Chairside Magazine Volume 2, Issue 1 - Glidewell Dental Labs

Q12: So you’re going to be giving an infraorbital and a nasopalatine
if you are doing crowns from second bicuspid to second
bicuspid? As opposed to giving 8 infiltrations over those teeth?
AB: Yes. I want blocks. As a rule of thumb a block will give
you twice as long a duration of anesthesia as an infiltration.
That’ll depend a little bit on your anesthetic and other
variables. But if you want hemostasis, if you’re gong to be
doing root planing or surgery or subgingival preps, anything
where you know you’ll be getting some bleeding, I will do
local infiltration using ideally Lidocaine with 1 to 50,000
epinephrine. That one little infiltration will give me a great
deal of hemostasis in a localized site. If I use 1 to 50,000, for
an I.A. block, my anesthesia will be about the same duration
as 1 to 100,000 but it won’t give me good hemostasis. So for
blocks, I want to use as low a concentration of vasoconstrictor
as I can. For example, Septocaine now has the 1 to 200,000
epi solution available and there are a number of studies
now, which are all quite similar, that there is no significant
difference in duration. It’s a little bit shorter duration with
1 to 200,000 than 1 to 100,000, but clinically it’s not really
significant. So why not use the safest one with the lowest
concentration? But if I am going to use it for hemostasis as a
local infiltration, I am going to use the highest one I can get
my hands on.
Q13: I have to tell you that I don’t know any of my friends who
are giving infraorbital injections with a nasopalatine for anterior
crowns like that, I think most of them are still giving 8 infiltrations.
Do you think there are a lot of GP’s using your technique?
AB: No
14: Can you explain to me how exactly you do it? Or do you even
recommend that the average GP does this?
AB: Absolutely, I have no hesitation. So what you do is feel
the lower rim of the orbit. You feel for the lowest part of the
rim, but it’s not right in the center. It is actually more towards
the base of the nose. Drop your finger down 1cm below that
rim and your finger is right over the foramen. And with many
people, if they’re a little bit thin there, you can press and they
can feel a little bit of nerve tingling. So you are right over
the foramen. Keep one fingertip there and I take my other
fingertip, usually my thumb and slide it up into the top of the
maxillary vestibule in the area of the cuspid to bicuspid. That
distance between those two fingertips is going to be the depth
of my penetration of the needle.
Q15: I am doing it on myself as you talk, and it doesn’t feel very
deep. It feels like a quarter inch or a half-inch to me.
AB: Yeah, for most people it’s less than 10mm, less than a
centimeter. So it’s not a big deal. So then I’m going to insert
a needle up into the top of the vestibule paralleling the slope
of the maxillary bone there until I feel that needle right up
underneath my fingertip that’s outside over the foramen.
Q16: So where’s the puncture point in relation to the crowns on
the teeth?
AB: I’m coming in really more over the bicuspids. I use a little
more posterior approach because it’s more comfortable, you
know, away from the midline. The technique I was taught in
school you came in over the lateral to cuspids and that brought
you in close to the base of the nose and patients always feel
that, so you go further posterior and it’s not as sensitive. I’m
coming into the vestibule over the bicuspids and paralleling
the bone until my needle is in about a centimeter so it’s right
up underneath my fingertip. I stop, aspirate, drop my bolus of
anesthetic and then with that same finger that’s been outside
the mouth the whole time, I just massage the bolus into the
foramen. I give the injection with the patient lying down and
I keep the patient lying down. Then that anesthetic is either
going to dissipate into the soft tissue or it’s going to flow
down into that foramen.
Q17: How often do you get a positive aspiration on that infraorbital
injection?
AB: Not very often. There are little blood vessels there but
they’re small enough to be of little consequence. And I give it
slowly. I give all my injections very slowly. To me it’s all about
patient comfort, but it’s also about safety. If I see any blanching
there, I’m giving it too fast. I shouldn’t see that.
Q18: So when you successfully give the infraorbital block, what
gets anesthetized?
AB: It’ll anesthetize the lip, the buccal soft tissue, and the
pulps of the anterior teeth cuspid to central. It won’t get
palatal soft tissues and it may or may not get the pulps of the
bicuspids. So I may have to infiltrate over the bicuspids in
some cases, maybe 25% of the time.
Q19: Do you think it’s safe to say that in dental school fifty years
from now or in general practices fifty years from now that the
Gow-Gates might be the routine and the IA blocks kind of the
thing of the past?
AB: It could be, but I honestly don’t think of it in those
terms, Mike, because to me, I want to know as many tricks
as possible, if “tricks” is the right word. No two people are
put together the same and there are always these oddball
situations where it helps to know different techniques. The
conventional IA technique has been around since the 1880’s,
it’s got a good track record. You know, I started using the
Gow-Gates initially because when my regular lower block
didn’t work I wanted a back up technique. And the Gow-Gates
technique usually worked. Then I started reading about it and
I was seeing the higher success rates in the literature and I
thought, if this is so successful, then why don’t I do this all
the time and use the other one, the conventional technique,
just when I need to for an alternative. And so now I almost
exclusively use the Gow-Gates. But I think it’s good to know
all the techniques. That’s my opinion.
And another troubleshooting tip is that, I advocate caution
giving additional inferior alveolar injections if the first one
doesn’t work. If I give an inferior alveolar nerve block conventional
technique, I was taught if you didn’t get it the first time,
to go a little higher and little deeper the second time, and, you
know, it usually worked.
Q20: By higher, by deeper, do you mean to the hub or do you
mean medially versus laterally? What do you mean by deeper?
AB: Well, that’s a great question because you are never quite
sure what people are referring to when they say that’s what
they do. By going a little bit higher I’m talking about a quarter
of an inch at the most higher up on my thumbnail at the
anterior border of the mandible. As far as deeper, what I’m
referring to is a slightly more posterior injection site, not necessarily
going in deeper with the needle because the bone
should still be in the same place, so it’s just that my injection
site is slightly more posterior than my initial one.
But what I’ve found reading the literature is that that higher
and deeper technique also led to increased incidents of positive
aspirations. I don’t really want to be more successful with
anesthesia at the risk of causing more bleeding. And that again
is what led me to look more closely at the Gow-Gates.
I didn’t start out using the Gow-Gates, I started out using
it only for back up and the more I used it the more I got
comfortable with it. Everything points to it being safer, being
more effective, being more efficient, and that’s why I’m a big
believer in it now.
Michael DiTolla: I’ve learned some great stuff today and if we
just inspire one or two people to take a look at their local anesthetic
procedures, and they can add a new technique that will
keep a patient comfortable while they are having dentistry done,
I think we’ve done our job. I look forward to taking
your cadaver course at the CDA meeting,
and thank you so much
for your time today.
AB: My pleasure
Mike,
I enjoyed talking
with you.
20 Questions with Dr. Alan Budenz