In a previous blog, I wrote about how we use multiple flavors of topical in my dental practice and the positive patient experience this creates. In this article, we will look at the topical application technique we use to create maximum patient comfort.

I have often debated in my mind whether topical actually makes patients feel more comfortable when anesthetic will be injected. The scientific literature confirms it works great on the surface of mucosa, but it does not reach nerves under the gums or in teeth. From working with my patients, I know it makes a difference to them in how they perceive the injection feels. And there are studies in which patients overwhelmingly self-report that the initial pinch feeling of the needle entering the tissue is reduced after topical.

Before applying topical, thoroughly dry the area so the topical goes directly on the tissue you want to numb. If topical is applied to saliva, its effectiveness is greatly reduced. Ideally, let the topical work for 60 seconds but minimally 30 seconds prior to beginning the injection. My technique is to thoroughly dry the mucosa, swab the dry area with topical, leave the cotton tip applicator in place against the mucosa, cover it with a 2×2, and have the patient close to hold it in place while I watch the clock for 60 seconds to make sure I am not rushing.

To deliver anesthetic I use The Wand computer-assisted anesthetic delivery technology. While I am waiting for the 60 seconds, I explain to the patient that the anesthetic delivery may be different than they have experienced before and how the anesthetic will be delivered.

In my last blog, I wrote about the value of offering patients a choice of topical flavors. I can also fill some of the 60 seconds by asking the patient if the topical administered tastes like the flavor of topical they selected. As soon as the 60 seconds have passed, I immediately remove the 2×2 and cotton tip applicator and begin delivering the anesthetic.

There is good science behind some types of topical acting faster than 60 seconds, so you may want to do some research and select one of these types.

Even if you think topical is not effective, think about the placebo effect topical has on the patient. We are doing something to improve their comfort. We are actively doing something to make the procedure more comfortable and to help them through the process. I believe this act of caring has value to the patient that even exceeds the value of the numbing effectiveness reported in clinical trials.

I wrote this article 20 years ago for The PankeyGram, and it is still relevant today.  

As I walked into the room, the nurse was applying medication to a hand wound my grandmother had received from a fall a week earlier. My eight-year-old son, Tim, and I had traveled a thousand miles to say goodbye to my grandmother. At 89 years of age, her body was finally ready to give in to breast cancer, and her mind had fallen victim to Alzheimer’s disease over previous several years. 

I knew she would hardly know who I was, and if she did remember, the memory would be gone moments after I left. However, my father was an only child, and it was important to help him through these difficult times. My son also needed to learn about his roots. 

It was sad to see her unable to hold herself up in a chair, and she seemed so frail and weak. I said hello to her, and she opened her eyes enough to gaze at me. Her air-filled voice repeated, “I’m so tired. I’m so tired.” I held her hand and comforted her the best I knew how. I showed Tim to her, and she struggled out a sincere smile towards him. I told her stories about my family, my job, my tree we planted in honor of my grandfather, and how full and complete our lives were. It was as if I was trying to justify her life through the one, I was able to live now. 

We had brought some cinnamon cookies with us, and I offered one to her. Her dry frail hand reached for a cookie. She slowly nibbled on it.  

As you spend time with someone who is close to death and appears to have lost everything, one naturally thinks about how unimportant much of one’s life can be. I thought about the worldly parts of my life: the cars, the boat, my home, or ability to travel. I thought about the simple function of life: walking, running, feeding ourselves, dressing ourselves…. We have so much when we are healthy. Being a dentist, I reflected on how trivial teeth seem at a moment such as this. I pondered these thoughts as the first cookie disappeared, then another. 

My grandmother’s exhausted manner seemed to temporarily dissipate. She had found pleasure in nibbling the cookies. With her eyes closed and body relaxed, my attention focused on a collage of colorful photographs hanging next to her bed. Looking down at me was a picture of my grandfather, almost as if he approved that I had come. 

My grandfather was a righteous man who always felt it was important to do things the correct way. His home was not large, but it was perfect. Every part of it was neat, crisp, and clean. The saying “everything has a place and every place has a thing” describes how well he took care of his belongings. In the same manner, his and my grandmother’s health had been important to them, including their teeth. They both had most, if not all their teeth until the end. Even at the time of my grandfather’s death at the age of 84, he was scheduled to have some major dental work completed. My grandfather had been comprehensive about caring for his health and life. 

My grandmother was now working on a fifth cookie. I watched as she gently grasped it, lifted it to her mouth, bit and sighed with pleasure at its wonderful taste. Suddenly, I realized that because she had her own teeth at age 89, she was able to find some pleasure in what most would consider horrible existence. She could still eat and experience the pleasure of taste! What had seemed small in the scheme of things a moment ago had renewed importance. 

Many patients judge the competence of a dentist based on whether they are free of pain. However, a dentist’s true competence is measured by whether patients still have the ability to eat at the end of their lives. This can only be achieved with a comprehensive long-term approach to dentistry and helping people understand the importance of this type of care.  

No matter what you do in this world, you need to treat people in a personalized, comprehensive fashion. Now I look at every patient with the hope that when they have lost everything else, including their mind and most body functions, they might enjoy the ability to eat and the sense of taste. 

As her hand reached out, her fragile voice whispered to me, “May I please have another cookie?” 

L.D. Pankey, when talking about the assimilation of knowledge would say, “First you get it in your hands, then your head, and finally in your heart,” meaning objective understanding and competence was only a step in becoming a complete dentist. 
 
This, of course, was a hard message to hear as a young clinician, because after rapidly proceeding through Pete Dawson’s curriculum, purchasing three Denar articulators, and then going on to The Pankey Institute, I felt that I was ready to start practicing as a “comprehensive dentist.” 
 
But unfortunately, most of my patients and the citizens of my berg didn’t get the memo. Most of them just looked at me suspiciously, while others left. Fortunately, a few of them allowed me to perform my “complete exam,” collect study models and take 35mm slide photography. And then, I’d spend hours waxing up cases, and preparing a thorough written report containing all of my findings and recommendations. Finally, I’d make  a “case presentation” appointment and unveil the brilliance of my understanding of complete dentistry–about which I was sure the patient would be impressed and then have no alternative but to say “yes” to my plan for them.

From there, it was easy for me to visualize a completely organized schedule full of people who had said “yes,” and a projected level of income of my choice based upon how hard I wanted to work, and the number of hours I was willing to commit to being at the office. It all sounded so perfectly logical, and it all fits quite well with my left brain driven in the world view of dentistry.

But things didn’t work out that way very often. And since that time, I’ve have spoken and consulted with literally hundreds of dentists who’ve experienced similar frustrations. Many of them told me that they eventually gave up on their effort to try and practice comprehensive dentistry. Others took their practice to near bankruptcy via their determination.

You see, most of us missed Dr. Pankey’s message the first time we heard it, or even after the next two or three times.

We failed to recognize that the concept of complete care also hinged on how each patient felt, what they wanted for themselves, and what the solution would mean to them on an emotional level.

It was only after this difficult realization that things began to improve for me and my practice. The work of Carl Rogers, Bob Barkley, Lynn Carlisle, Avrom King, Sandy Roth, Mary Osborne, and many others, helped me to make some critical adjustments regarding how I was communicating with my patients–and perhaps even more critically– when.

Patient-centered dentistry is just that, patient-centered, not treatment centered.

This means we must first come to appreciate each person without imposing our beliefs and expectations upon them. This is a process that involves feelings first (their feelings not ours) before cognition–and before the discussion of any solutions. We must first be able to grasp the contextual meaning of the dentistry in each person’s life, and by so doing, better appreciate their perspective.

When we become better at doing this, we’ll feel that our knowledge has finally reached our hearts and the hearts of our patients as well. And it’s only at that moment that things will start to become easier and our patient’s behavior more predictable. It’s only at that moment that the “yes” to comprehensive dentistry will happen on a regular basis. 

How many of us have had a patient call who was really upset with us or our office?

The other day, my office manager came to me and said, “Mrs. Jones called and is super upset.” We had just completed an upper and lower reconstruction. Due to the complexity of the case, I opted to place the lowers in permanently, but I placed the upper in with temporary cement, in case there were any modifications that she wanted made prior to finalizing the case with permanent cement.

My office manager continued, “her new bridge is loose, and she said she is going to get an attorney because she paid a lot of money for this and it is already failing.” I told my office manager it was in with temporary cement, and the patient must have forgotten that I told her this, which in fact was the case.

I asked my office manager to bring her in immediately, and I would take care of it. Mrs. Jones presented, and I greeted her with a smile. I said, “I will take care of you immediately.” I proceeded to remind her that the upper arch was in with temporary cement, and she said, “Oh yeah! I forgot about that.”

After allaying her concerns and asking her if she had any difficulties over the last month, to which she said no, I opted to place the restoration on with permanent cement.

I reminded her that there was one other section, which still needed to be put in permanently, but I would do this in the future, since I was unable to tap it off at the time. (Sometimes, when the seal is really excellent, even temporary cement will hold very well.) I reassured her that all should be well and to always remember that “We’re here for you!”

This can be one of the greatest statements you can make to a patient. So often they feel “discarded” once their work is completed, and you “have their money.” Or they feel like they are being bothersome if they contact you to make any adjustments. They feel that any issues they are having will work themselves out, or they will just get used to it.

I remind them that we are always there for them and want to make any needed adjustments or corrections to the work we’ve done before any other problems arise. We want to be proactive in taking care of their issues and not be reactive. Often it is a very simple correction.

Letting a patient know “We’re there for you” can go a long way to creating a patient missionary and can be one of your greatest practice builders. “We’re there for you” is one of my favorite messages to convey to my patients, and I repeat it often.