A topical discussion
You’ve been there. You’ve been a hygiene hustler all morning. You have listened to the many stories your patients tell you, your tired, hungry, thirsty, wearing all your PPE and ready for that lunch break. Only one more patient to go and you can BREATHE.
In your chair is a young, healthy woman who's faithful with her recall appointments. You think “awesome a simple prophy and I can take a break” except, this patient flinches in pain when you pick up the mouth mirror. Yeah, that’s right, this is one of "those patients" who requires soft tissue anesthesia to clean her entire mouth.
You open the drawer and see a few options. You could use injectable anesthesia, but that doesn’t make sense for this case. There are some other non-injectable choices in that drawer of chaos as well, so now you have a decision to make.
Which topical anesthetic do you use?
Why would you pick one over another?
So, what is the answer? It depends....on your patient’s health and what you are doing.
Let’s review some of the most common options available.
From time to time I have put a glob of 20% benzocaine on a swab and smeared it across the gingival tissue. While this is an easy go-to choice, it is not always the most effective. It works great for pre-injection numbing because of the thin lining mucosa. But when it comes to the thicker keratinized gingival tissue this anesthetic will not penetrate as deep. This means you might be able to get away with probing or exploring but anything more invasive than that would be more challenging.
Most commonly found as a gel, there are some companies that package benzocaine as a spray and even in a canula delivery system so it can go subgingival. For a situation like this using a canula delivery of benzocaine would be preferred over the topical gel you'd swab on. One such brand is called Gingicaine. It's simple and effective.
Benzocaine can take about 30 seconds to take effect and last about 15 minutes. Which is great for a full mouth perio assessment, but may not be the best for a full mouth prophy.
Be cautious with using large amounts of this topical. It can cause tissue sloughing, which is a sign of mild allergic reaction. Speaking of allergic reactions don’t forget this is part of the ester family which tend to have a higher rate of allergic reaction because it metabolizes into para-amino-benzoic acid (PABA). It should be used sparingly with pregnant patients and has been associated with methemoglobinemia.
This is a great mixture of anesthetics. The most common is a 2.5% Lidocaine and 2.5% Prilocaine blend (Oraqix). The great thing about this combo is it will have a greater depth of anesthesia compared to just benzocaine. What I like about this non-injectable is how easy it is to use. It flows easily into the sulcus. The other bonus is lidocaine and prilocaine are considerably safer for our pregnant patients which make this solution a great choice.
Because it enters the sulcus as a liquid form it will flow around the tooth nicely. Once in the sulcus it turns into a gel like substance. After a minute, the patient should have soft tissue anesthesia which can last 15-30 min. I’ve even had some patients achieve short term pulpal anesthesia as well. This is great for full mouth debridement and quadrant scaling. Even with the use of an ultrasonic instrument.
Since these are both part of the amide family we do not have to worry about allergic reactions as much. However, prilocaine has been associated with methemoglobinemia.
This ester-based combination has several different formulations. The one we see most often in dentistry is Cetacaine. It takes effect quickly (30 seconds) and will last for nearly 45 minutes. It works great for soft tissue anesthesia and some pulpal anesthesia as well. You can find it in a few different delivery methods such as a cream, spray or as a liquid to express into the sulcus. Just as with Oraqix, this non-injectable is ideal for full mouth debridement or scaling with hand and ultrasonic instrumentation.
It is highly effective; however, it must be used with caution. Remember all the precautions discussed with benzocaine earlier? Those all apply with this formulation, since it is an ester based anesthetic.
You may have used this solution before because it is often found in throat spray. This ketone-based anesthetic is a great alternative for patients with an allergy to other topicals. Currently, you can find this from Septodont as a solution called DycloPro.
You can use for procedures like x-rays or taking impressions. Some clinicians use it as topical for injections or for those situations which you can’t give an injection but still need to numb the gingiva.
It takes 2-10 minutes to take effect but can last for almost 30 minutes.
If you’re reading the heading and thinking “what in the heck is that?”, well you are not alone.
We already looked at tetracaine, an ester based anesthetic, used in Cetacaine. Oxymetazoline is a drug commonly found in nasal decongestants. It constricts the blood vessels therefor allowing air to flow easier into the nasal region.
These two drugs combined create the first ever FDA approved nasal inhaled anesthesia called Kovanaze. I have never used it on a patient. I have used it on a cadaver when I was at a hands-on CE course reviewing head and neck anatomy just a few years ago…yes, the course was AWESOME!
This drug will provide soft and pulpal anesthesia to the maxilla, from 2nd premolar to 2nd premolar. This sounds pretty cool to me. The literature says it takes about 10 minutes to take effect and only lasts approximately 11 minutes. Remember it does have tetracaine, an ester based anesthetic. So, you must take precaution for patients who are susceptible to these drugs (allergy and pregnancy).
This could be a good option for our pediatric patients and the highly needle phobic ones as well. I am eager to give this particular type of topical a try. Don’t get me wrong. I love giving injections…I mean HELLO! But I'm also game to try out options that could benefit my patients too.
There are many different types of topical anesthetics available to us. More than I even discussed here. Sometimes we forget to explore what is available. I encourage you to have a couple of options handy as well. Just like you use different injectable anesthetics depending on the procedure and the patient’s health status, you need to have the same thought process for your non-injectables as well. Just remember these solutions don't last very long so you may have to re-apply several times during a procedure, and you wont have the benefit of hemostasis as well.
The next time you find yourself in the situation with your “tender patient”, you can quickly select the topical which works best for the job at hand. Keeping these little bits of information in mind will help you GIVE YOUR BEST SHOT…I mean non-injectable anesthesia.
P.S. Do you want a quick reference guide for your oral injections? Head to www.teachertinardh.com to gain access to your FREE anesthesia landmark guide and learn how you can get CE regarding anesthesia including techniques to gain confidence in your injections.
Bassett, DiMarco, Naughton: Local Anesthesia for the Dental Professionals 2nd ed
Bell: Topical Anesthesia for Dental Hygiene Procedures. Dimensions of Dental Hygiene. July 12, 2017
Patel: Update on Dental Topical Anesthetics. Decisions in Dentistry. May 2019
Malamed: Handbook of Local Anesthesia 6th ed.