Episode #443: Are Your Patients Getting Comfortably Numb?, with Dr. Alan Budenz

How sure are you that your patients are comfortably numb? Are you 100% sure? Do you just hope they are? There's a better way to know than just guessing! And to help you know with 99.9% certainty, Kirk Behrendt brings in Dr. Alan Budenz to share some techniques you can start using today. Numbing is the first step to high-quality dentistry! To learn how to give patients the most comfortable experience, listen to Episode 443 of The Best Practices Show!

Main Takeaways:

• Learn as many anesthesia techniques as you possibly can.
• Always ask patients about their history with anesthesia.
• Tell patients what you're doing. Don't surprise them!
• Know the best ways to assess anesthesia.
• Even experts will miss from time to time.

Quotes:

• “Getting your patients comfortably numb is incredibly important. You can't do good-quality dental work if the patient is feeling pain and fighting you, so you've got to have good control.” (2:54—3:06)
• “I want to deliver local anesthesia as efficiently as possible, because I've never had a patient beg me to give them more shots. I always think of the movie, Little Shop of Horrors, with Steve Martin and Bill Murray, and Bill Murray’s like, ‘Oh, yeah, doc. Hurt me!’ It’s like, no, no, no, no, no. That's not real people. So, we’re not going there. I want to be really efficient with local anesthesia. And in giving the shot, inherently — you don't want to cause the patient pain giving the shot either.” (3:09—3:41)
• “Although the injectable needles are still, by far and away, the most reliable, we’re still looking for better ways, easier ways, more comfortable ways to deliver the anesthetic. And that's encouraging.” (9:58—10:12)
• “I think we’re still going to be using needles for a good while. But I think that some of these patch delivery techniques, like the iontophoresis, some of the things that have been developed more for medicine and trying to adapt them for dentistry. Part of the problem with dentistry is that versus putting a patch on the skin for anesthesia like they do in medicine, we’re dealing with a very moist environment. So, a patch may not stick well onto the mucosa. We’re usually trying to get deeper nerves. Like, the inferior alveolar nerve is rather deep through the tissue. It’s hard to direct the anesthetic that deep from a patch. So, I think these things may have promise, but I think it’s going to take quite a while to get developed.” (10:31—11:25)
• “When I'm delivering local anesthesia to the patient, before I do it, I tell them what I'm going to do.” (16:05—16:13)
• “As I go along, I'm walking through and I'm talking to the patient as I'm [administering the anesthesia]. I'm telling them what to expect, what they're going to feel. And so, for example, if I'm going to shake the cheek, I tell them, ‘I'm going to shake the cheek,’ rather than staying stoic and silent, and then I'm suddenly doing something, the patient is startled, ‘What? Why is this guy shaking my cheek?’ or these kinds of things. I want to avoid surprises.” (17:04—17:31)
• “I'm trying to tell the patient what I'm doing and what to anticipate in terms of feeling and so forth. But I know that sometimes patients totally tune me out, and all they're hearing is, ‘Blah, blah, blah, blah, blah,’ in a calm, quiet voice. But you know what? If that's hypnotic to them, that's fine too. It still works to relax them and remove some of that anxiety. But the bottom line is that as I'm doing everything, I'm telling them what I'm doing to make this more comfortable for them. I'm telling them what I do to make this a better experience for them. That, to me, is extremely important.” (17:34—18:19)
• “How do we normally assess anesthesia? We ask the patient, ‘Do you feel numb?’ ‘Uh, yeah. My lip feels kind of numb.’ So, you pick up an explorer and you poke around. Right? Well, hopefully, they don't feel that. And then, you pick up your drill or your curette, whatever, and you get ready to go to work. And it’s going through your mind, ‘God, I hope they don't feel this.’ Last thing I want is for the patient to jump. So, I got tired of that. It’s like, ‘This is killing me.’ So, simple thing to do, I squirt a little bit of Endo-Ice on a Q-tip, put that on the center of the tooth on the mandible. It’ll be the most posterior tooth that I'm going to work on. If the patient doesn't feel that cold, you've got pulpal anesthesia — 99.9% sure they're not going to feel anything. That's pretty darn good confidence.” (18:37—19:31)
• “Learn as many different techniques as you can. Again, the first technique we teach you is the traditional inferior alveolar regional nerve block technique. And that's the one that most dentists use to anesthetize one side of the mandible. But there are other techniques. I'm a huge fan of the Gow-Gates. It’s far more efficient. It has a higher success rate once you learn how to do it well. But you have to practice it to learn how to do it well. And there's another technique, the Vazirani-Akinosi. You can also use infiltrations. There are different things that you can use, and you can use them in different combinations. So, learn them. Don't be afraid to apply them where you feel that they're going to help you. And the more you use them, the better you get at them.” (29:46—30:35)
• “I miss injections, just like everybody — well, hopefully, I have a good success rate. But I do miss injections. Let's leave it at that. And so, the point is, I don't care how expert you are, you're never going to be perfect. And you do still have a lot of anatomical variation out there. People are built differently. As a dentist, I wish they were all identical. It would make giving anesthesia easy. But that's not the way the human race is. And it’s good, because it would be a boring world if we were all identical. So, my point is, again, knowing different techniques allows you to accommodate all the different variances of human anatomy.” (30:57—31:39)
• “There's so much to learn, and there's no way you can learn it all, remember it all. I think, unfortunately, our students come from college, and our education up through college, students are largely memorizing information and then just spewing it back out for an exam. Dentistry, that's not going to work. You need to actually learn things. And so, it takes learning those facts and figuring out how do they apply, how do they integrate together, how do they work together, understanding why we do certain things the way we do.” (33:22—34:05)
• “You're going to make mistakes. We all do. Try not to make big ones. Try not to make dangerous or costly ones. Pay attention. Learn from your mistakes. Don't be afraid to make a mistake. But don't be stupid enough to not learn from your mistake.” (34:30—34:48)

Snippets:

• 0:00 Introduction.
• 2:25 Dr. Budenz’s background.
• 5:04 How dental students learn about local anesthesia.
• 7:20 The evolution of local anesthesia.
• 10:12 What we can anticipate for the future of local anesthesia.
• 11:47 Understanding potential drug interactions with local anesthetics.
• 15:33 Defining comfortably numb.
• 18:20 How do you know when patients are comfortably numb?
• 19:47 Guidelines for anesthesia by state.
• 21:51 Dr. Budenz’s opinion on others administering anesthesia.
• 24:25 Ask patients about dental and anesthesia history.
• 26:53 Typical injection timeframes.
• 29:28 Last thoughts on local anesthesia.
• 32:53 Advice for dentists.
• 35:04 More about Dr. Budenz and how to get in touch.

Reach Out to Dr. Budenz:

Dr. Budenz’s email: [email protected] 

Dr. Budenz’s website: https://alanbudenz.com/

Resources:

Lexicomp: https://online.lexi.com/lco/action/login

Dr. Alan Budenz Bio:

Dr. Alan Budenz is a professor in the Department of Biomedical Sciences and the Department of Diagnostic Sciences at the University of the Pacific, Arthur A. Dugoni School of Dentistry in San Francisco. He received his graduate degree in Anatomy from UCLA, and his dental degree from UCSF. He has more than 35 years of general practice experience in San Francisco, as well as teaching clinical, preclinical, and anatomy courses at Pacific since 1984. Dr. Budenz has had the pleasure to lecture nationally and internationally on local anesthesia, human anatomy, cariology, and oral medicine/oral pathology topics. Since 2005, he has been recognized each year as an Annual Leader in Dental Continuing Education by Dentistry Today.