I might be getting a dental crown so, to distract myself, I’m asking this question I’ve been wondering:
When I was little, say, from 1990-2000, it seemed that every dental procedure that involved drilling required a numbing injection. But ever since I’ve grown up, I’ve only gotten injections for major drilling and wisdom teeth extraction. Other than that, I’ve got a few fillings, but they didn’t give me any injections for those.
So, why do they give less injections now? Is it because I’m an adult, or have dental conventions changed? I imagine, for children, it’s easier to give a ~5 minute injection then not have to struggle with them for 30 minutes, despite the fear of injections. Do they still give injections for minor procedures in children? Or have drilling techniques improved / anaesthetic was found to be bad, so they try to avoid using it, in both adults and children?
I had far too much dental work done through my early 20s - combination of cavity-prone teeth and two overzealous dentists - and I went from injections (as a kid) to gas (when it was faddish, maybe when I was 12 or so on) and back to injections.
About a year into gas, the dentist said, “You know, I have the active turned down so low I’m not sure you even need it. Do you want to try it without anesthetic?” So I did, and other than the same few seconds of pain right at the peak of drilling, it was no different. I probably had 6-10 fillings done or redone with no anesthetic at all.
Then I got a really, really, really good dentist (from about 25 until just a few years ago, when we moved) and he was a master of numb-ology; very fast and accurate with the needle and in judging amount of novocaine. He would go in with four or fast five little shots - the occasional deep one for some work - and it was both painless and fast-acting AND wore off much more quickly than any I recall - no numb-face for hours.
I think the entire practice of dental anesthesia has become much more sophisticated on every level; it used to be “numb 'em dead” and now it’s as selective and minimal as they can get away with. They are watching your pain response and use it to adjust things the next time.
Low- and no-anesthesia work is also dependent on a highly skilled assistant, who knows exactly what the drill is doing and keeps cooling water flow at the maximum needed. It’s heat that causes pain in drilling, and a proper drilling technique (slow, with pauses) and cooling method can reduce pain to the point where anesthesia is more for calming than pain control.
Oh ya the other factor might be the dentist, because my “more injections” phase was with a certain dentist, and the other phase was with several dentists. I don’t have anything against anaesthetic. I find the sensation interesting.
I’m extremely hard to numb, and I haven’t found dentists to withhold local anesthetic more now than in the past. I usually have to ask for more (sometimes 3 shots for one tooth for an ordinary filling) but that’s been true my whole life and hasn’t changed recently. I’ve never had a dentist suggest proceeding without any anesthetic!
I end to be very proactive in my pain control needs, and spend some time talking to a new dentist about my experiences. Maybe if I walked in and never said anything about it, leaving the dentist entirely to their own devices, I’d have different experience in that regard.
I have terrible teeth, so I’ve had lots of chances to try out every available method. My favorite is conscious sedation, but you can’t do that if you need to drive yourself home from the visit. I’ve had local wear off halfway into a root canal… very upsetting, for me, the endodontist, and the other patients who had to listen to me scream. The next time, he gave me four shots spaced out over a 1/2 hour, before he even started. And used nitrous, as well.
it can vary with the cavity. if it doesn’t go near the nerve then you might not have any pain. the dentist can judge the situation (both you and the tooth).
a dentist may not want to give anesthetic where not effective because it is bad practice and takes time with you taking up the chair.
a dentist may want to give anesthetic if you might get uncomfortable and wiggle because then they could take a slight bit longer to drill.
I’m lucky in that my dentist is a total mensch who does both gas and anesthetic for any work.
I met him 20 years ago when I installed TVs in the ceiling above the chairs in his practice. The way I describe the experience of being worked on by him…you’ve got headphones on, the TV remote in your hand, tripping on gas…anything happening below your nose is like war in some far-off country. You know about it vaguely, and realize that it’s probably bloody and awful, but it is hard to get really concerned about it.
Over the past couple of years I have spent a little over a year’s salary on dental restoration - implants, crowns, bridges, sinus augmentations, root canals, veneers, etc. I think my dentist uses anesthetics by the gallon. My body seems to absorb the stuff very quickly. A couple of the longer surgeries involved 4-5 hours in the chair and he would have to inject me 3 or 4 times with the 8-hour stuff. Even with that, it was still uncomfortable at times.
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I’ve had pretty horrible experiences with dental work, and am extremely hard to numb. Part of the problem when I was a teenager is that if one shot didn’t work, they’d just give you another IN THE SAME AREA. Right. Didn’t work so good. Oh, and they would always jab, then start work within a minute or two without giving the damn thing a chance to work.
I had one dentist, who had been told of the problem. I reacted in pain to a filling, and he said “Oh, you must have an extra nerve, let me sizzle that sucker”. :eek:
Once he peeled me off the ceiling, I saw that the thing in his hand was a novocaine needle, not a cauterizing device as I had thought.
Still had trouble with fillings, and the “pièce de résistance” was when I had a root canal. The crown on that same tooth hadn’t been too awful, so I opted to go in without any kind of on-board sedative.
That… was a mistake. The first injection had me screaming in agony. I should have left then, but opted to stay, which was a very bad idea. Yeah, pain kept cropping in, including sufficient to have me shriek and jump while the drill was inside the tooth. The endodontist actually offered me a Dalmane (strong benzo) right after the first shot but said “you’ll have to have someone drive you home”. So I took out my cell phone and tried to call my husband, but my hands were shaking so badly I couldn’t even dial at first. And it didn’t help - it kicked in after the procedure was over.
So when the fucking root canal failed, I had the tooth extracted with IV sedation.
I went to a new dentist a year or so later (long story, but he’d badly misjudged a situation with my daughter resulting in her losing a baby tooth to decay / abscess), explained my history, and she said “we can help”. Like you, conscious sedation.
Nitrous is my friend, too. Nobody offered that when I was a kid (and I gather it’s best used along with novocaine, not instead of). I spent 5+ hours in the chair getting stuff fixed I’d been too afraid of before. And I didn’t care. Wheeeee.
Since then, I’ve graduated to the point where for a normal filling / crown, I can get by with just nitrous + novocaine. My dentist sold her practice, and the first time I had work done with the new dentist I asked for nitrous. She seemed a bit surprised, but I assured her it would make it easier on both of us. Much, much easier.
As far as dentists using less in general, that would surprise me. They may well be getting better with placement, and not needing as much quantity-wise, to get better pain control. I have no clue whether doing things slowly / cooling things really makes that big a difference; in my case, even things that shouldn’t hurt require novocaine (e.g. replacing the temp crown with the permanent one).
I’ve also noticed that at least some dentists will react to any sign of pain on my part with additional medication, even if it’s something that I could tough through. This may just be with me, because I have such a rough history.
Also, if you go in under greater stress, you will require more pain relief and it will not work as well. It took 7 injections to redo a temporary crown once and I was pretty well hysterical afterward (as in, quite literally went into the bathroom and cried).
I’m having work done next week - a couple of crowns / inlays. Dentist wanted to do it over two visits because it’s on different sides of the mouth. I said “any real reason why it CAN’T be done in one?” and she said “well no”. So I’m doing the benzo + nitrous and it’ll save me a trip.
I lovehate the nitrous. It sets up a slight panic response at first, and my hands / feet seem to go a bit numb. Not pleasant at all. But then it kicks in and makes me disconnected and very relaxed. I can’t imagine using it recreationally as I’ve heard some people do because it’s so unpleasant when it first hits me. I must admit I’m always slightly disappointed when they turn it off and I have to come back to reality.
the location of the tooth will determine where an injection will be done. not always right next to that tooth so aiming isn’t always easy. they are after the nerve that goes to that tooth.
I think they may be getting more precise with the injections as well so they don’t need so much.
For my work today I had 3 injections. Even then, I wasn’t totally numb - I could feel the outside of my cheek. I seemed to be able to feel vague sensations everywhere. Yet I didn’t feel anything when drilling.
Well, I’ve been numbing folks up in my chair for 26 years. I routinely numb up the majority of patients for most work except very superficial decay. Some people don’t want anesthetic. I’ve done root canals on 3 patients and extractions on 2 without anes. A lot of people don’t want to be numbed up and they do fine, other people wouldn’t dream of it. There is no one size fits all everybody is different in what they can tolerate.
Genrally on upper teeth you get anesthesia almost every time with just one injection above the tooth were the gums and cheek/lips meet. For extractions and root canals I’ll give one on the roof of the mouth side also but it is seldom needed for a filling or crown. Usually each tooth needs it’s own injetion.
Lower teeth are a bit different we usually give the injection in the back of the mouth were the nerve is in the soft tissue prior to it entering the jaw. This will get all the teeth on that side numb with one injection. Due to human variation of course we don’t know exactly were the nerve is but using anatomical landmarks we can usually get it with one injection about 90% of the time. If I miss I get it on the second injection about 99% of the time. I ajust the location on second injections because it is never a volume problem but always a location error.
Gas is great for some folks to help calm them down. It doesn’t however lessen pain you would still need anesthetic for that.
All that being said the anesthetic I use now(septocaine) is better at moving across the nerve membrane then lidocaine was. It’s been on the market here in the U.S. about 10 years and comprises about half of all dental injections now. It works better so I inject less. It is still the same number of injections but less volume of anestetic.
I wanted to comment on the gas though: I don’t know how much anesthesia it offers; back when it was first “discovered” I gather they felt it really did. Better than nothing at least.
My husband, as a kid, had fillings done by one dentist who decided that gas was better than injections. He tells me that it didn’t really relieve the pain, just made him not care as much. He wasn’t impressed.
In my case, I have strong history linking anxiety / tension to poor anesthesia results. As in, if I went in tense / frightened, the anesthesia did not work as well. I don’t know what cites / studies there might be documenting that but I’ve run into similar comments in a lot of places. Adding the gas as you noted makes me much more relaxed, and lets the anesthetic do a better job. I also usually take an oral analgesic beforehand (ibuprofen or acetominophen) unless there’s some reason not to - I gather that helps with post-procedure pain by interrupting it before it gets bad.
Plus, it means I’m not tense, terrified and jumping and screaming at every little sensation, which has got to make it a lot easier on the practitioner. Note to medical people: when a patient is in pain and reacting to the pain, yelling at them to NOT MOVE and RELAX… well, just doesn’t work. Assholes. Yeah, I’ve had that several times (including that nightmarish root canal).
I kind of doubt that; it’s not like they’ve discovered some kind of mouth anatomy in the past couple of decades that was previously unknown. It’s all been mapped out since the eighteenth century, or at the latest, the 19th.
What probably has happened is that anesthetics have become more sophisticated, and rather than being a nuclear weapon that numbs the entire quadrant of your face for 5 hours, they’re now more of a 500 lb smart bomb that is able to numb just the part of your face that needs to be numb, and only for a short and predictable amount of time.
Beyond that, there have been major strides in the materials used for dentistry- I haven’t had a silver filling in over 25 years- it’s all nifty composites with all sorts of surface prep that they didn’t do in the past- etching, UV light, etc…
For whatever reason, it tends to be faster, so it’s possible that patients used to need the long-term anesthetic, but now dentists can do it faster and use the shorter acting stuff.
My experience and conversation with two dentists is that they used to use a relatively large amount of anesthetic at the major nerve junctions towards the back of the jaw for everything. That’s why half your face would be dead meat for most of the day.
The increasingly sophisticated practice is to use shorter-duration meds, more precisely delivered to the nerves affected - from one large do-all shot to one to three pinpoint shots. So while anatomy may not have changed, the way dentists perceive and manipulate it certainly has.
Hmm we’ve known where the nerves are for that long? I always thought that was a recent discovery. But I get the distinct impression they’re aiming for something, because they don’t always inject near the tooth. This targeted delivery reminds me of botox, when they aim for lifelike results instead of paralysing the entire face.
That “sizzle that sucker” dentist mentioned that the extra nerve was something that was not always taught in dental school. Another dentist, a couple years later, told me the same thing. Now, this was in the mid-to-late 1980s, so more recently-trained dentists may be taught about that sort of thing more consistently.
In any case, yes, they are clearly learning more about dental anatomy.
I think that they must be getting better at targetting / using less / using shorter-acting stuff because it’s been a long time since I’ve had the “whole face numb” feeling, even for an extraction.
Another thing they’re better about doing: reducing the pain of the injections themselves. For example, many now put numbing gel on the spots they plan to inject. I guess it’s debatable as to whether that really does anything or is merely psychological - I mean, it’ll numb the gum but that needle goes deeper than the gum!! They leave it on for a few minutes, so it may actually numb things deep enough to make a difference. They also will gently pinch your cheek and shake it a bit while doing the injection - not sure why, whether it’s just a distraction or genuinely reduces the pain. In any case, it seems to help (or makes me think it does, which is almost as good).
Here’s an interesting articleI found, that I’m fairly sure I read before, on ensuring adequate numbness (targeted at endodontic therapy but good general info anyway). The following paragraph could have been written about me:
My second root canal (different tooth), I had already seen a new general dentist (who instituted the benzo+nitrous protocol with me). I made a point of going to a different endodontist, one who used nitrous. I asked him about using an oral sedative as well. He seemed surprised (not sure whether it was the oral sedative in general, or the specific one, Halcion). I assured him that it would be best if I was stoned out of my gourd for the procedure. And the experience was fine. I remember at one point being vaguely aware that the tooth was sorta thinking about starting to hurt and I might need to wave my hand or something, but that very brief discomfort stopped and it was a non-issue. I’m quite sure that had I not had drugs on board, it would have impinged on my consciousness much faster and harder, leading to the whole anxiety/pain/injection/more anxiety chain reaction.
to clarify on my previous post. In the begining folks were breathing pure n2o so it did have analgesic and anesthetic effect. Now we go about 30% n2o and 70% oxygen(or less n2o) so the effects are more anti anxiety then the other two. Another effect is that it also make you loose track of time so long appointments seem to go by much quicker.
Ah - I didn’t realize that was the difference. Didn’t people sorta, yanno, suffocate on pure N2O???
The first time I did this particular mix (Halcion + N2O) I knew the appointment was taking a very long time, I just didn’t care :D. 5+ hours in the chair that time… And I generally understood what was going on, just didn’t care - except when I heard them talking and thought they were going to need to schedule me for another session!
So I mimed writing on a pad of paper. Took 'em a minute to realize what I meant, then they laughed and gave me pad/paper. With my eyes closed, and stoned out of my mind, I wrote “can you fix it today”. Evidently, my writing was clear enough that they understood the message (no, they didn’t proceed on my say-so, they phoned my husband for consent!!). I wish I’d had the presence of mind afterward to ask to see the paper to see how garbled my writing was.
As an aside, one of the few times I’ve outright lied to my kids was at the dentist. My daughter’s primary teeth were evidently made of B-grade swiss cheese, and she had a number of fillings and a few extractions. For one (first one done by new dentist), the tooth had abscessed and though it hadn’t bothered her yet, it needed to go. She was freaking out a bit, but we offered her nitrous. Still anxious, so I sat in the chair, put on the nose-hose, they pretended to turn it on, and I pretended to be stoned. She thought this was funny, and poked me in the leg, HARD, to see if it really relieved pain. I mumbled “huh? you’re pressing on my leg, right?”. So she was convinced, got the nitrous (plus local), got the tooth yanked, and all was well. Turns out she’s a happy drunk :).
so, to distract myself, I’m asking this question I’ve been wondering:
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