Dental Practice: It’s Just Anesthesia, Right?

By Dr. Aaron Nicholas

October 4, 2022

We All Do It

It’s a throw away. We all achieve it multiple times a day. It’s almost a no-brainer. And yet, it can bring your day and your productivity to a standstill.

In the realm of increased productivity, we pay it almost no attention at all. It’s not new and exciting. We’ve probably been doing it mostly the same way since dental school. In some states, we can even get someone else to do it for us. (Lucky docs!)

OK, so what is it? It’s anesthesia! Hang on, don’t close the article just yet.

Every day docs ask me about hacks or tips on becoming faster and more confident. What trick or technique have I picked up over 34 years of dentistry that can move them forward a few more steps? Well, anesthesia is a BIG deal!

No one can be productive or feel confident with a patient that is not profoundly numb. They are always moving. You can’t do your best work. Sooner or later they start to doubt you and sometimes you even start to doubt yourself. So rather than have an “inject and pray” methodology for administering anesthesia, we need to have a better decision tree: a more predictable path.

First, EXACTLY how long does it take the average patient to get numb? Most docs have no idea. So now, we don’t know how long to wait before we start the procedure. What if they’re not numb after 5 minutes, 10 minutes? Are we keeping track?

Do we try the same injection again? Change anesthetics? Change injection technique?

If we’re wasting 10-20 minutes at the beginning of every procedure trying to get the patient numb, is it a wonder that our schedule frequently runs behind?

Let’s look at a simplified decision tree for anesthesia.

Unless there are exceptional circumstances, we’re going to infiltrate everything except lower molars (and sometimes even those, but we’ll talk about that later).

Place your favorite topical and then let’s get to work.


My System

For years I have used one carpule of Citanest w/o Epi followed by one carpule of Articaine with 1/200k epi. The Citanest w/o Epi is pH balanced and therefore doesn’t burn. The Articaine has a lower pH and would “burn” as it is injected except that the tissue its being injected into tissue that has been “pre-numbed”.  So, using this process, the patient doesn’t feel it. Articaine diffuses effectively through the alveolus, so for most teeth this is sufficient. It even works well with some mandibular first molars that have thin buccal bone covering them.

Recently, we have been experimenting with buffering the Articaine with Sodium Bicarbonate. The Sodium Bicarbonate is drawn up into a tuberculin syringe and injected into the Articaine carpule till 1/3 – 1/2 of the rubber stopper is sticking out of the back of the carpule. Now the combo is injected for the infiltration. Patients seem to experience no pain on injection and onset of action is about ½ of what it was using the “two carpule method.”

With this method we’ve eliminated the Citanest “pre numb”. And, as I once heard someone say, “they get stupid numb.” Now if you want to give this a try, don’t go out and buy any of the fancy systems for mixing the bicarbonate into the carpule. Buy a vial of injectable Bicarbonate and a box of tuberculin syringes. Total cost is less than $100. Cheap enough for anyone to give it a try.

We prebuffer 10 carpules at the start of the day and then use them as needed. If not all are used, they seem to keep well until the next day.

If we’ve determined that we want to block an arch, I’ve been using the same Citanest/Articaine combo, but the Articaine is buffered. I want to give the entire carpule at my target site, so I use the Citanest to get my needle back there as painlessly as possible. Then, I give the buffered Articaine to achieve the anesthesia for the procedure. Works even better than this combo unbuffered.

If you’ll stay in the room with the patient the first few times you do this and cold test the tooth at 30 second intervals, you can determine the average numbing time you need with this anesthetic and technique combo. Now you know how long to wait to start the procedure or give a second injection.

Give this a try and you could easily reclaim an extra 5-10 minutes of time in each procedure and spend less time running behind during your day.