored too long.
Bad Batch – Manufacturing problems may cause issues with the concentration or other ingredients. This is extremely rare especially if your dentist uses a reputable supply company.
Type of Anesthetic – Anesthetics without epinephrine don’t get you nearly as numb as anesthetics with it do. Certain anesthetics are also quite a bit more effective than other types. Currently articaine has been shown to be the most effective for most dental applications.
Dentist Error
Sometimes your dentist may place the anesthetic in the wrong place. Just like you have good and bad days, so do dentists. Sometimes we don’t estimate well or aren’t paying as attention as well as we should be. I had a couple of bad days in a row where I couldn’t seem to get people numb. I was sure that there was something wrong with the anesthetic so I took a carpule and injected it on myself. Of course, I got super numb and I had to admit that I was just having a bad couple of days! Shortly after that, everything went back to normal.
Dental Isolation Systems
One of the most critical parts of placing fillings or doing a root canal correctly is keeping the tooth entirely isolated from any saliva or blood in the mouth. How does your dentist do this effectively? What can you do to help?
Rubber Dam
The rubber dam was invented in the 1800’s and is still in use today. Most people think of it as a medieval torture device and many dentists aren’t a big fan of it either. I don’t personally love it either but there are definitely some situations where it is a good option. It works by putting a small metal clamp around one of your teeth. A thin square sheet of rubber (usually latex based but there are other options) is then stretched around the clamp and over the teeth and a metal frame used to stretch the sheet over your mouth.
Rubber dams are the only acceptable way to keep a tooth isolated for a root canal. If your dentist isn’t using one while doing a root canal, either insist they use one or find another dentist. The rubber dam protects you from accidentally swallowing the small files used during treatment as well the harsh chemicals used to disinfect your tooth.
Positives:
- When put in place well, it is the single most effective method for keeping your teeth isolated.
Negatives:
- If you’re claustrophobic, it can be quite disconcerting.
- The clamp can irritate the gum tissue if placed too far down.
- Some procedures can’t be done with a rubber dam in place.
Isolite
About 150 years after the invention of the rubber dam, a company finally invented a viable alternative to rubber dams for most dental procedures. An Isolite mouthpiece is a disposable rubber device that attaches to your dentist’s suction system. It consists of a bite block (something to keep your mouth open) as well a rubber barrier that pulls your tongue and cheeks out of the way. It simultaneously isolates all the teeth on the top and bottom of one side of your mouth as well as suctioning away any water or saliva.
Positives:
- Good isolation for most procedures.
- Isolates more teeth at once than a rubber dam
- Multiple sizes for a comfortable fit.
- Very effective for use while doing fillings.
- Not as scary looking or as claustrophobic as a rubber dam.
Negatives:
- Not quite as effective as a rubber dam for isolation.
- Not currently recommended for use during root canals.
- Can be quite loud with the suction on.
- Can cause some gagging if you have a bad gag reflex.
Cotton Rolls
This is the most common method dentists use to keep your teeth dry. It’s the easiest method to use, especially for small or limited treatment.
Positives:
- Easy to put in place.
- Causes the least amount of gagging
- Can be used anywhere
Negatives:
- Isolation is only OK.
- If the cotton rolls get saturated with water and saliva, they won’t work anymore.
What You Can Do To Help
- Relax your tongue as best you can. Anytime your tongue touches the tooth that is being worked on, it will contaminate it.
- Stay still. The more still you are, the faster your dentist can work.
- Keep your mouth open. Common sense right? You’d be surprised. Many people either won’t open all the way or try to close while we’re working.
- Try not to talk. You’d think this would be another common sense tip. I’ve literally had people talk all the way through procedures which makes it very challenging to do a good job.
- Floss for at least the week before your appointment. This will reduce bleeding during the procedure.
Local Anesthetics Used In Dentistry
Ever wondered what is in the anesthetics that your dentist gives you? I’ve got all the information you need here.
Topical Anesthetic (Pre-numbing gel)
Most dentists will place a topical anesthetic on the tissue where the needle will be inserted. This helps reduce and in some cases remove entirely the initial “prick” you get when they give you a shot. Unfortunately, because it only numbs the very top area you can still get some discomfort. Perhaps someday, a better topical anesthetic will come out is able to numb these areas more deeply.
Benzocaine (20%) – Benzocaine is by far the most common topical anesthetic used in dentistry. It is quite effective at numbing the top 1-2 mm of tissue when left in the area for 30 seconds up to about 2 minutes.
TAC – TAC stands for Tetracaine – Adrenaline – Cocaine. It is a pretty standard topical anesthetic in medicine but not widely used in dentistry. It is quite a bit more effective than standard benzocaine but it’s common side effect is causing the tissue to slough off afterwards which can be pretty painful.
EMLA – This stands for “Eutectic Mixure of Local Anesthetics”. There are quite a few different combinations ranging from 2-4 different anesthetics used. Again, this is used quite a bit in medicine and pretty rarely in dentistry. It also tends to cause some sloughing of the tissue afterwards.
Local Anesthetics
The local anesthetic is the anesthetic that your dentist injects you with to actually numb your tooth or teeth. Each type of local anesthetic is slightly different and each has their own set of benefits and downsides. The most important parts of a local anesthetic are it’s safety, duration of action, and effectiveness.
Lidocaine (Xylocaine) – Lidocaine is the most commonly used local anesthetic, although it is quickly being overtaken by Articaine in many areas. It has a medium duration of action, is effective, and has a good safety profile. You’ll usually be numb for anywhere from 2-4 hours when this is used for the injection.
Articaine (Septocaine) – Articaine is probably the most effective local anesthetic dentist have available to them today. It tends to diffuse through bone better and provide more effective anesthesia. It has a medium duration of action similar to lidocaine. The biggest downside to articaine is that it comes in a more concentrated solution than lidocaine and your dentist can’t use quite as much.
Bupivicaine (Marcaine) – Bupivicaine is mainly used in oral surgery when your dentist or oral surgeon would like you to be numb for a LONG time! Especially for wisdom tooth extractions or implant placements this can be very helpful. It has a very long duration action (about twice as long as lidocaine or articaine). It does have a higher risk of causing rare heart complications.
Mepivicaine (Carbocaine) – This is the local anesthetic most often used when your dentist would like to avoid the use of epinephrine (for medically compromised patients, especially with heart problems) or for people who have an allergy to metabisulfite (see the section on additional ingredients). As a result, it’s duration of action is shorter than most other anesthetics.
Prilocaine (Citanest) – This is used in many of the same situations as mepivicaine is used. It can also be used without epinephrine.
Outdated Local Anesthetics
Novocaine (Procaine) – Many people still think that dentists used Novocaine. This has pretty much been phased out of dentistry today because it isn’t as effective and has a much higher rate of allergies than the previously mentioned local anesthetics.
Cocaine – Did you know cocaine is still occasionally used as an anesthetic in certain medical procedures. The biggest benefit to cocaine is that in addition to it’s anesthetic effects, it also causes the blood vessels in the area to constrict, decreasing bleeding. Most other local anesthetics require the addition of epinephrine to achieve the same effect. On the same note, high doses can cause heart problems, which is often seen in people who abuse cocaine recreationally.
Other Ingredients In Local Anesthetics
Vasoconstrictor – Most local anesthetics (with the exception of cocaine) cause blood vessels in the area to get bigger (dilate). This increased blood flow can cause problems with bleeding during surgery as well as increasing the rate at which the local anesthetic is removed from the area. As a result, most local anesthetics include epinephrine or a similar vasoconstrictor to make the blood vessels smaller. This helps the local anesthetic to have a longer duration as well increasing the amount your dentist can give you.
Sterile water – The local anesthetic as well as the other ingredients are dissolved in sterile water.
Antioxidant – Sodium Metabisulfite is used to keep the epinephrine from breaking apart and becoming ineffective. This increases the shelf life of local anesthetics. Most allergic reactions to local anesthetics are a result of this specific ingredient. There are formulations without it.
Possible Complications and Side Effects of Local Anesthetics
Racing heart – The most common side effect I see as a dentist, is people who say that their heart feels like it is racing. Some people say that they feel like they are having a panic attack. This is a side effect of the epinephrine in the local anesthetic. In addition to causing blood vessels to constrict, it can also stimulate your heart temporarily. This side effect usually goes away within a couple minutes after the injection.
Soreness of the injection area – Anywhere the needle pierced will likely be sore a day up to a week. This is especially true of nerve block injections for the bottom teeth where the needle must pass through several muscles. It isn’t unusual to have significant soreness when opening and closing your mouth for about a week following.
Bruising – If the needle nicks an artery it can cause bleeding in the area. This bleeding leads to bruising. It is a random occurrence and your dentist can’t do much to avoid this.
Allergy – Most allergies to local anesthetics aren’t actually to the the local anesthetic itself. It is usually to the metabisulfite that is used to keep the epinpherine from breaking down. If you’ve had an allergic reaction to a local anesthetic, ask for the version without preservatives.
Prolonged anesthesia or paresthesia – In very rare circumstances (about 1 in 10,000 odds) there can be nerve damage as a result of an injection. The damage can be caused by the needle brushing the nerve, too much pressure in the space, or the anesthetic itself causing some toxicity to the nerve. This is another of those random occurrences that your dentist can’t do much about. The good news is that most cases of nerve damage will resolve on their own within about 6 months.
Methemoglobinemia – Some anesthetics such as benzocaine or prilocaine can cause a problem where you develop a higher level of methemoglobin in your blood than what is normal. This causes your oxygen carrying capability to go down leading to a variety of symptoms. The most noticeable is your skin turning a blue color (cyanosis). Treatment with oxygen and methylene blue is highly effective.
Overdose – This is very rare in adults but much more likely to occur in children as they can have a very limited amount of local anesthetic. A local anesthetic overdose causes problems with the functioning of your nervous system as well collapse of your blood vessels. Untreated overdoses can be fatal.
Pericoronitis
One of the big reasons why a lot of dentists recommend getting wisdom teeth out routinely is a condition known as pericoronitis. Wisdom teeth, especially in your bottom jaw, typically don’t have quite enough space to come in all the way. If they do come in all the way, they still have quite a bit of gum tissue around the back of them. Because of the excess gum tissue back there and the difficulty is keeping it clean, this gum tissue will sometimes become inflamed and/or infected. When the gum tissue becomes inflamed, it actually starts to grow and get bigger, eventually covering part of the tooth. When you bite down, you traumatize the gum tissue which only makes it more inflamed. To add insult to injury, food will get trapped under this excess gum tissue and the area will then get infected. Common symptoms of pericoronitis include pain in your wisdom tooth area, excess gum tissue around the tooth, swelling, a bad taste, and difficulty opening your mouth. The symptoms are pretty similar to what you develop with a bad tooth abscess and many people mistakenly think that is actually what is happening.
Treatment for pericoronitis consists of several things…
- If you have facial swelling or pus coming from the area your dentist will put you on an appropriate antibiotic. If you don’t have either of these things, you usually don’t need a systemic antibiotic.
- A prescription for a chlorhexidine antibacterial mouthrinse. Your dentist will usually have you swish with this 2-3 times a day. In cases where the gum tissue is severely overgrown, they’ll often give you a small monoject syringe to use to irrigate under the flap of gum tissue.
- Minor surgery to remove the excess gum tissue. This is known as an operculectomy.
- Definitive treatment for pericoronitis is to take out the tooth (usually the wisdom tooth) where it is occurring.