First, let’s open the communication lines. Talk to your dentist and ask questions of him or her and their staff. Get a feel for what their practice philosophy is and see if it matches your own. Dentists are not like medical doctors. They usually are more personable because they have greater time allotted for each patient, so get to know yours. Patients in my office usually see me first for an initial consultation before they even reach my hygienist. They get an office tour, meet my staff, radiographs are taken, an initial periodontal screening is done, an oral cancer Velscope exam is completed, and a treatment sequence is planned. Dentistry is a highly reimbursed field so look for quality of service and a staff that takes its time.

Look for a clean office. Ask about sterilization techniques and make sure that they meet OSHA requirements. Remember that dentistry always has new and evolving technology, so check to see if your doc uses such equipment. Consider dental radiography, which even in the traditional form has far less radiation than any medical scans. A full mouth series or FMX has eighteen xrays but contains 56,000X less radiation than an upper GI, 800X less radiation than a chest xray, and 40X less exposure than what a person is exposed to throughout his day. Digital radiography has an 80% reduction in radiation exposure on top of the figures I listed above, and I believe it to be a must in a modern practice. Digital xrays produce an instantaneous image without the use of processing chemicals and enable far superior diagnostics for the clinician. Infection is diagnosed in its beginning stages, and treatment can often be kept conservative saving the patient money, time, and pain.

Another important diagnostic tool to look for is the presence of a thorough periodontal screening system to diagnose gum and periodontal disease. Remember that bleeding gums during flossing and brushing is not normal and are signs of infection. The bacteria in gum and periodontal disease can enter your bloodstream through damaged vessels in your gums. This bacteria produces toxins that increase a patient’s risk for stroke, cardiovascular disease, insullin resistance, lung disease, and stomach ulcers. Your mouth’s health is very much linked to the rest of your body’s overall well being,  and so your dental hygienist should be probing six surfaces around each of your teeth to check for pockets and inflammation during your check-ups.

Oral cancer is another concern. It is important to have a complete oral cancer screening performed once a year. Your dentist will check your head, face, neck, and mouth for any lumps, bumps, or unusual sores that do not disappear within two weeks. Current statistics from the American Cancer Society state that 25% of oral cancer sufferers neither smoke nor drink and their five year survival rate is about half. Those are scary numbers. Therefore no dental exam is complete without a yearly oral cancer evaluation. In our office we use the Velscope Oral Cancer Screening System. This machine emits a safe flourescent light that penetrates the tissue through the epithelium to the basement membrane, the area where most oral cancers start. Abnormal tissue does not flouresce and appears dark. Normal tissue flouresces green.  While the Velscope does not diagnose cancer, it is an excellent tool that aids in identifying premalignant change. Its light reaches where your eye cannot. So if there is dysplasia present, we no longer  have to wait for it to spread through the epithelium and into the mouth to detect it with loops. The Velscope will detect these changes in its earliest stages when treatment can be most successful.

Also important are your dentist’s cosmetic skills. There are many beautiful and lifelike restorations available for patient care. These include porcelain crowns and veneers, cerinate veneers, all porcelain bridges, implants for tooth replacement, cosmetic bonding, invisable braces, and deep tooth whitening.   

Other excellent dental equipment to look for in a well equipped office include a diagnodent early caries laser detector, an intraoral camera that shows patients what clinicians see, and a CadCam Cerec unit. The Cerec stands for Chairside Economical Restoration of Esthetic Ceramics and is manufactured by Sirona Dental in Germany. It is truly an awesome technology that provides same day porcelain  restorations. That means no 2-3 weeks in a temporary, no impression, and no return visit. The cavity preparation is scanned with an intraoral camera and stored as a 3D digital model in the unit. The doctor then refines the model using 3D CAD software and then a milling unit actually carves the exact restoration from a solid block of porcelain. Crowns, onlays, and inlays are made this way and are then cemented into a tooth. I have been using this machine since 2005 and I am still in awe of it, as our my patients. They love to watch the design and artistryof it, and many of them say that the enlarged images look like clouds, mountains, and toes. Use your imagination.

So to summarize, look for a clean and technologically advanced dental office. The doctor and staff should be current with changing dental technology which indicates that they strive to excell, educate themselves, and provide high end service to their patients.  Find a clinician who you connect with, who you are comfortable with, and who you trust. After all a good patient-dentist relationship will last decades, and you will likely bring those you hold dearest to them.

Such cosmetic dental work produces predictable and dazzling results because the patient’s smile is redesigned with porcelain. The artistry is in the hands of the dentist and ceramist, and this material will give beautiful and translucent results. However, if you have a fairly young, compliant patient who has nicely alligned and nonrestored anterior teeth, then tooth whitening also is a good way to brighten their smile.

Certainly more affordable and conservative than porcelain, tooth whitening systems do have their place in our cosmetic driven society, and people are hungry for it. Pick your patients carefully, however, and keep their expectations low because bleaching results are far less predictable as most of the control goes to the inherent biology of patients’ teeth and habits, not your skills. We are dealing with individual tooth composition, patient compliance, and occasional sensitivity concerns that all limit tooth whitening efficacy. However, almost every patient is interested in whitening their teeth, and I do believe that whitening works for certain people, so I will blog on the system that I use.

First let’s review the bleaching vs. whitening ideas. The FDA allows the word “bleaching” to be used only for products that contain hydrogen peroxide or carbamide peroxide…these two products will lighten a tooth to a shade lighter than its natural color. The word “whitening” can be used in the abscence of peroxides and when a tooth is cleaned of plaque, calculus, debris. Your hygienist’s prophy whitens teeth. Toothpastes also are advertised as tooth whiteners.

Think of the pearly whites of little kids’ teeth. As we age our teeth lose this luster because our enamel, the tooth’s outer covering, thins, cracks, and allows the dentin to poke through. Dentin is yellower and so teeth look duller. Extrinsic stain gets into our thinning enamel and discolors it even more…think colored drinks, smokes, grinding and bruxing, tartar. These types of stains are easily removed with prophys and bleaching. Intrinsic stain, however,  is more stubborn because it discolors teeth from the inside…tetracycline during tooth formation, excessive fluoride ingestion, internal resorption, trauma. Tooth bleaching systems claim to work here, but I am skeptical. I usually end up veneering or crowning such teeth.

It is also important to remember that every person has their individual tooth color make-up. This is the natural shade of their own teeth that they start out with before bleaching or any other cosmetic procedures. Some teeth are more green-grey and others are yellow-brown. Yellow-brown whitens better.

There are three whitening modalities today: over-the-counter products, in-office professional treatments, and professionally dispersed take home whitening products.

The over-the-counter whiteners are sold just as they sound…at your local store. They have a lower concentration of peroxide and contain strips, paint-on gels, or standard trays that the solution is applied into to and then placed in your mouth. Such popular products include Crest White Strips, Colgate Simply White Night, Crest Night Effects. I believe Crest White Strips are the most bang for your buck. My patients have reported the best results from this over-the-counter product. Average cost of these products range from $20-$100. 

A note on over-the-counter toothpastes that advertise to whiten teeth. They contain a negligible 1% peroxide and are applied to your teeth too briefly to take effect. They will clean your teeth but they will not whiten them, so don’t waste your money. 

In-office treatments are the second kind of whitening modality.  These bleaching lights and lasers promise a quick result with little vested time and so have great appeal in our busy society. Unfortunately current research shows that lights and lasers do not whiten teeth more, they simply dehydrate teeth and produce more sensitivity. Cost averages between $400-800 per session. Zoom, BriteSmile, LaserSmile, LumaCool, and Sapphire are such products. Patients ask for these because of the quick result, but I have found that the initial shade drop disappears just as quickly as it is achieved. The patient is out a considerable fee and two weeks later has yellow teeth again.

The third kind of whitening modality is take home products that are applied to teeth in custom fitting trays from one hour up to overnight. When made properly these trays can even be used in sensitive areas like recessed gums because they can be cut short. The patient has to be instructed on proper filling technique and amount and are then observed throughout the whitening duration (usually 2 weeks- 1 month). I have found that continued exposure to peroxide over a period of time whitens teeth most effectively, and so I like this bleaching modality the most of the three. 

In our office we use the Kor Whitening Deep Bleaching System from Evolve Technologies, a combination of two in-office treatments (up to one hour each) and one take home kit that patients sleep in. We also give out desensitizing applicators. This combination of in-office or boost treatments as I call them, coupled with take home solutions applied into carefully constructed custom trays for 2 weeks gives awesome results.  Dr. Rod Kurthy is the developer… www.korwhitening.com (866-763-7753) or  international +1-949-713-0909.  Again we are dependent on individual tooth morphology and personal habits, patients need to stay as free of tea, coffee, smokes, wine, colored sodas as their will power allows during whitening for best effects, but this system has produced the best results I have seen from a whitening system. Our fee is $570.

Those resorption figures will continue to slowely increase as time goes in an edentulous area. This means that your lovely ovate pontics will eventually trap food and you will lose precious bone arond the top threads of your implants. So I have begun placing bone graft into my surgical sights, sometimes with a membrane and sometimes without.

Let me review graft materials:

Autogenous Bone: Originally considered the best source for grafting; the procedure of taking bone from the patient from another sight (chin, tuberosity, hip) and then placing it in the defect.

Allografts: Freeze dried cadaver bone or from living human donors

Xenografts: Bone from nonhuman species such as cows (bovine bone)

Barrier Membranes: These membranes block epithelial and connective tissue cells from entering bone voids and thus allow bone cells to properly fill in these voids.

I buy my graft material from Keystone Dental (Massachusetts; 866-902-9272; www.keystonedental.com). Their products include DynaGraft-D putty and DynaGraft-D gel. I like the gel because it comes in a preloaded and paste filled syringe. It is easily and cleanly deposited into your extraction socket and slightly overflows at the crest. The putty is excellent for buccal plate defects around an implant. Once my material is applied as needed, I then place the extracellular membrane known as DynaMatrix over the surgical site and suture it in place. This membrane is also an allograft and the manufacturer receives its donors from tissue banks. Although this membrane is strong enough to be either sutured or tacked, I will usually use silk sutures to anchor it down. I have been shying away from chromic gut because in my hands, silk is easier to manipulate and will hold the membrane snugger. The patient will return in 7 days for follow up and I will remove the stitches.

It seems that Xenografts like Bio-Oss made from cows are more in use than the Allograft that I use. I haven’t used Bio-Oss so I can not comment on which is better. I can say that when my patients return months after the graft has been placed, I see a nice wide, tall ridge, and I am happy…they usually are too with the restoration that follows.

When Invisalign started promoting clear braces without wires and brackets and helped treatment plan with their orthodontists, I was interested. I became an Invisalign provider in 2002 after a two day course in Manhattan. A couple years later I was further certified in advanced Invisalign (Invisalign II).  All one had to do was take good PVS impressions, photos, bite registration and complete a rudimentary script. The aligners would be fabricated in bulk and switched every two weeks. The teeth would move into proper alignment predictably, without trauma, and what was the biggest selling point to adult patients…nearly invisably.

Invisalign approved nearly any case you sent. Even with unpredictable movements like extrusions, intrusions, rotations and difficult cases like open bites and cross-bites, Invisalign provided a successful clincheck. This of course was nonsense and after a few poor results, I quickly learned Invisalign’s limitations. The technology was great for minimal to moderate crowding and if one chose cases that demanded more advanced movement, the doc and patient had to be prepared for mid-course corrections, refinements, and likely fixed ortho at the case’s end for tweaking.  

I complete an average of half a dozen cases per year and get questions daily from interested patients whose main turn off is cost.  However, things have changed. In 2009 Invisalign sent out written and email communications explaining new requirements now placed on certified docs. Clinicians now need 10 active cases per year and 10 Invisalign specific CE credits. Unless these requirements are maintained, dentists no longer will maintain active account status.

I am all for continuing education but 10 active cases for a GP is ludicrous.  Orthodontists can easily meet this quota because ortho is the only discipline of dentistry practiced. However, as a GP, ortho is a small section of mine. My labs do not place requirements on how many crown and bridge or implants units I restore with them. I have paid thousands of dollars to Invisalign for their certification courses, CEs, and cases submitted for treatment. Now Invisalign wants even more.   

I say leave it behind. One of the awesome aspects of our profession is its autonomy. We are not owned by anyone. We practice dentistry with our own ethics, by our own rules, and we stand behind it alone and proud. This bravado is rare in healthcare today, and I am proud to be part of a profession that allows such gifts.

So I have turned to other avenues of ortho. Six month smiles is fixed ortho that does not change angle classification but does align the anteriors. It is also more predictable than aligner therapy. Clear Correct is a company out Houston that has found its niche among providers ousted by Invisalign. It is the same aligner therapy but cheaper and there are no requirements on clinicians. They do not, however, have all the bells and whistles of Align’s website and 3D clincheck system. I am about to start my first Clear Correct case and will blog my thoughts in the months ahead.

Haiti is the poorest nation in the western hemisphere. Its citizens live in applorable conditions that lack food, shelter, and basic sanitation.  Haiti has a history of overthrown, assassinated, or executed presidents and political unrest. Today Renee Preval remains president until February 2011. None of its  leaders has made Haiti prosper, instead its citizens live in a nation so impoverished that it exists as a fifth world nation.

Some facts on Haiti I took from the internet: 1. The average income is $90-300 US dollars per year.

2. Tiny mud shacks with roofs made of banana leaves will house a family with multiple children. Many of these children will die from drinking filthy water.

3. The unemployment rate is greater than 80% and more than 60% live in poverty.

4.  Less than 20% of those age 15 and over can read.

5. Haiti has the highest AIDS/HIV rate in the western hemisphere with 1/20 persons infected. There are approximately 150,000 AIDS orphans. The UN estimates that 6% of Haitians are infected with AIDS

Our trip was to last one week. Everyone in the group received Malaria pills and boosters of Hepatitis B. We packed all kinds of supplies:  dental instruments, antibiotics, pain meds, anesthetics, toothbrushes, toothpaste, toys, clothes, food, beverages. Our trip was to take us from Philadelphia to Miami to Port-au-Prince and finally to our ultimate destination, Jeremie. Known as the city of poets, Jeremie  is the capital city of the department of Grand’Anse in Haiti and has a population of 31,000.

When my group arrived in Port-au-Prince, we entered a hot and barely functional airport with only one receiving belt for luggage. The belt spins noisily and malfunctions often. So too do the overhead lights which turn off unexpectedly and throw the sticky overcrowded room into confusion. Once my group claimed its luggage we ventured outside to find our guide, Paris, who was always the driver for the Temple outreach group.

A crowd of Haitians, adults and children alike, stood outside the airport doors many without legs, arms, eyes, ears. They were beggers anxious to find some way to earn money. Paris found us quickly,  ushered us into his white minibus, and drove us to our hotel.  After a one night layover, we boarded a small charter plane and flew just under one hour south into Jeremie. There was no runway and we landed on grass. We packed into large white trucks and drove to the Haitian Health Foundation, a center started by Dr. Jeremiah Lowney, a dentist from Norwich, CT. Run by nuns, this center exists to provide healthcare to this very isolated city.

Jeremie has no outgoing communication.  The HHF has one phone that seldom works, a poor internet connection,  and no electricity. My group showered at night because the water in the incoming pipes was  warmest then having been been heated throughout the day by the sun. We walked the dark halls at night in pairs with flashlights or head lamps that strapped onto our foreheads like miners. After dinner we sat on the balcony illuminated by the largest moon. They fed us well, even packed lunches for our daily outings, and cooked for us at night as we ate amidst a nation of starving children.

Each morning we piled into white SUVs and drove through unpaved roads to as far as the cars could take us. Then we would hike the rest of the way, sometimes for several hours, crossing streams on foot or even on donkey, until we reached our destinations. We worked in a school, outside a clinic, but mostly in the jungle. Our group would divide into three teams…one to triage, one to numb, one to extract. We had no xrays and no motors, just our skills and help from the most resilient, appreciative and tough people I had ever encountered. 

We worked without stop because there were so many people in pain who had not seen a dentist and would not until the next outreach group. That would be at least one year. Word of mouth spread quickly and within one hour of setting up our instruments and chairs, miles of  Haitians waited to be treated. Their mouths were usually perfect with two rows of white strong teeth except the infection site which was often accompanied with facial swellings, abscesses, cellulitis. So we worked until the lack of sunlight made it impossible to see and then hiked back through the jungle to our waiting white trucks. I felt like I had stepped into a page of the Jungle Book.

The HHF is a superb organization that has saved countless Haitians from preventable deaths. They have organized programs like Give-a-Goat, Happy House, and Clean Latrines that aid in healthcare (particularly for children and women), and bring relief for meals, clothing, and education. They save lives, period. The HHF also functions at the extremely low overhead of  only 8 cents per dollar.  That means 92 cents of every dollar donated goes directly to services for the poor.   

There will be over 30,000 refugees fleeing by boats from Port-au-Prince to Jeremie in the days ahead. They will require food, shelter, and medical aid. Inaction on our part means death to these people. We must be generous and begin to give back a little of our surplus via mail or internet. Visit www.hatianhealthfoundation.org to learn where to send money and how to help. It is time the world stop forgetting about Haiti.  Perhaps finally now the tragedies spinning from this earthquake will make the rest of us help Haiti rebuild and create a stronger infrastructure for herself.

magic mouthwash

A strange name perhaps, but Magic Mouthwash works wonders when perscribed for sore mouths, raw throats, and thrush. I used to suggest sea salt and hydrogen peroxide rinses and I still do. However, if a patient presents in acute discomfort and the origin looks traumatic, write a script for Magic Mouthwash and they will think you are a hero.

Perscription only, Magic Mouthwash is a compound rinse and is made of varying drugs in varying ratios. You need to specify to the pharmacist what compounded medications are required and in what proportions. The original formula consists of equal parts viscous lidocaine and diphenhyrdamine for analgesia and an atacid like maalox. However, you could also add nystatin for oral yeast infections, a corticosteroid to decrease inflammation, and even an antibiotic to lower bacterial count. If you do not specify your ingredients and proportions, the pharmacist will likely compund the traditional formula known as Magic Mouthwash I: lidocaine, Benadryl, and maalox.

Other names of similar compounds are as follows:

Miracle Mouthwash: Tetracycline, Nystatin, Dexamethasone, Diphenhydramine

Duke’s Magic Mouthwash: Nystatin 100,000 u/ml, 30 ml; Hydrocortisone 60 mg; Benadryl

I have also read of Kaiser Mouthwash, Kraemer Mouthwash, Powell Mouthwash, Reynold Mouthwash, and Stanford Moutwash.

Google these rinses to find out their components. However, you do not have to name a particular coined rinse when perscribing. Simply write for Magic Mouthwash and specify what you want inside the bottle. Any concoction of lidocaine, Benadryl, an antacid, a coritcosteroid, and/or an antibiotic all in suspension will do fine. The ingredients just depend on the condition(s) you are treating. ENTs or internists perscribe such a rinse for sore throats as it is safe for swallowing. The instructions I give my patients are to swish then spit three times a day for ten days.

Magic Mouthwash  is superb for mouth sores like minor or major apthous ulcers, bites, burns, cuts, herpetic infections within the mouth (do not include a corticosteroid component for treatment of the Herpes virus), allergic mucosal rashes, sore throats, thrush, and traumatic ulcerative reactions to dental work. If your patient returns with white and red ulcerated and painful gums after a crown prep or some pdl injections, perscribe them Magic Mouthwash and they will love you for the relief.

Poor oral hygiene would be culprit number one. Improper brushing or flossing that leaves food on or in between the teeth will cause odor. As we chew, digestion begins and food particles breakdown in our mouths. If they are not properly removed with either subsequent brushing/flossing and rinsing they will accumulate on your teeth as plaque, collect bacteria, and release Hydrogen Sulfide vapors, or bad breath.

Bleeding gums or lose shifting teeth are a sign of gingivitis or periodontal disease which will also cause halitosis. Don’t forget to clean your tongue, especially the posterior 1/3, every time you brush. Most bad smells come from the back of your tongue. Take a soft bristle brush and scrub your tongue well twice a day to clean off accumulated dead epithelium. Even if it gags you, scrub well.

Poor fitting dental work like open crown margins, leaky root canals, decaying old fillings, or poorly cleaned dentures all cause bacteria to grow which emits a bad odor. If you have had any teeth extracted and are now developing a pain radiating through your jaw coupled with a bad smell, you may have an alveolar osteitis or dry socket. This is a painful condition when a blood clot is lost prematurely. You need to visit your dentist ASAP for treatment because this condition will not resolve on its own.

Dry mouth can also cause bad breath. This condition is caused by either poorly functioning salivary glands or may be a side effect from certain medications. Saliva washes out dead epithelial cells and bacteria which are usually swallowed. However, people afflicted with dry mouth have low saliva production and so these dead cells accumulate on the teeth, tongue, and tissue, and like in morning mouth, cause odor. Chewing sugar-free gum, parsley, mints, and mouth rinses are good ways to temporarily combat this. Also it is imperative that your dentist make you fluoride trays which will strengthen your tooth enamel and slow down root surface decay.

If your dentist has reviewed all of the above conditions with you and they are within normal limits yet you still maintain chronic bad breath, then a visit to your internist is warranted. Allergies or chronic sinusitis can cause a postnasal drip into the back of your throat resulting in an odor. Blood work should be taken and evaluated to rule out certain systemic diseases as well. Metabolic disorders of the kidneys can cause urine-like breath. Problems with the pancrease like noncontrolled diabetes can create a fruity-like odor. The lungs need to be evaluated to rule out infection as does your gastrointestinal tract for disorders like gastroesophageal reflux disease or GERD.

Certain diets particularly those high in protein can cause ketosis which makes your breath small acidic.

Most cases of bad breath can be treated with proper oral hygiene techniques, i.e. brushing twice a day, flossing at least once, rinsing your mouth with appropriate rinses or even warm water after you eat, and certainly cleaning your tongue. One mouth rinse that I recommend to my patients is the all natural Tooth and Gum Tonic. It is excellent for your gums and really makes your mouth feel fresh.

Visit your hygienist at least twice per year for cleanings, polishings, and your dentist for check-ups. Your dentist will help to determine if a case of bad breath can be managed in house, or if perhaps there is an underlying condition that needs to be addressed. Remember that prevention is key and dental problems are like a can of worms. Once they start and if left to progress, your mouth will deteriorate quickly, and mouth infection, be it soft tissue, bone, or tooth related, usually goes unnoticed until it becomes advanced. Early detection by your dentist will save you money, energy, and time and if arrested quickly can be maintained for a lifetime.

Toochache

The medications needed to properly treat dental infections are often prescription drugs and inaccessible to patients. Perhaps they don’t have a dentist or worse can’t reach their dentist. So they are  stuck, it’s the weekend, it’s late, and their tooth aches horribly and shoots radiating pain everywhere. What can they do ?

The following is a list of at home and over the counter remedies that I suggest. They will make your toothache temporarily better but in no way will they treat it. You will have to visit a dentist for proper diagnoses and treatment to get completely pain-free.

So here goes:

A Motrin and Tylenol analgesic mix works great for mouth pain and it is over the counter. Four Motrin is 800mg which is prescription strength. Take the pills with food, wait 20 minutes and take one extra strength Tylenol. This combination works wonders. Just make sure your health or current list of medications allows you to take drugs from the NSAIDs family. The above drug regimen may repeated every six to eight hours.

Oil of clove contains eugenol which is calming for hot teeth. If your tooth is cracked or has a hole in it, carefully clean out any debris with either a toothpick or a cotton pellet. Soak a q-tip in the oil of clove and apply it directly to your achy tooth.  Be careful not to touch the oil to any soft tissue as this will burn. Some people complain of the taste but the relief is far worth it.

Rinse your mouth with straight Hydrogen Peroxide followed by warm sea salt water. Do this many times throughout the day.

Famous Hippocrates praised garlic and all its medicinal properties. When crushed, garlic releases allicin, a compound with an antibiotic effect that theoretically may slow down the acids produced by the bacteria in your tooth, and hence slow down your pain. It is also good during flu season.

Apply either vanilla or almond extract on a q-tip to your tooth.

 Synergistically, all of the above remedies bring relief to a toothache but none of them cure it. Remember that dental infections come from many sources and there is no cookbook way to treat them. The infection’s etiology, or cause,  must first be determined before proper treatment applied. This diagnoses needs a dentist so make sure you visit yours regularly. However, if you’re that unlucky soul who develops that blaring nasty toothache Saturday night, follow my home remedies and you will feel better.

Try as we dentists might, shots scare nearly all of our patients and if given improperly can be down right painful. Plus the aftereffects of the anesthesia are annoying…slurred speech, big fat lip, bitten tongue…. and are often prolonged. So how do we make the art of injection more pleasant?

Give a painless shot.

No, this is not an oxymoron.

Here is my technique. An excellent topical anesthetic is a must. I only use Hurricaine which is 20% Benzocaine like the other brands, but only this stuff works. The other brands DO NOT. Dry the tissue completely and apply the Hurricaine liberally. Cover it up with enough cotton so that no saliva gets through and let it sit for 5-10 minutes. Small talk, do a hygiene exam, pass the time and then remove all of the cotton. The patient will be really numb..topically, that is.

Your needle should be a 30 guage extra short…which means the thinnest, shortest, and smallest. Your local anesthesia is Septocaine 1:100,000 unless your patient can’t handle epinephrine. Tell them to open wide, position the injection where you need it, take hold of the lip, ask them to close halfway, shake their lip just before the needle punctures the tissue. Shake until you have about half a carpule in because after that it doesn’t matter.

Inject slowely.

The lip shaking is a great distraction. Ever heard of the Gateway Theory of Pain? The human brain can concentrate on only one major sensation at one time. So if you shake the lip hard enough…not too hard now…just before the prick, the prick is not felt. There is no prick. You will hear the delicious question dentists love…”What was that? Was that the needle?”

And oh yes, singing always helps during a shot too.

Humming counts too.

That’s right…sing to your patients. I have found that nearly each person I treat, especially the anxious and scared people, are calmed and pacified by a singing dentist.  Perhaps it’s the distraction from dentistry’s sounds and smells. Perhaps it’s the amusement of having me engage in silly rhythm and out of tune melody. Maybe they just like my taste in music, or not, and the tunes bring them back to different memories.

I don’t know what it is. But I promise that you too would find a singing dentist amusing. It often sparks cute conversation, if not between me and my patients, then certainly between me and my eighties loving assistants. We often fall into music trivia regarding the singers and the time of the music. I had a patient ask me the other day if I had big hair in the eighties? No, I answered, I was a teenager in the eighties and I had a perm. Permed hair and braces…mmhh.

Music is like smell, it instantly draws a memory which is a good thing in the dental chair. We want our patients to be distracted because nobody wants to have the private and tender space of their mouth invaded. But if they must, then who better to be the invader then their singing dentist?