Dentistry and Art: Sans Douleur by Engelman after Roehn

This lithograph was produced by the French artist Gottfried Engelman (born 1788 died 1839). Some websites and textbooks put his first name as Godefroy. While he initially studied painting and drawing, he began studying lithography on/around 1814. This lithograph was based on a work by the French artist Adolphe Roehn (born 1780 died 1867). This work is believed to have been produced sometime in the 1820s.

Sans Doleur tooth extraction and dentist lithograph by Engelman after Roehn

The title – Sans Douleur – means “without pain.” However, at this time, given that local anesthesia was not invented until the 1860s, there was no way a tooth extraction could be done without pain.

In this lithograph, a French dentist/charlatan displays quite proudly the tooth he has just extracted from the young man to his left. There is the usual group of onlookers typical for these scenes. Behind the charlatan/dentist, a trained monkey mimics him. Would you go to a dentist who has a monkey in his/her office?

This is another reminder of how much dentistry has changed in the past 200 years.

 

Doc, That Short Hurt – Part II

In Part I of this series, I wrote about why some dental injections hurt while others do not. I approached this topic knowing that there were more than five factors affecting the amount of pain felt from the “shot at the dentist.” So here we go with five more reasons:

6. Size Matters?

Dental needle photo showing needles of different sizes

Wouldn’t you be more scared of the bigger one?

Many people – both dentists and patients – incorrectly assume that the larger the needle, the more painful the dental shot is going to be. While that may seem to be true, some well designed research studies contradict this.

What is true – and this is based on years of my own observations – is that when a patient sees a large needle coming at them – they are WAY more likely to complain that it hurt.

So, the last time you received a painful shot at the dentist, did you look at the needle? If yes, the sheer size may have “psyched you” in to thinking it was going to hurt! Perhaps the time it didn’t hurt was when the dentist and/or assistant distracted you so you didn’t see the needle.

7. Good Good Good Vibrations

It is unlikely that the Beach Boys were thinking of their trips to the dentist when they composed this famous song. However, when it comes to dental injections, vibrations are good.

Many dentists, myself included, will rapidly jiggle and wiggle the area we’re about to inject. Why? According to the Gate Control Theory of Pain, the intense stimulation of the wiggling will essentially prevent the pain of the needle. Stated another way, by wiggling the area so much, that wiggling “closes the gate” that the pain signals need to travel through. See the wikipedia article if you want more info.

Dentalvibe works by creating vibrations to prevent injection pain

The DentalVibe

I can promise you that if I give you an injection without doing any wiggling, you will feel it. However, if I apply techniques from Part I of this post and wiggle a lot, you will barely feel it!

Vibrating can make such a profound impact on whether you feel pain or not that there is even a product you can buy! It is called the DentalVibe and it is basically a professional wiggler. I have not used it but have seen it demonstrated at various dental conventions.

So, if you received a dental injection that hurt, it could be in part because your dentist did not wiggle the area (please note that in some circumstances it is not possible to wiggle).

8. Speed Kills

Many patients think that the most painful part of the injection is the initial pinch as the needle penetrates. In reality, there is another part that can also hurt: the forceful pushing of the fluid (the local anesthetic) into a confined area (the cheek or gums).

photo of teaspoon and tablespoon to depict amounts of dental local anesthetic

Imagine over 1/3rd of a teaspoon injected into you over 4 seconds. Ouch! (Image courtesy wiki commons)

So, what do you think happens when you receive an entire dental shot – 1.8 cc – approx 1/3rd of a teaspoon – into your mouth in under 5 seconds? It will hurt! That entry creates tremendous pressure on the tissue at the injection site, and that leads to pain. This study confirms this fact.

One of the key elements of a pain free injection is to go slowly. I try to do it very slowly – at least 30 seconds – sometimes as long as a minute. In nearly all cases, patients say “Doc, that took a long time, but I didn’t feel a thing!”

9. Local Anesthetic Buffering

This is distantly related to Point #5 –  Choice of Local Anesthetic. But it is different enough – and its impact large enough – to warrant its own entry. And this the buffering of the local anesthetic injection. But what the heck is a buffer?

lidocaine with epinephrine has a pH below 4

This comes at a pH of less than 4.

The pH, which is a measure of the acidity of your bloodstream and tissues, is approximately 7.4. In general, the closer the local anesthetic pH is to 7.4, the less it will sting during administration. One of the most common dental anesthetic formulations in the United States – 2% lidocaine with 1:100,000 epinephrine – has a pH of 3.85! Don’t you think that will sting?

Anutra Medical buffered local anesthetic

The Anutra Local Anesthetic Buffering System I use in my office.

One way to get around this is to buffer the local anesthetic. I won’t bore you with the chemistry but ask any high schooler who took AP Chemistry and he/she can explain it in more detail. But in essence, buffering will raise the pH close to your body’s normal pH. Do you think that an injection at a pH equal to that of your body will sting? No. And many research studies support this.

So why don’t all dentists use buffered local anesthetics? Well, it is not that easy. Local anesthetics cannot be manufactured this way because they would break down with 24-48 hours. However, a new product on the market called Anutra Medical allows dentists to do just this. It has not been widely adopted yet because it is new, requires special supplies be kept in stock, and is also slightly more expensive compared to traditional injections.

Having used the product, I can say with 100% certainty that it works. Patients feel less of the shot. It’s that simple.

10. Your attitude

This is the perhaps the most important factor but also the most difficult one to describe.

If you come in feeling nervous and anxious, act somewhat hostile to the dentist and/or assistant, complain that the topical anesthetic tastes bad, don’t want to open your mouth, stare at the needle as it comes towards you, move and jerk around as the needle goes in, then the injection will hurt. I’ve had patients where I’ve employed nearly every point in this post – and it still hurt because they did not let me do my job.

If you come in nervous but allow yourself to be relaxed, keep an open mind about things, and allow us to use our techniques (super topical anesthetic, wiggling, buffering, etc.), then you will feel little to no pain on injection.

Now I realize that not all dentists are the same – and not all dentists actively seek out new products/techniques to reduce injection pain. But most do. And most will be happy to talk to you about how to reduce the pain of the injection.

Might there be a Part 3 of this series? Maybe. If you have ideas, techniques, or products, email me at nick@directionsindentistry.net and maybe I’ll come up with reasons 11 through 15!

Doc, That Shot Hurt – Part I

As a dentist in private practice, I probably administer local anesthetic about ten times a day. Or to state this in terms that patients like to use, I probably give about ten shots each day. Sometimes more, sometimes less.

Very often, my patient will say something like “Wow, I barely felt that! You’re good.” But other times, I’ll hear “Wow, that hurt! My last dentist didn’t hurt me like this!”

The degree to which you will feel the shot while in the dental chair is dependent upon a number of factors. In fact, there are so many factors that they will be spread across two blog posts. Here’s part 1:

1. Location, Location, Location!

roof of the mouth or palate shot photograph

Any injection on the palate will hurt!

Just as the real estate saying goes, location is probably the number one factor in determining how much, if at all, a dental injection will hurt.

It is universally agreed upon by both dentists and patients that the shot on the roof of the mouth (more formally known as a palatal injection) hurts the most. Why? First off, the type of gum tissue present does not allow for topical anesthetic to work effectively. Secondly, the tissue is so tight and firm that the local anesthetic fluid has literally nowhere to go – making it very painful as the fluid is pushed in.

Conversely, other areas, such as on the outside of an upper tooth, we can make almost painless. You would literally not even know the injection occurred. This, however, assumes other factors are taken into account (those factors are outlined here and in the next post).

2. Topical Anesthetic

topical anesthetic used for dental injections photo

Topical Anesthetic

Topical anesthetic, more frequently referred to as “numbing jelly,” will reduce the initial “pinch” of the injection.

How does it do it?

The jelly is actually an anesthetic – just a viscous form similar to what is injected. When applied to the inside of the mouth, it will numb the area in approximately 1 minute. By making the superficial layers numb, the initial sensation of the pinch of the needle is either eliminated or reduced.

Most dentists use standard topical anesthesia these days. Some dentists, myself included, will use a high powered version that is compounded at a local pharmacy. When used properly, this type can almost completely eliminate the sensation of the needle.

If your dentist does not use topical anestheisa, you should request it. It makes a BIG difference.

3. Temperature

thermometer photo showing temperature affects pain from dental shots

Temperature of the local anesthetic affects how much you feel it.

This should be very obvious. Dental anesthetic is typically at room temperature – approximately 68 degrees Fahrenheit – and your body temperature is approximately 98 degrees Fahrenheit. Don’t you think that the 30 degree difference in temperature will make the shot be more painful?

If you answered yes, you are correct. And many research studies have confirmed this. It can make such a difference that there are actually local anesthetic warmers that dentists can buy.

Having used warmers before, I can attest that they appear to make a difference in how much you feel. But again, this assumes all other techniques are being used.

4. Presence of an Infection

Occasionally, a patient will have a significant dental infection that requires treatment. In many of those cases, an injection needs to made directly into the infected site.

pericoronitis photo where the dental shot will hurt

An injection into this infected tooth – with pericoronitis – will hurt.

Infected tissue is already hypersensitive. And the patient is already extremely distressed. And in many cases, there is a buildup of pus which is causing an increase in pressure. So what happens when you inject 1.8 cc of a local anesthetic into the infected area? You feel pain. This is because of the hypersensitivity, the likely buildup of pus underneath, and the stress.

So, injections into infected areas will always hurt, no matter what I or any other dentist try to do.

5. Choice of Local Anesthetic

First off, we dentists no longer use novocaine. In the United States, there are many different type of local anesthetics available. These include lidocaine, articaine, mepivicaine, bupivicaine, and many others. Some come with epinephrine and some come without.

According to some research studies, the choice of local anesthetic can affect how much pain you feel. This is because of differences in pH (the acidity). In humans, the pH at the injection site is typically 7.4. Doesn’t it make sense that the closer the local anesthetic is to 7.4 the less pain you will feel?

Lidocaine local anesthetic used for dentist shots

Some research says lidocaine hurts more than other local anesthetics!

One local anesthetic, prilocaine (brand name Citanest), has a pH of between 6.0 and 7.0. Many other common local anesthetics have pHs of approximately 5.0. So it stands to reason that prilocaine will hurt less because its pH is much closer to our body’s normal pH.

Well, one study confirms this finding, while another study finds no difference in type of anesthetic.

You might be asking then, why don’t all dentists use prilocaine? Prilocaine does not last as long as other local anesthetics. And many dentists (myself included) feel it is not as effective in getting patients properly numb. So many dentists elect not to use it.

Believe it or not, there are 5 more reasons why some shots hurt more than others. Part II can be found here.

Dentistry and Art: A Charlatan Dentist by Jan Miense Molenaer

Jan Miense Molenaer was a Dutch Golden Age genre painter who lived from 1610 to 1668. His paintings depict normal life for the Dutch at that period of time. Not surprisingly, he has more than one work that depicts dentists (or more accurately – individuals claiming to have dental skills).

The following painting does not have a true name, but is often described as a Charlatan dentist:

The Charlatan Dentist painting by the Dutch painter Jan Miense Molenaer

The Charlatan Dentist. Clicking on the image will show a very high resolution reproduction.

The painting shows the “dentist” in a dramatic red hat. He is most likely pulling a tooth with his bare hands and no instruments. The usual onlookers are present. An elderly woman in a black hat – whose sunken in face suggests no remaining teeth – is holding the patient’s arm down.

You can see the typical basket of eggs that is usually paid to the dentist/charlatan for his work. And you can also observe someone stealing an item from the basket being held by the lady in red. This thievery is is seen in many other paintings, such as The Tooth Puller by Gerard Van Honthorst.

When you see a painting like this, just be glad that when you show up for your appointment, your dentist is not wearing a red hat like that guy!