Michael DiTolla, DDS, FAGD
One of the lessons I picked up early on from retired dentist-practice management guru Dr. Earl Estep was his philosophy on seating crowns. He firmly believed that the crown cementation appointment had a lot to do with the overall longevity of the crown, and could influence it if the restoration lasted five or 15 years. Earl believed that salivary contamination of the cement at the seat appointment could doom an otherwise perfect crown. He convinced me years ago to numb all crown seats to do it right.
I still talk to many practitioners who try to get through the crown seat appointment without local for a number of reasons. From the dentist's perspective, it is a hassle to give a lower block, for example, just to cement a crown. Many doctors prefer that their patients be unanesthetized so that they can evaluate the occlusion of the crown during try-in and after cementation more accurately.
From the patient's point of view, having a lower block to just cement a crown on tooth No. 19 may seem like overkill. Patients have commented that if no drilling is going to take place, then they are fine without any local. Of course, at this point, they still haven't felt the cold air blast on their dentin. Especially on lowers, patients hate to have the entire half of their jaw numbed for just one tooth.
So my search began years ago for a way to satisfy Earl's requirement that all crown seats be numbed, but to do it in a way that was both doctor- and patient-friendly as well. First, that meant no lower blocks could be used since these are not really patient-friendly. Whether it's having to take the needle through the two pterygoid muscles, or the fact that it incapacitates half the patient's lower lip and half of his or her tongue-which makes talking and eating difficult for the duration of the anesthetic - the lower block is not a patient favorite. I began to look for a way to anesthetize mandibular teeth individually and without all the soft tissue involvement of a block.
The first breakthrough I had was finding an incredibly strong topical anesthetic being made by a pharmacy here in Southern California. The topical is called Profound and is sold by Steven's Pharmacy in Costa Mesa, Calif. The pharmacy's phone number is (714) 540-8911. The nationwide toll-free number is (800)-352-DRUG. The topical comes in a 30-gram tube with a 10-gram syringe for direct subgingival placement for hygiene uses, packing cord, etc. Profound works well because it is a combination of prilocaine, lidocaine, and tetracaine. This differs from most topicals, which are just benzocaine. The first time I used Profound, I placed some above No. 8 and No. 9 and left it there for a few minutes. To my amazement, I had pulpal anesthesia on these two teeth - just from this topical!
Since then, I have found that I can get mild pulpal anesthesia with Profound anywhere the cortical plate of bone is thin. This includes maxillary and mandibular incisors but not the cuspids. The good news is that, if you do need to use a local anesthetic, the injection site has been completely anesthetized with Profound and is ready for a painless injection of anesthetic based on your duration requirements. For crown seats, I typically like to use a local anesthetic with high absorption through bone and shorter duration. Septocaine does just that. The absorption of Septocaine is so high that, in addition to using it for maxillary infiltrations, it works quite well for mandibular infiltrations, including bicuspids.
This leaves us with the molars - the teeth most likely to require crowns. In order to anesthetize these teeth without the soft tissue, pdl injections in the furcation are quite effective. I use Profound in the syringe with an 18-gauge disposable Endo-Eze tip from Ultradent to place the topical anesthetic into the sulcus and over the furcation. After letting it absorb for 60 seconds, I am able to give a painless injection from a standard syringe with a 30-gauge extra short needle that results in pulpal anesthesia without any of the unwanted soft tissue effects.
The use of an ultra-strong topical like Profound allows us to painlessly regain the moisture control at the crown seat appointment. When necessary, Septocaine is an excellent local anesthetic with high absorption and shorter duration for these quick procedures. If anesthetizing your crown seats in a patient-friendly and patient-acceptable manner allows you to maintain ideal moisture control and increase the longevity of your crowns, then this is a great "win-win" situation for your restorative dentistry.
Dr. Michael DiTolla is director of clinical research and education at Glidewell Labs in Newport Beach, Calif., where he also teaches over-the-shoulder courses on topics such as aesthetic restorative dentistry. Dr. DiTolla also teaches a two-day, live-patient, hands-on laser-training course that emphasizes diode and erbium lasers. In addition, he teaches a two-day, hands-on digital photography course emphasizing intraoral and portrait photography, and image manipulation. More information on these and other courses can be found by email at [email protected] or by calling (888) 535-1289.
