Hints From Howard :: Problem Solved

While in the service, one of my friends, a senior officer/dentist, once told me that if you practice long enough, you’ll learn techniques that you wished you learned in dental school. Being a long-time dental educator, I have taken my friend’s advice to heart by making sure I provide my students with what I refer to as “problem solvers”. You know, those pearls that you pick up in CE courses or when you are chewing the fat with another dentist about a problem you had, and lo and behold, they had a solution. In fact, I call these problems solvers that I send to the students “Hints from Howard” (Clever, don’t you think?). About once a week I send out a Powerpoint presentation to my students with a problem solver in response to a topic students don’t know or understand. If this information was presented as part of their core lectures, it would probably be forgotten because it is not connected to a real-life experience. The technique or concept would seem to be a throwaway, and not be a question on their final exam. Well, these are not throwaways, so here goes…

Is the tooth numb?
Certainly, this is a question for the ages. You have administered local anesthesia (usually I need to do this for mandibular blocks) and you want to be certain the pulp is anesthetized. The literature states that 15-20% of the time, profound pulpal anesthesia for mandibular blocks is difficult to achieve. Usually, when a patient has existing restorations in the mandibular posterior quadrant, I ask before administering local anesthetic, if they have ever had a hard time getting numb. If they say yes, I will use the Gow-Gates technique. For a Gow-Gates, you inject coming across the premolars similar to a mandibular block; but instead of orienting the needle at the middle of the fingernail of the gloved finger you are using to palpate the notch of the ramus, you inject higher at the top of the finger, parallel to the maxillary posterior plane. This problem solver is not about using a different injection, but rather for all local anesthetic administration. When I want to verify profound anesthesia, I test for pulpal vitality. While soft tissues are anesthetized adjacent to the tooth, you can poke an explorer tip into the attached gingival without a response. Profound pulpal anesthesia that would allow you to prepare a tooth with a bur or diamond in a high-speed handpiece needs a higher level of anesthesia. I test the tooth to be prepared with a cold test. If you get no response, then you usually have profound pulpal anesthesia.

Un-numbing a tooth
You have finished preparing the tooth or teeth and the patient is thinking about whether they can go back to work or maybe go out that evening because they are still numb. No one wants to drool while speaking or slur their words when talking to someone else. By now, most dentists have heard about or tried OraVerse (Novalar Pharmaceuticals). It is an anesthetic reversal agent. OraVerse (phentoalamine mesylate) is a vasodilator and reverses the action of the vasoconstrictor in your local anesthesia. You would use OraVerse one-to-one with a local anesthetic agent that contains a vasoconstrictor (up to two carpules). The way I use OraVerse, is when I have completed the preparation, before I place the restoration, I inject with OraVerse at the same site as where I administered my local anesthetic with vasoconstrictor. By the completed the restoration, the patient is getting their normal sensation back. Verifying occlusion is easier and my patients and other dentist friends have told me that their patients report regained feeling by the time they have driven to their next destination.
Although there is a cost-per-carpule from those dentists I know that have incorporated OraVerse in their practices, patients knowing they will have normal sensation back sooner have no problem with the additional fee. One very good friend, Dr. Michael Mann, doesn’t charge when he uses OraVerse because he has found that using this anesthetic reversal agent in his practice is a better practice builder than advertising in the Yellow Pages. The published research reports show that patients shorten the post-treatment local anesthetic effects by more than 50%. Where a patient may be waiting to recover feeling in their lower lip in two hours after leaving the office following a mandibular block, they completely recover in half the time. When I have restorations done, especially the mandibular posterior, I want OraVerse for me.

Loose bridge, how do you check?
Fixed partial dentures can come loose on one or more of the abutment teeth. Hopefully it is not a restoration that you did. Patients may come in with a chief complaint that the crown feels like it is moving, the tooth is more sensitive, there is an odor coming from my mouth or my bite has shifted. How can you check if the bridge is loose? If you can’t identify the movement of the bridge abutment easily, but the patient has a history of pain when chewing on the bridge and you are suspicious that one or more of the abutments are loose, dry the abutment crown that you think is uncemented (Figure 1). Push on the crown with a gloved finger or just occlude on the restoration. If the crown is loose, you will usually see bubbles around some of the margins of the crown as the saliva that has seeped into and under the crown is pushed out by the force of seating the crown under pressure (Figure 2). You may need to repeat this test to be certain, but it works most of the time.

Marking highly polished metal or glazed porcelain when checking occlusion.
I don’t know about you, but I have always had problems marking the occlusion of an all-metal (usually gold) crown, onlay or a glazed surface of a porcelain-metal, or all-ceramic crown with a precision articulating ribbon. I usually use Accufilm II (Parkell) because it is the thinnest articulating ribbon around. I still use shim stock, an extremely thin metal foil for checking the final occlusion. To use shim stock, you take a piece before trying in the indirect restoration to find opposing teeth in occlusal contact. I hold the shim stock with a hemostat, have the patient bite down and if the shim stock tape cannot be pulled out, it is being held by the occlusion of the teeth. Now place the restoration onto the preparation and recheck the occlusion with the shim stock with the teeth you just checked. If you can pull the shim stock out from between the teeth, the restoration is “high” in occlusion and needs adjustment. For highly polished metal and glazed porcelain, fine articulating marking ribbons don’t mark this very smooth and polished surface well. To get the Accufilm II to mark the occlusal surface, I take a Bend-A-Brush (any disposable brush will do, but not a microbrush) and I paint a thin film of petroleum jelly (Vaseline) on the articulating ribbon (Figure 3). Now, when the patient bites down on the Vaseline-coated ribbon, it will mark the occlusal surface in maximum intercuspation and in excursive movements (Figure 4). This technique works really well.

Howard E. Strassler, DMD, FADM, FAGD is a professor and Director of Operative Dentistry in the Department of Restorative Dentistry at the University of Maryland Dental School. His practice is located in Pikesville, Maryland.