Archives for January 2013

Dentistry and Art: The Tooth Puller

One of my many dental hobbies outside of clinical practice is the appreciation of artwork portraying dentistry.  Specifically, Baroque and Renaissance paintings showing dentists (or people pretending to be dentists) are among my favorites.  It is always a reminder of how far dentistry and dental care has come along!

The painting below is by the Dutch Baroque era painter Gerard van Honthorst (1599 – 1656).  His name is also spelled Gerrit Van Honthorst and he is frequently referred to Gherardo della Notte (Italian for Gerard of the Night).  This painting is most commonly called The Tooth Puller or The Tooth Extractor.  This masterpiece is currently in the Musee du Louvre in Paris.

Gerard Van Honhorst Painting showing a dentist pulling a tooth with onlookers and no local anesthesia

This painting is dated 1627.  Here we see a dentist standing behind the patient pulling a tooth. Note that in dentistry today, oral surgery is still performed standing up.  When I remove a tooth on a patient, I am always standing up. Notice how the dentist is not putting his knee or foot on the patient’s chest for extra leverage, contrary to today’s myths.

In the painting, we can see 5 observers, each keenly eyeing the procedure.  The graphic details make us wonder what the onlookers were thinking nearly 400 years ago.  Whatever they were thinking, we can all say that the 5 observers are glad that they are not the one in the chair!

This “tooth pulling” is being done without any numbing as the first local anesthetic, cocaine, was not used until the late 1800s.  The “dentist” is not wearing gloves. And do you think his “pliers” were sterilized beforehand?

This painting, with its graphic details, should make everyone appreciate how far dentistry has come since 1627.

Redhead Dread Part II

A couple of months ago, I wrote an extensive blog post about my experiences as a general dentist treating redheads.  I called it Redhead Dread to suggest that redheads dread going to the dentist.  The post was based upon research which found that individuals with red hair required more local anesthesia than non-redheads.  A natural conclusion from that research was that redheads would avoid dental care and/or be fearful of the dentist because of a greater likelihood of a past, painful experience in the dental chair.

Joan on Mad Men is a Redhead - does she dread the dentist

Joan (Christina Hendricks) plays a sassy character on Mad Men. But would she secretly dread a trip to the dentist? (image from

A research paper released just last month by the Journal of Endodontics detailed the findings of a well designed study which looked at the effects of dental local anesthesia on women with red hair.  This study had a control group of women with dark hair in order to observe the differences. Some of the findings were surprising. Key conclusions were:

  1. In standard injections for the lower teeth using lidocaine (not novocaine), there was no difference in the success of the local anesthesia between redheads and dark haired females.
  2. Redheads felt more pain on needle insertion than dark haired females.
  3. Redheads experienced “significantly higher levels of dental anxiety” when compared to dark haired females.

Considerations for Dental Patients

The first conclusion stunned me, as it contradicted both previous research as well as my own experiences treating dozens of redheads over the past several years.  This was a well designed study but there was a relatively small number of study subjects.  Could the small number of participants explain the unexpected response? Possibly.  But I am not going to doubt or second guess the authors.  Nevertheless, a follow-up study with more participants would be beneficial.

In my own observations as a general dentist, conclusions 2 and 3 are closely linked and were expected. The anticipation of pain can make anyone, regardless of hair color, either amplify a minor pain stimulus into a very painful one, or create a perception of pain when no pain should have occurred.  Stated another way, an expectation of pain can create pain out of nowhere!

Because the first conclusion was a surprise, I do expect there will be additional research on this topic, which I will write about. Until then, we can conclude:

Redheads will have greater anxiety when it comes to receiving dental care. If you are a redhead, don’t be afraid to tell your dentist about any fears you may have!

Dental MythBuster #4 – Dentists Still Use Novocaine

Dental MythBuster #4 – Dentists still use novocaine

There are some dental myths I hear quite frequently in my dental office in Orange, CT. The novocaine myth is one of the most common.  Invariably, as I am talking about a procedure with my patient in the chair, he/she will say something to the effect of:

“So you are going to give me a shot of novocaine, right?”

I usually do not correct the patient, unless he/she works in the medical or pharmaceutical field.  If I were to answer the question, I would say:

“No, I am not going to give you a shot of novocaine. Dentists stopped injecting novocaine over 30 years ago. We use local anesthetics that are more effective and have less potential for allergic reactions now.”

History of Local Anesthetics in Dentistry

Cocaine is still used as local anesthetic in certain medical fields

Cocaine as a local anesthetic

Local anesthetics have been used in dentistry for over 100 years. The first widely used local anesthetic was actually cocaine.  Cocaine was first used in a dental procedure in 1884.   Prior to that, many other techniques were used, with the most common being the consumption of large quantities of alcohol before a dental procedure.  Cocaine was certainly more effective than no local anesthetic (or drunkenness), but there were many drawbacks, most notably its high potential for addiction, its short duration of action, and its effects on the heart and entire cardiovascular system.

In 1905, procaine was synthesized, and it was immediately adopted as a replacement to cocaine.  One manufacturer came up with the brand name Novocaine (also called Novocain and misspelled as novacaine ).  Due to the marketing efforts of this manufacturer, Novocaine became immediately popular with dentists and it subsequently entered the vocabulary of most Americans.

Lidocaine is used by dentist as a local anesthetic instead of novocaine

Lidocaine – the most frequently used dental local anesthetic in the U.S.

Novocaine was widely used in dentistry in the early decades of the 1900s with great success. However, it was noticed that some patients suffered allergic reactions to Novocaine.  While some of the allergic reactions were mild, others were more serious (note that people are not allergic to novocaine; people can be allergic to PABA, a direct metabolite of novocaine). As a result, a new class of local anesthetics was developed in the 1940s that did not have the same incidence of allergic reactions. They became commercially available in the 1950s, and then the use of Novocaine began to decline in the 1960s. By the 1980s, nearly all dentists had stopped using Novocaine in the United States, and lidocaine (pictured above) became the most frequently used local anesthetic.

Why this dental myth persists…

One would think that I, as a practicing dentist, would know exactly why this myth has persisted for so long.  I am unsure. But here are some ideas:

  1. Many parents indoctrinate their kids with stories (and phobias) about dentistry.  If the parents use the term Novocaine, then kids get used to the term too.  Many of those kids are now grown up and pass along the “novocaine” myth to their kids.
  2. Procaine (the generic name of Novocaine) is still occasionally used in certain fields in medicine.  In addition, other local anesthetics in the same family as novocaine are used in dentistry as topical anesthetics.   This might be a reason.
  3. Dentistry is filled with many myths such as “the dentist who pulled my tooth put his knee on my chest” and “Diet soda is not bad for my teeth” and “When I was pregnant my baby stole calcium from my teeth“.  People may hate going to the dentist, but patients love to tell dental stories. Perhaps because so many patients seem to relish in recounting and exaggerating dental stories that we have so many dental myths, including the novocaine one.

Regardless of why this dental myth is still around, it needs to be busted, so I will summarize it by writing:

Dentists no longer use novocaine and haven’t used it routinely in over thirty years!


Oral Cancer: Your Dentist is Looking for it.

Babe Ruth had oral cancer which dentists screen for

Babe Ruth

What do the following people all have in common:

  • Larry Hagman (played J.R. Ewing on Dallas)
  • Beatle George Harrison
  • British author Aldous Huxley (he wrote Brave New World)
  • Babe Ruth
  • TV Producer Aaron Spelling
  • Jack Klugmam (from the Odd Couple)

The answer is that all of these people – and hundreds of thousands of others – all were diagnosed with oral cancer that either directly or indirectly led to their deaths.

There is a perception amongst the public that dentists only deal with teeth. It is only natural to think that.  After all, the prefix “dent” means “tooth” in Latin.  So a dentist must only deal with teeth, right?

But that characterization could not be farther from the truth.  As a practicing dentist, I diagnose or aid in the identification of many pathologies and conditions beyond those which affect the teeth.  These include: obstructive sleep apnea, tonsillitis, acute maxillary sinusitis, Type II diabetes, Sjogrens Syndrome, AIDs, tonsilloliths, oral cancer, and numerous others.  So when your dentist is doing an exam at your six month cleaning, he/she is evaluating and analyzing areas that go way beyond your teeth and gums.

Many Americans see their dentist and hygienist more frequently than their primary care physician.  Where I practice in Orange, CT, the hygienists and I collectively spend close to an hour in rather intimate contact with a patient every six months. If there is going to be a pathology with an impact on the oral cavity, we will be the ones to catch it.

Larry Hagman Oral Cancer Directions in Dentistry your dentist screens for throat cancer

We all know who shot J.R. Ewing. We don’t all know that Larry Hagman died from a form of oral cancer that dentists frequently identify. Courtesy of Getty Images.

Oral cancer is actually a blanket term for multiple types of cancer that can affect strutures in oral cavity.  Oral cancer can affect the salivary glands, the tongue, the larynx, the floor of the mouth, the roof of the mouth, the inside of the cheek, the angle of the lower jaw, and other areas.  It can vary in its presentation from being visible on the soft tissue only to only being detectable with dental x-rays.  Some forms are benign and slow growing and will generally not produce a fatality; other forms are aggressive and can metastasize, leading to a poor long term prognosis.

Screening for oral cancer is a routine part of your six month recall exam.  Dental x-rays are taken at appropriate intervals based upon your risk for dental decay (cavities); if there is a suspiscious finding suggestive of oral cancer of the hard tissue then additional x-rays may be warranted.  Next, the entire oral cavity, including the tongue is inspected.  Our hygienists will typically have the patient stick out their tongue so that the right, left, top and bottom of the tongue can be analyzed.  The floor of the mouth underneath the tongue is also looked at.

Some vendors promote a screening device that purpotedly assists in the identification of soft tissue abnormalities.  An example is Velscope and another is Vizilite.   While it is beyond the scope of this blog post to comment on the efficacy of each technique, the acceptance and use of these techniques is not uniform across the United States.

As a practicing dentist who has identified two cases of oral cancer in my career, I can’t stress the importance of regular cleanings and exams. Remember, even though “dent” means tooth in Latin, your dentist and hygienist are looking at many other things besides your teeth!