by Sheri B. Doniger, DDS
Hygienists who deliver local anesthetic can be a powerful asset to the dental practice. Their very qualities make them especially proficient.
You know the drill (no pun intended). Imagine this as a slow-motion movie: The camera focuses on the dental hygienist, who sits patiently, chatting idly with the patient in the chair. The camera turns to the patient, who appears nervous and impatient. The only other sounds you hear are the background hissing of the evacuation system, ready and waiting to be utilized, and the loud ticking of the clock. Tick, tick, tick ... “Time’s a’wastin’,” it appears to say. Cut and scene. How many times have you been in that slow-motion sequence? Waiting ... waiting ... waiting, because the dentist is in the middle of a procedure that he or she is unable to get out of, even for a few minutes.
Now, think about it from the dentist’s point of view. Same movie, different operatory. Mrs. Lane’s procedure is evidently not going as smoothly as anticipated. The dental assistant is working as quickly as possible to find a window of time for the dentist to graciously exit the treatment room to administer local anesthetic to the hygiene patient. The hygienist is already running minutes behind, because she didn’t realize Mrs. Wilson would be so sensitive during her appointment. Again, time seems to go by slowly, because the patient’s needs in the dentist’s chair cannot be rushed. The camera pans to the clock; it is now 10 minutes after the hygienist originally asked for local administration. The frame is frozen in time.
An all-too-familiar scenario? Local anesthetic is a necessity in the world of dentistry. It is a rare patient who will undergo a restorative procedure without being numb. Patients expect to be given an injection of anesthetic. They equate receiving anesthetic with modern dental care. Dentists usually expect to anesthetize patients unless they specifically request that none be given, which is uncommon.
Scaling and root planing are not the most comfortable dental hygiene procedures. Root sensitivity, difficult instrumentation, and inflammatory and hemorrhagic gingival tissues are also causes of discomfort. When we consider treatment planning for the operative or restorative patient, local anesthetic is usually requisite. Why isn’t this same courtesy of pain control afforded in the dental hygiene realm?
The delivery of local anesthetic has been added to the scope of dental hygiene practice slowly over the past 30 years. Currently, 35 states allow dental hygienists to deliver local anesthetic. As of August 2004, New York and South Carolina are the only states in which dental hygienists are able to give local infiltration and not block anesthetic. Proficiency is determined by coursework during the dental hygiene program or completion of appropriate training in an accredited continuing education setting. States vary in the amount of coursework, required minimal education, and necessity of examination prior to certification. Additionally, some states govern anesthetic practices by statute, some by rules.
When considering the dental hygiene treatment plan, patient comfort is paramount. If our patients are not comfortable, they may not return for further therapy. All patients differ in their threshold of pain. Some patients are more anxious than others. They may be more sensitive, with no apparent clinical indication. They may anticipate pain, hence not “sit still” or maintain a stable position during treatment.
When the situation calls for pain management, dental hygienists can provide both comfort and excellent treatment. Delivery of local anesthetic will assure patient comfort to a more superior level than topical anesthetic. Newer, injectible topical anesthetic gels that combine two amide agents, 2.5 percent lidocaine and 2.5 percent prilocaine, have been introduced into the marketplace. These function well and have their place in the practice of dental hygiene, but for the scope of this article, only injectible anesthetics with or without vasoconstrictors will be considered.
Local anesthetic offers a variety of benefits aside from pain control. During the course of treatment, patients may have bleeding due to accretions deposited on the teeth and the subsequent inflammatory response of the gingival tissues. Hemostasis is achieved via the vasoconstrictor in the anesthetic. By controlling the bleeding, proper visualization of the tissues and the working end of the instrument can be achieved.
Let’s go back to our initial scenarios. For the enhancement of the practice and proper management of the patient, the dental hygienist’s ability to deliver local anesthetic is crucial. Prior discussion with the dentist regarding the review of systems, health history, dental history, and possible contraindications will assist in developing the patient’s treatment plan. Including anesthetic in the treatment regimen will allow the patient’s procedure time to be uninterrupted. This is time management at its finest. After the initial assessment, taking of vital signs, and review of current status, the hygienist may administer the local anesthetic as indicated in the treatment plan. No waiting for the dentist. No walking from the hygiene operatory to the restorative operatory to exchange nonverbal communication with the dental assistant. When the patient arrives, the anesthetic protocol can be followed and administered. The appointment is managed more efficiently, and schedules are maintained. We move from slow motion to an action film.
On more than one occasion, patient status may change. Patients may be more sensitive to a procedure than the last time it was performed. There may be an area with deep furcation or abnormal root curvatures. Sometimes patients may experience sensitivity after periodontal surgery. Although the patient presents with a valid treatment plan, we may need to be fluid in our protocol. When the need for anesthetic arises, the hygienist should be able to discuss the developments and review all pertinent information with the dentist, then proceed with administration of local anesthesia to perform the scheduled tasks. Again, this will increase the patient’s comfort, decrease anxiety levels, and enhance the practice’s marketability. Remember, a happy patient will talk favorably about your practice. Dissatisfied or uncomfortable patients will not be eager to promote your office.
Whether by a concern for following procedures to the letter or just the method of delivery, dental hygienists tend to give local anesthetic less traumatically than their dentist counterparts. Speaking from personal knowledge (I graduated from the dental hygiene program at Loyola University and then went to dental school), I was trained in local anesthetic during my hygiene program. My experience came at a time when dental hygienists were not allowed to perform local anesthetic procedures in the State of Illinois, but since our program was in a private university, we were given the opportunity to have this expanded function added to our scope of education.
Between rigorous coursework and practical experience, the dental hygienist gains knowledge of the technique taught at a slower pace than in dental school. Slow injection techniques are easier to implement when the focus is on only one patient. On occasion, dental offices may have two patient treatment rooms running at one time. The dentist may tend to give the anesthetic solution too quickly, hence causing discomfort. Not all dentists do the rapid injection technique; some are very sensitive to protocols. As I explain to my patients, it is like filling up a balloon. If you pump air in too quickly, the material doesn’t have adequate time to expand, so it will break. If you inject anesthetic rapidly into the tissues, there is inadequate time for those tissues to be gently moved by the bolus of fluid being placed into “their space.” The tissue may tear under the forced fluid pressure. Since the hygienist only has one patient to focus on at a time, there is little need for speed.
An additional benefit of having the hygienist administer local anesthetic is purely from a practice-management standpoint. In a multichair setting, how many times is the dentist slightly short of time and running late? The hygienist could be available to administer local anesthetic for the restorative procedure, decreasing the patient’s waiting time. This builds team rapport, facilitates time efficiency, and increases patient satisfaction. It is a win/win situation for a dynamic practice.
Margaret Fehrenbach has a wonderful technique of anesthetic delivery that she refers to as “The Velvet Touch.” She believes in “making local anesthetic a standard operating procedure.” For patient comfort, utilization of local anesthetic is a key component in treatment planning. Her article, which appeared in the February issue of RDH, was a phenomenal overview of anesthetic and its proper administration.
Local anesthetic delivery to patients is an incredible asset to the substantial arsenal of abilities the dental hygienist brings to the dental practice. If your state allows hygienists to be certified in local anesthetic and you have not yet received this certification, make this your year to do it. If you were a dental hygiene graduate long ago, as I was, seek out training through local dental schools. And, finally, use that wonderful skill every day. Offer your anesthetic ability whenever the dentist feels it would be appropriate - not only when the doctor is running late, but when you have some time between patients and the restorative procedure has not yet begun. Suggest that your dentist allow you to perform local anesthetic on a variety of patient experiences to keep your skills honed. Don’t be afraid to ask; you will both benefit from it.
Every anesthetic experience is slightly different. We all know that the more we perform a given task, the more confidence we gain and the more we increase our performance level. Infiltrations are usually infallible. Maxillary blocks may run the risk of hematoma formation. Not every mandibular nerve is in the same spot each time. The more you do, the better you will become. The clear winner is the patient.
Dr. Stanley Malamed has indicated that dental hygienists are proficient in giving anesthetic. Being more attentive to detail, slower in delivery, more empathetic, and performing a more atraumatic injection, they succeed in advancing pain control. Local anesthetic for dental hygienists? Definitely. From so many aspects of patient care to time management, the administration of local anesthetic is a practice enhancer.
The author wishes to thank Mrs. Joy Alber, hygienist and educator extraordinaire, great friend, and amazing reference asset, especially on a blustery, winter blizzard day. Joy, you are the best.
Dr. Sheri Doniger has been in the private practice of family and preventive dentistry for 20 years. She is currently focusing on women’s health and well-being issues. She can be contacted at (847) 677-1101 or [email protected].
• Overman P. Controlling the pain. Dimensions of Dental Hygiene, Nov. 2004. http://www.dimensionsofdentalhygiene.com/ddhright.asp?id=386. Accessed: Jan. 22, 2005.
• Dental hygienist worksheet from the Occupational Informational Network. www.silvanetwork.com/job_seekers/oco/ocos097.htm. Accessed: Jan. 22, 2005.
• Fehrenbach MJ. Integration of pain control in a dental hygiene practice. Course description. http://www.amyrdh.com/cepresenters6.html. Accessed Jan. 22, 2005.
• Department of Labor and Economic Growth, SB 1009, Jan. 2002. http://www.michigan.gov/cis/0%2C1607%2C7-154-10573_11549-45194--%2C00.html (some proposed legislation with rationales). Accessed: Jan. 22, 2005.
• Northeast Regional Board of Dental Examiners. Manual for the local anesthesia examination for dental hygienists, 2003. http://www.nerb.org/pdf/Hygiene_LA.pdf#search=’local%20anesthetic%20for%20dental%20hygienists’. Accessed: Jan. 22, 2005.
• States permitting unsupervised practice/less restrictive supervision. ADHA Division of Governmental Affairs, Nov. 2004. http://www.adha.org/governmental_affairs/downloads/unsupervisedchart.pdf#search=’local%20anesthetic%20for%20dental%20hygienists’. Accessed: Jan. 22, 2005.
• Licensing requirements chart 28: anesthesia requirements for dental hygienists: composite. American Association of Dental Examiners. Jan. 2004, 15th edition.
• Local anesthetic administration by dental hygienists state chart. ADHA governmental affairs. http://www.adha.org/governmental_affairs/downloads/LocalAnthsiachart.pdf.
• Malamed S. Handbook of local anesthetic. Mosby 1997, 4th edition.