The Palatal Injection: Dentistry’s Most Painful Shot

Probably the most frequently commented upon topic on this blog involves what the majority of patients dread the most: the shot. As a result, I’ve posted many articles related to dental injections, including articles on novocaine (no, we don’t use it anymore), epinephrine (the racing heart does not mean you are allergic to it), why some people/teeth are hard to get numb (over ten different reasons), etc.

I’ve also done a two part series on what factors cause some dental injections to hurt more than others (located here and here). However, given the number of comments and questions about palatal injections, it was warranted to create an individual post on what can be considered dentistry’s most painful injection.

What is a Palatal Injection?

This may seem somewhat obvious but it is worth explaining. We’ll start with a photo.

palatal injection photo - most painful dental shot

Injection into the palate on the right side. If it looks painful, it’s because it is painful.

In a palatal injection, local anesthetic is injected into the soft tissue covering the hard palate, just adjacent to the tooth/teeth to be worked upon. It is not an injection into the soft palate nor the uvula. And it is only done for top teeth.

These types of injections are performed when you need the gum tissue on the roof of the mouth to be numb and/or when the procedure requires the tooth to be super numb (like an extraction or root canal). In my experience, for most fillings of upper teeth, palatal injections are NOT needed.

Why Palatal Injections Hurt so Darn Much!

There are two major reasons to explain why these hurt so much:

Tightness/Density – the tissue lining the hard palate is very dense and tight. There’s no “give” to it. The needle initially goes in and is accompanied by a pinch. That pinch is actually not the worst part. The worst part is when the local anesthetic fluid is forced in. There’s literally no room for it because the tissue is so dense. That forcible entry of fluid into this tissue is what causes the pain.

Topical anesthetic does not help with palatal injections

Traditional topical anesthetic does little to help with palatal injections.

Want an analogy? Imagine you have a turkey baster injector. Plunge the injector deep into the breast or thigh. Then try to inject. It will take GREAT force to get even a little fluid into this dense muscle. This is like a palatal injection. Next, move the tip of baster until it is just at the border of the thigh and skin. Then try to inject. There is little to no resistance. Fluid goes in with great ease, taking advantage of the looseness at the skin/muscle junction. This is like most other dental injections.

Traditional Topical Anesthetic Doesn’t Work Well – traditional topical anesthetic, a.k.a numbing jelly, doesn’t penetrate the tissue very easily, regardless of how long you wait. As a result, it exerts little to no effect, thus offering little to no pain relief.

How Palatal Injection Pain Can be Reduced

Fortunately, there are ways to reduce the pain associated with palatal injections. Note, however, that these are all done by the dentist himself/herself (except the last one which involves both dentist and patient).

  1. cotton applicator applying pressure can reduce pain of injection on the palate

    Application of pressure can reduce the pain.

    Waiting – in nearly all cases, if you are going to get an injection on the palate, you will also receive an injection on the cheek side. In many cases, if the dentist waits 10 minutes or so after the “cheek side” injection, some of that local anesthetic will work its way over and partially anesthetize the palate. This will make it so that the palatal injection is less painful.

  2. Pressure – placing firm pressure with a cotton applicator for at 30 seconds can slightly numb or obtund the pain sensation. The pressure is applied on the roof of the mouth right where the injection is going to go.
  3. Super Topical Anesthesia – some dentists will use a pharmacy compounded topical anesthetic that is several times more powerful than traditional topical. Using this correctly can also reduced the pain.
  4. Cold – application of a cold cotton applicator with pressure right before the injection can also reduce the sensation.
  5. Sedation – if you are sedated, you are unlikely to even feel the painful injection, let alone remember it. Sedation dentistry is very effective – I do it routinely in my office.

Not all dentists employ the above techniques. But all dentists are aware of the painful nature of this injection and do their best to only do it when necessary.

 

Nail Biting: Why You Do it and How You Can Stop

I am pleased to have Tsgoyna Tanzman contribute this unique and informative article. Please keep in mind that the information posted represents her opinions – and does not mean I endorse or validate her techniques. While I can personally validate the majority of her information on nail biting, I cannot attest to the efficacy of NLP.

Why do People Bite Their Nails?

Simple. The same reason people do anything.

To gain pleasure and/or avoid pain. No matter what we do in life, it nearly always boils down to this simplistic behavior. Whether you’re going after a goal such as getting a dream job or finding your soul mate, we believe the pursuit and attainment of that end goal will make us feel good (pleasure) and help us avoid pain (homelessness and loneliness).

Why do YOU Bite Your Nails?

At some point in your early life there was most likely a condition, perhaps a parent or other significant role model, who bit his or her nails and your duckling brain imprinted it as a means of connection and identification. You felt good. You belonged. Then the next layer of feel good happened when you associated the behavior with more pleasure. In other words, the behavior became a self-soothing event. It rewarded you. You felt calmer.

photo of fingernail worn down from nail biting

The evidence! The wear pattern on this fingernail is consistent with chronic nail biting.

Unbeknownst to you, you activated your parasympathetic nervous system, triggering a cascade of hormones that calmed you down and gave you pleasure. Your brain subconsciously made a connection, conditioning you to connect the two events. Since the brain likes efficiency, it got to work and laid down a neural highway. If I do this (bite my nails) then I get this (pleasure and I avoid pain).

Dental Complications from Nail Biting

Nail biting is complicated because it is both pleasure and pain tied up in a one-two punch. It has the immediate short-term effect of soothing, but it is coupled with some pretty nasty long-term side effects.   Here’s the ugly truth:

  1. Despite the fact that enamel is the strongest substance in your body, your teeth are not meant to be chew nails. Excessive and continual pressure from nail biting can cause your enamel to wear down, chip, fracture and/or misalign your teeth, as well as potentially contribute to temporomandibular joint pain. (TMJ). In fact, the Academy of General Dentistry estimates nail biting can result in up to $4000 more in dental bills. So much for the pleasure principle.
  2. Beneath our nails are some of the most gnarly bacteria, viruses, and fungi. In fact, there are as many as 150 different bacteria that can live under our nails including salmonella and E.coli.
  3. As a nail biter you’re a transporter of bacteria and those bacteria can lead to infections that may lead to gingivitis.
  4. Broken and/or jagged nails can tear or cut the gums. The Mayo Clinic warns that viral infections like herpes and the HPV virus can be transmitted from open cuts to the gums.
Nail biting photo showing characteristic groove with front teeth.

Photo showing a pronounced groove on her two lower front teeth from chronic nail biting. She is in her mid 20s. If this continues, what will her teeth look like in her 40s? Photo Dr. Nicholas Calcaterra.

Despite all of this, people will continue. The logical part of your brain tells you to stop biting your nails. If you’re like most nail biters you’ve already tried “everything.” You’ve tried the bitter nail polish and while it initially worked you strangely overrode the aversion, sufficient to keep biting. You’ve tried rubber bands, Band-Aids, gloves, chewing gum, and exhaustive willpower. You can never punish your way into changing a behavior and expect it to last. These “outer game” strategies are like trying to stop a train going 100 mph.

So How Do You Stop Nail Biting?

Before it begins and from the inside out.

If that just caused you to chomp down, on your very last nail, hold on. One of the first questions I ask my nail biting clients is, “How do you know it’s time to bite.” Most often they immediately answer, “I don’t, it’s unconscious.“

As a Master Practitioner of Neurolinguistic Programming, I know that all behavior is encoded in our brains in patterns we repeat efficiently. Bringing that pattern of behavior to a conscious level right down to the nanosecond, just before the fingers are in the mouth, is the most important first step to effectively altering the pattern. The truth is you’re an expert at biting your nails and everyone has a unique repeatable sequence of events. It may begin with a visual or tactile inspection. Your right thumb is the lead inspector, rubbing each finger to find roughness. Or perhaps you rub your fingers against some fabric. Or you visually inspect for evidence of a hangnail. When we are able to identify a pattern and then consciously decide on a desired different behavior we want, it sets the foundation for making this neurological shift.

How Does Neurolinguistic Programming Help?

Besides being a mouthful of syllables, it’s a method of influencing brain behavior (“neuro”) through the use of language (“linguistic”) and other types of communication to enable a person to “recode” the way the brain responds to stimuli (“programming”) and manifest new and better behaviors. This field of science/psychology came on the scene in the 1970’s and if it were renamed today, it might be called Upgrade Your Operating System.  Why NLP works quickly and effectively is because it scrambles the pattern of behavior, much like scratching a record, rendering it unable to play the same way.  It fixes the bugs and re-patterns the brain to new more desirable behaviors. Using our basic modalities Visual, Auditory, Kinesthetic (feeling), Olfactory (smell) and Gustatory (taste) we are able to modify and shift old behaviors.

If you truly want to stop biting your nails, you have to work from the inside out. Align your subconscious and conscious minds. Re-pattern the behavior and re-condition your associations.

What’s the upside? Healthy aligned teeth, beautiful nails, restored confidence and overall improved health, and you might just save thousands of dollars.

Webmaster’s Note: I hope you enjoyed this article from Tsgoyna Tanzman. If you would like to learn more about this unique approach, visit her website at howtostopbitingnails.com. She offers a complementary “Let’s Get Growing” consultation.

Aspirin next to your tooth helps your heart and not your toothache

Since publishing Dental MythBuster #5 – Placing aspirin on a tooth cures a toothache, the post has racked up over 47,000 views and averages approximately 100 per day (as of March 2016). No wonder. People are always looking for home remedies and a do-it-yourself solution for a toothache is searched upon quite often.

low_dose_aspirin

Placing this next to your tooth might give you an unexpected reaction

Many have posted comments claiming I am wrong.  But the only piece of evidence offered by the posters is simply a summary of their own personal experience(s). It goes something like this:

I did it – and the pain went away – so it works – so you’re wrong.

Making broad generalizations based upon one single experience does not prove anything. What if I wrote this:

I smoked 2 packs a day for fifty years and I don’t have lung cancer. So cigarettes must not cause lung cancer then.

Would you agree with that person? Or would you say – everyone knows smoking will cause lung cancer – you can’t generalize based on one experience.

A Home Remedy for a Heart Attack

No, this is not a joke. I am bringing up this specific example to show that placing an aspirin next to a broken tooth will do more for your heart than the tooth!

Many readers know that if/when a heart attack is suspected, one of the first things you are supposed to do (besides calling 911) is to chew on an aspirin. Note that we said chew and not swallow. There are literally hundreds of sources for this, including the Red Cross and the American Heart Association. In fact, it is a critical part of the BLS/CPR algorithm (here is a link from the New York Times).

broken tooth showing where you should NOT put an aspirin

Placing aspirin next to this broken tooth will result in burned gums and a healthy heart but no toothache relief.

Why should you chew and not swallow the aspirin?

Simple. Because the thin mucous membrane of the mouth – especially under the tongue – allows for the aspirin to be absorbed into the bloodstream quickly. In this study, chewed aspirin exerted its desired effect almost two and half times faster than aspirin that was swallowed.

So, to summarize, when you place an aspirin in most areas of the mouth, it goes into the bloodstream quickly and goes to exert its effects on the heart and other organs – all far away from the mouth.

But What about the Tooth?

So if the asprin is absorbed and enters the bloodstream, how does it help the tooth? It doesn’t. Or more accurately, for toothache relief, it doesn’t matter whether you swallow, chew, or place the aspirin next to the tooth.

aspirin for a toothache

For a toothache, it doesn’t matter if you chew or swallow.

To those who are still claiming that placement of an aspirin next to the tooth will cure a toothache, I’ll ask this question:

How does the aspirin know to leave the mouth and go to the coronary arteries of a heart attack victim but to stay next to a throbbing tooth?

It doesn’t. This is why placement of an aspirin next a tooth won’t work any more effectively for toothache than swallowing it. The only difference is that you can get a nasty chemical burn of your gums (as seen in the first post).

What Does a Cavity Under a Crown Look Like?

As this blog approaches nearly 3 years of age and well over 150,000 views, I am able to see what the more popular dental topics are out there. Currently, the fourth most popular post on this site, clocking in with a little more than 19,000 views (as of July 2015), is Dental MythBuster #9: You can’t get a cavity under a crown.

In analyzing what people search for online, many readers – hundreds that is – searched for some variation of: what does a cavity under a dental crown look like?

I had just finished compiling this information when a long time patient of mine – one who I had been telling for several months now about decay under one of her crowns – called to finally schedule her extraction.

Photos and X-rays of Cavities Under a Crown

In this particular case, the decay was so deep that her only option was extraction (see below for why extraction was her only options). Below is a bitewing x-ray:

dental bitewing x-ray showing decay under a crown

The x-ray shows the definite shadow of decay underneath a crown.

I had first diagnosed this nearly a year ago primarily based on the x-ray. In this area of the mouth – the last tooth on the lower left – the cheek drapes up against the tooth – making it very difficult to see – and very difficult to brush!.

I then removed the tooth. And no, I did not put my knee on her chest! The decay was unmistakable. Upon completing the procedure and having the patient go home, the first thing I thought was: “this will make a great photo for my blog!” So here it is:

high quality detailed photo of extracted tooth with decayed cavity under a dental crown

The extracted tooth in all its glory. If you dare, you can click on it to see a larger version!

You can clearly see the decay on this crown when it is out of the mouth. However, when it was in her mouth, it was nearly impossible to see. It could only be “felt” with a dental instrument. But the x-ray showed it.

Why was the tooth extracted?

If you get decay underneath a crown, it doesn’t always mean that the tooth has to be extracted. Before I explain why this was extracted, let’s look at one where the tooth was able to be fixed:

high quality photo of a cavity under an incisor crown

The decay underneath this crown was predictably fixed with a new crown.

The tooth directly above could be saved because the decay was easily accessible and only extended slightly underneath the gum tissue. The tooth had already had a root canal.

For the first tooth, the decay extended deep underneath the gum tissue and went into the furcation (the furcation is where the two roots of two-rooted tooth meet). No amount of modern dental procedures could have saved the tooth. So we extracted it and placed a dental implant.

Please note that I have greatly simplified the criteria for when a tooth can be saved vs. extracted. There are dozens of other factors – all beyond the scope of this post.

So, to summarize:

  • You can get decay or cavities underneath a crown.
  • The extent and location of the decay as well as other factors will dictate the treatment needed to correct the problem.

As always, your dentist should answer all your questions. If he/she doesn’t, it’s time to look for a new one.