Do your ID blocks work all the time? How about your management of the dreaded ‘hot pulp’? As a part of the Back to Basic series this August, I asked Dr Pynadath George, who practices advanced surgical and implant dentistry, about dental hacks for success with every dimension of local anaesthesia in Dentistry.
Protrusive Dental Pearl: Give painless local anaesthesia (aside from topical anaesthetic, we know that already!) by massaging the mucosa and the lip with your index finger and thumb. Get just a few drops of LA first and give it a minute to work. Then you can go back in and deliver your anaesthetic much faster and the patient will love you for painless anaesthesia!
“If you want good success with the ID blocks, you need to look at and study the anatomy, even if it’s on a skull, and then relate that to your patient..” – Dr George
In this episode we discussed about:
- Is Lidocaine/Articaine enough to numb patients as a GDP, or do we need to stock other anaesthetics such a Mepivicaine? (15:09)
- Avoidance of Articaine for ID block in some countries – if that really necessary? (18:35)
- Shift of mindset with young dentists practicing defensively (20:38)
- Tips on achieving successful ID blocks (27:04)
- Hitting bone during ID blocks – do you HAVE to hit bone? Can that be harmful? (33:38)
- How to manage the dreaded hot pulp! (36:39)
- Moderate and advanced local anaesthetic techniques in Dentistry (47:31)
- Tips on getting painless palatal injections (especially on ultra nervous patients) (51:05)
Want to learn more? Check out this Advanced Implant Training by Dr George Pynadath
I hope you are enjoying this Back to Basics series of episodes! If you liked this episode, you will also enjoy Basic Implant Occlusion and Work Life Balance – PDP012 with Implant Ninja!
Click below for full episode transcript:Opening Snippet: As i gave the intra pulpal, I didn't realize the sound was being recorded but as i gave myself an intra pulpal, as i was reviewing back the videos all i could hear was myself grunting going 'ah because it was that painful I had to keep my mouth open while i'm numbing myself up through the pulp but honestly after that was done it was like magic i could you know i found all four canals, extirpate it, done...
Jaz’s Introduction: Hello, Protruserati! I’m Jaz Gulati and welcome back to another episode of the Protrusive Dental podcast. This month is back to basics. So it’s episode number two of back to basics on a huge daily conundrum which is getting success in local anesthesia like how many times in your career so far maybe you have, maybe you haven’t but i’m pretty sure you might have had this where you’ve gone through a bad phase or a bad patch of your ID blocks just not working or how to manage that patient with a hot pulp? That lower molar with throbbing pain and no matter how many infiltrations you give, you can’t get the patient numb or how about the fact that most of the anesthesia we use is just usually lidocaine or Articaine and that’s generally my experience, is there anything more to it? Now to answer these questions i’ve got George. His first name is far too complex from around so we shall call him Dr George, who is a very well known name in the UK. He actually does lots of advanced surgical dentistry, pterygoid implants, zygomatic implants, full arches that kind of stuff. He also does some general dentistry as well but that’s his real niche that he’s known for and along with that he does teach on very advanced local anesthesia techniques like how to give extra oral blocks for example or how to give anesthesia in areas where you’re not really taught at dental school but we’re gonna really bring it back to basics in this episode to go through how to get success from the more basic techniques like what are the the factors involved in getting success in anesthesia and right at the end we even cover the top tips in getting painless anesthesia for palatal, those dreaded palatal injections. Now it’s interesting when i was in Vietnam on my elective, I was with these dentists who are 25 years qualified and they were celebrating like having a reunion and we’re on this charity project in a village near Da Nang and it was a school. So were at the school. We were about to do restorations extractions and basically any sort of dentistry these children needed and there was a queue of children and before they’d have their treatment like for example a restoration or a tooth out, we would numb them up. I’ll never forget how these children were given id blocks so inferior alveolar nerve blocks before they had their restorations on their lower teeth for example right? But the interesting thing that the leader of the group he said that 50% of id blocks failed. That’s what he said “50% of ID blocks fail so let’s give these kids two id blocks each before they have dental treatment just in case they had this language barrier and they were actually having pain and they weren’t just expressing themselves so just to avoid that possibility of a child feeling pain” They gave two id blocks that always stuck with me i know 50% is quite a strong number and maybe it’s hopefully it’s not very true. I’m hoping that our ID blocks are more successful than 50% time but it’s an international issue that we all face on a daily basis. So the Protrusive dental pearl i have for this episode is a local anesthesia one and it’s very simple. If you want to give painless anesthesia, give the topical anesthetic enough time we know that already but the other thing is that when you start giving your infiltration for example you want to first very slowly just give a few drops, just a few drops and you will get these drops ever so slowly and you want to distract the patient the way i do this is by massaging the mucosa massaging the lip with my between my finger and my thumb as i’m doing it. So they’re really feeling this massaging rather than concentrating on the anaesthetic. So give very very slowly just a few drops and you come out give those few drops a minute to work and then you can go back in and deliver your anesthetic much faster and you can actually see the ballooning or swelling of the mucosa which you usually do that’s fine but it the whole point is that if you give the first few drops pain-free very slowly after topical anesthetic the patient i trust you has already had a painless experience and then the second or the main dose of anesthetic you can give much faster without hurting the patient. So hope you enjoy this episode back to basics with George on local anesthesia techniques I’ll catch you in the outro.
Main Interview: All right we’re going to call you Dr George because as you said in the before part when we’re offline and people struggle but just for the flavor do tell us your full name. how your mother tongue was supposed to pronounce it. So it’s Pynadath. I’ve heard all kinds but it’s Pynadath and that’s why everyone calls me George because people forget how to pronounce that and it makes me cringe every time i hear it pronounced incorrectly. We will definitely stick to George. Welcome to the Protrusive dental podcast, my friend. How are you? I’m good thanks. I’m very good thanks Jaz, i’ve not seen you in some time it’s been a long time since i i think we last saw each other and when i last saw Simran as well so your course you know you used to teach my wife, yes you used to teach my wife she was an undergrad at liverpool and she spoke very highly of you so that’s when you first came my radar maybe 10 years ago now and i remember you are as a dentist back in the day when i was a student i was going like on online on dentinal tubules and stuff and reading the thing that struck me most about you was that you’re a dentist who wasn’t afraid to speak your mind and i liked that and i hope it was a i wouldn’t say controversial but i enjoyed the fact that you were you’re calling a spade a spade so i think this this will make a very interesting episode. Actually i’m actually quite excited to cover the topics we’re going to cover today now with you coming on we could have spoken about so much because obviously i’ll let you do a formal introduction about the kind of things you do but in my eyes like you’re the pterygoid man you know anytime that you know anyone needs any fancy kind of implants no one else can sort it out, they’re going to send it to you as the implant guy tohave some sort of fixed solution. So that’s in my mind that’s who you are but please tell us about the kind of things that you do, where you’re based? So that those who haven’t heard of you can learn more about you. I don’t know where to start actually Jaz, i think most people i think you’re right i think most people know me as a person who does implants and sometimes people know me as a person who tends to just do complex implants, so pterygoids as you said i obviously do zygomatics, trans-sinus nasal lift as well as complex bone grafting so maybe not small grafts i’m kind of more associated to more complex work or it may not even be the work it may be a medically compromised patient. I’ll get referrals for that but i’m not sure if people are aware that i also do restorative dentistry so my background is restorative dentistry and i still like doing removable dentures, complete removable dentures i still like doing implant over dentures i think there’s a little bit of a bias to what you see on facebook and people know me for very set procedures but actually i do the full range and i still do the odd fixed conventional prosthetics so think fixed bridge work. I still do the other Endo single canal endo that is. I don’t touch multi-root. There are other people much better than me doing that i teach surgical Endo. What else, so i’ve got a bit of a range i think the only thing i don’t do is ortho grade multi-root canal endo i think that’s the only thing i don’t do but otherwise i do a fair range of oral surgery implants and restorative dentistry. I did appreciate that i did think like a lot of people would think that you just limited to one aspect but it’s great they do a bit of everything so i suppose it gives you a foundation that you’ve built on over the years. So what i want to know is what got you into the kind of advanced things that you do now? Who are your mentors? Who are the people that inspired you to do the kind of crazy complex surgical kind of stuff that you’re into now? Oh god you know what i probably fell into it by accident i went i started doing implants pretty early on after vt to be honest it was probably not a good idea to do that and then i ended up doing more of a formal course in Birmingham with Tatum. Hilt Tatum and i went down that pathway and on the course it was very much Eastman lecturers on the course. So there was Ben Aghabeigi who was a Eastman oral surgery consultant but on that course we also had someone called Richard Tucker who was a periodontist and he headed up i think at the time he headed up the the perio employing dents at the eastman i don’t think he’s there anymore and when i spoke to him about more perio surgery and more refining restorative work. He suggested i come down and do the msc restorative dentistry, the msc restorative dentistry at the Eastman. So i went down that pathway because i looked up to these guys but before that i also spoke to Callum Youngson. I’m sure you know who Callum Youngson is. He was still dean when Simran was a student in Liverpool. Really charismatic chap like the way the story of sim would tell me about him he just seemed like the coolest guy on earth. yeah yeah and you know i would echo that he is an unbelievable man he did a hell of a lot for the university i still look up to him he was one of the big inspirations to me as well as Ben as well as Hilt Tatum. There are a few other guys who have also mentored me as well there’s a guy called Vijay who’s also meliali like me who originally started off Ev dental.So i started Evo dental i think 2012/’13 and we started working together obviously i was already doing implants at that point but there’s been a number of people who have inspired me also people who have inspired me from a distance so not necessarily people who i’ve met but i used to speak to the late chamel tana who was a quite well-known implant dentist over in Romania. He’s passed away due to covid quite sadly but yeah there’s quite a few people who have inspired me but then also non-dentists and my dad. I always looked up to my dad he was a was or is an oncoplastic breast surgeon so his background was general surgery then went into breast cancer large reconstruction and then when it kind of the role changed and this title became oncoplastic breast surgeon but he showed me a lot, taught me a lot about suturing, surgical skills, assessment of patients. So i think that’s everyone really isn’t it? I mean that makes a lot of sense to me i mean that makes a lot of sense to me George because i often think how does one without following a maxfacts pathway get to raise these big flaps or or get to you know how many dentists will get to see a pterygoid in their lifetime right and then doing you’re in those areas of anatomy all the time so i was thinking where was your surgical real inspiration sounds like your father being a surgeon himself was a big role in that. Yeah absolutely i mean not just from a surgical point of view but also from the point of view you know i wasn’t born in the UK, i was born in India i went back to India for schooling i came back i think when i was 10 and when we came over in the 80s it was quite it wasn’t as you know as it was now there weren’t that many of us in certain areas of the UK, my dad didn’t know how to speak english so he came over as a medical doctor, had to pass the PLAB while not knowing english so he had to learn english at the same time. I think he failed the first PLAB exam then learn english a bit more fluently then sat it the second time round, passed the exam and then he early came to the UK so he could sit his FRCS, his fellowship in the royal college of surgeons, he did that and then he wanted to stay on really for both my brother and i are our kind of education, he felt at the time good education from the UK would be better than in India so he ended up staying here and i think it then came to a point where he realized he couldn’t go back to India, he had stayed out of the country even though we were going every year to see family he stayed up the country a little bit too much and adapted to his surroundings and i you know even when my parents go back now for long extended visits for maybe two three months at the end of the two months they’ve had enough they can’t cope with the heat, with the mosquitoes, with the service you know Kerala is a very very laid back state in India, it’s not you know it’s not a busy hustle bustle type of place and my mum when she wants things done, she wants it done. Yesterday and she can’t cope with the way the Indians do stuff. Amazing. I’d love to go Kerala one day is the place in India i want to go to. I’ve been to Delhi as you know my wife is from Delhi and i hate the place i’m sorry to offend anyone but i hate going to Delhi i like Mumbai but Kerala is definitely on the map for me. What a beautiful country i will be for state even i’d love to go Karela one day. Interesting you mentioned about your father not speaking uor not knowing english like my father when we came in the 90s from Afghanistan, my father he still doesn’t read the right english actually he’s just about to get away because he owns a corner shop you see so it’s interesting the sacrifices are our parents make you know to the next generation which is it really touched me actually. So amazing well let’s head to the main part of this episode which is the back to basic series we’re doing and it’s about local anaesthetic because as i was saying that because with you George we could have spoken about pterygoids, we could have spoken about all sorts of advanced things you do but i really do think as a first episode if you just get some foundations some most common things that or the most foundation thing that we need to be able to be good at as a dentist is painless dentistry and that’s where local anaesthetic comes in but it’s a daily struggle like we know lots of situations where we haven’t been able to successfully numb a patient. It happens to me not too often nowadays but still it does catch me up now and again like it does all good dentists. So let’s start with a very basic question, in my armamentarium i pretty much use two or three things it’ll be articaine, 90% of the time. It’ll be lidocaine when i’m doing an ID block and even then i’m doing less and less of those and then sometimes when someone says that they can have adrenaline, i’ll have a adrenaline b or alternative. So that’s it now this is i believe and correct me if i’m wrong George but i believe that this is the state of gdp’s generally. Are we missing a trick or do we is that all we genuinely need to get 100% success in anesthesia? It’s a really difficult question isn’t it? I wouldn’t say it’s the only thing you need but i would say 99.9999% that’s the only only stuff you need you don’t need anything more and it’s the 99.9999 percent of material i use as well articaine Lignocaine i of course have Citanest and you know all the other types of local with adrenaline free but i hardly use it and often it’s a case of educating the patient you know i do big procedures really big procedures and patients coming in saying they can’t have adrenaline in their local anesthetic it’s really going to compromise like massively it will compromise the work that i can perform and do and a it’s a case of re-educating the patient and explaining you’re not allergic to adrenaline, you’ve got adrenaline in the body you can’t be allergic to it, you may be sensitive to it but often that maybe the previous dentist who may have given an injection or infiltration or a block and they put some of that local into avascular you know region and they felt the palpitation mixed with anxiety, it may have set off a bad reaction. It’s very rare to have a patient who is truly allergic to anesthetics of course there are patients who are allergic to anesthetics often that may be the ingredients, the other ingredients, the preservatives within the anesthetic it’s not really going to be the adrenaline and if those patients are truly allergic you would know even before you see them because they’d know the full history and they would have got tested in hospital and all kinds because they would struggle with routine dentistry let alone some of the more advanced or complex stuff that you may have to do like extractions or root canals and things like that. So yeah generally i use Articaine and Lignocaine now if you imagine the stuff that we do we generally do full mouth stuff. We’re going into a much bigger type of surgery than your average general dentistry that you would expect in primary care and all we use is Lignocaine and articaine. I do use the odd time Bupivacaine and that’s more of a longer lasting type of anesthetic it can last for four to eight hours so really quite long. The onset takes a long time as well but most people who use bupivacaine use it as a pain relief. So maybe after removal of all four wisdom teeth or we’ve done zygomatic implants and we’re putting it as a post-op pain relief so the patients have a certain level of pain relief for when they get home and for a long period after that so yeah other than that, other than removal of all four wisdom teeth or a very deeply impacted wisdom tooth or maybe zygomatics, the odd time i don’t use Bupivacaine so it’s just articaine and Lignocaine. Good because i really didn’t know what you would say to this you know maybe you’d give like a recipe of 7 different 8 things that you you’d be using but i’m actually pleased to hear that you’re achieving great results with the stuff that we all have in our drawers so that’s amazing. Now this question i didn’t actually tell you in advance but just came to my mind the whole thing about avoiding articaine for id blocks. Now some countries that’s not a thing, in this country it seems to be a thing George, is it a thing? To be honest i don’t think so but and although i don’t disagree with using articaine in for blocks and it doesn’t have to be id blocks it could be blocks in other parts of the mouth. I don’t believe articaine is an issue i think the issue is normally down to trauma of the nerve because you see the same kind of complications with lignocaine or it could be certain preservatives. Now some countries who also have articaine like Germany or other parts of Europe. There articaine makeup as in the other ingredients or preservatives are slightly different but in reality i think the the real issue and the issue we’re talking about is more nerve damage or nerve related issues especially associated with id blocks i don’t think that’s due to articaine i think that’s due to trauma and the technique and so on however in saying that i still use lignocaine for my id blocks and the only reason to use lignocaine is because i know if anything goes wrong in the case and it goes in front of a medical or a dental expert. I’m sure there will be one dental expert witness out there who will on the side of prosecution put that forward as a problem but no other reason so it’s purely down to medical legal reasons. It’s true and actually i’d love for you to to share what you were telling me before we actually started recording about we were talking about the kind of things you do and you surprised me and said yeah it’s a little bit of general dentistry as well and i thought you limited to the pterygoids and stuff and then you said i was talking about the fact that i now in a situation where i work in Reading i’m trying to consolidate everything here not having to commute so much and you said actually don’t have that luxury because you’re traveling around the country, mentoring people, implants and advanced techniques but we need that we know we still need that someone there to help us hold our hands when we’re doing these advanced techniques and then you said something really interesting about how there’s been a shift in the kinds of experience that young dentists are getting can you just elaborate on that i really enjoyed that. Yeah i think obviously i used to teach as an undergrad lecturer i don’t do that anymore i still teach as a postgrad lecturer so i will teach half a day at Liverpool uni teaching the post grad the specialist trainees with the undergrads and i’d also say the post grads the guy you know the guys and girls coming through they may not have experienced the same amount of clinical work and complications as we would have done 20 years ago or even 15 year or 10 years ago so that means you know the number of cases they do not just at university but also at vt and not just that vt but also at you know dct one, two, three. I’m not sure if the newer generation are are seeing the same number of clinical cases as we would have on a day and even if they were to i see a lot of medics and dentists it’s not just limited to dentistry but medics and dentists are surgeons, medical surgeons and dental surgeons limiting the type of work they do because they’re practicing defensively which is a real shame so with the increase in medical legal or dental legal complaints and the lawyers out there, there’s a lot of us practicing defensively i mean a few minutes ago i just said i don’t use articaine for an id block even though i believe it’s fine because of the medical legal consequences i mean it’s a real shame so we’re all practicing defensively however you know my generation 10 15 years ago we could practice and get mentored in complex work knowing that if there were any complications the patient would be often very reasonable except the risks of the surgery even you know because they were told in advance and knew that you know it’s failed and we can either try and fix it or you know that’s it and while these days it’s really quite difficult i mean we’ve got consent which you know even though we consent to patients for whatever in the world even the work that i do a lawyer will always be able to find a hole in that consent paperwork and you know there will be dental expert witnesses who will always be able to find a hole in our clinical notes, it’s really quite tough for the new generation and i really feel for them i don’t know what the solution is for them which is why i also try and mentor as much as possible because it’s quite difficult to learn advanced and complex work without some sort of mentoring pathway i think that is a solution George i think it is finding it if you’re the young dentist who is feeling like you have a lack of clinical exposure or you are practicing defensively the only way out is through mentorship i think and i think it’s great that you do that and i think it’s great for the dentist to put their hands up and say yes i do need mentorship for this like we all know that comfort zones are a nice place to be but nothing ever grows in them so as even as a dentist i’m always looking at that next opportunity to go it’s just slightly now before maybe you make it but when you know in your colleagues that when you were learning you could have taken giant leaps out of your comfort zone i do feel now we’re taking baby steps but yeah but you know but it’s still good to take those baby steps out of your comfort zone. Yesterday i did my first ever in practice by myself i did my first ever and the patient knew was my first time and we hadn’t you know had this conversation beforehand stuff palatal functional crown lengthening case. I raised a massive for me massive flap upper three to three okay and my mentor for that was Amit Patel who you know very well. Which Amit Patel because there’s a couple of Amit Patel. The perio chip guy. The periodontist in Birmingham? Yeah. It’s okay so he mentored you for that crown thing case, did he? He did but the way we did it nowadays you know we we i sat down with the photos and he described the protocol to me he drew it for me, sending me a photo on whatsapp saying this is what i do then i sent him back to my thoughts let me exchange some voice messages and then he sent me some youtube links to watch from the university of michigan so it was a great like remote mentorship of that but i have enough surgical background that i was able to to know didn’t need hand holding on the day i was able to crack on with it but i’ve taken some photos i’m not gonna send it back to him and he’s gonna give me some feedback so we have that thing going on but again it’s a whole thing about taking small baby steps for for me and it’s taking me eight years to get this point where i think okay now i can do this kind of stuff you see. So this is the kind of stuff that we need, we need more mentorship and you gotta identify any way you can to to get that so i’m really glad you mentioned about you know whole defensive dentistry because it’s true it happens all the time. Now we’re talking about exactly id blocks and it’s interesting how you also practice defensively like i do because i also believe that in other countries they use articaine on blocks and it’s not an issue so i do tend to stick to lidocaine for my id blocks just like you for the same reason. Any tips you can give on success for id blocks? Interesting story when i was in Vietnam on my elective right? I thought you’re going to say in the army when i was in vietnam during the war or something that’s how that story started. There was this group of dentists who were from canada who were celebrating 25 years out of dental school and we were all doing this a big charity project so we went to like rural village in near Da Nang an hour away and we went to this school and we set up a base there we did all their restorations, fissure sealants, a lot it was a great experience as a student to see these experienced dentists are teaching us and and one thing is before these children had any sort of restorations done they’d be um in one queue they’d be given an id block so you’d go around give an id block to them okay then they’d go to the next queue and they’d be given a second id block George from the same place because the rationale of the lead dentist yeah these kids he was like you know nine ten years old okay and the rationale this was maybe 12 years ago right George or maybe less, maybe 10 years ago? So the rationale there George was and this is what he said really lovely guy great dentist but this is what he said to me he said 50% of all id blocks fail, so let’s give these kids two id blocks so by time they come to have their restoration because what they didn’t want is that their language barrier right? They didn’t want these little kids to be suffering and the language barrier and not be able to communicate, so what they did they just gave them two id blocks and then they sat down they had their dental work. It was like a whole factory operation just a cool story they’d tell you in terms of an interesting experience i had but that just highlights the fact that in general dentistry you know id blocks they can be a little bit hit and miss so where are we going wrong any tips that you can give us for success? Yeah so in reality the only time it goes wrong is it’s not because of it being an id block it’s because of the technique isn’t it?Often it’s a mixture of the technique and the anatomy and i don’t actually see anything wrong with giving two id blocks but on kids you know it’s quite difficult to give an id block on a nine-year-old anyway you know i’ve got a nine-year-old son, i’ve got a five-year-old son, i’ve got a twelve-year-old daughter that eleven-year-old sorry daughter and to give id blocks on that kind of age group that’s difficult especially if you can’t communicate although i’m sure the Vietnamese kids were rock hard they just had to get on with it and you know if their parents were there they’d probably get a slap if they messed about with the dentist helping them because i know i did in India, we were here you know it was quite harsh punishment if we didn’t sit still but yeah it’s technique isn’t it and i do see a lot of colleagues and not just dentists i’m talking about therapists as well maybe hygienists they’ll shy away from the id blocks because they feel oh you know what it’s not a reliable technique and so i’ll move on to other techniques like intra-ligamentaries for dentists, it could be other techniques like intraosseous although I’m not, i don’t think intraosseous is as commonly used but it’s a very, it’s an excellent technique but colleagues shy away from id blocks because they you know they feel they’re not very good at it and unless you’re doing more and more you won’t really understand the anatomy or the feel or where that needle needs to go i see sometimes colleagues often freshly and not just recent qualified but you know people who have been 10 years plus they don’t actually know where that needle and the tip is meant to go. So if you don’t know where the needle tip is meant to go you can’t visualize where you’re meant to be going with the id block and if you can’t visualize where you’re meant to go with the id block it’s always going to be hit and miss because you just don’t know what you’re trying to achieve so i would always say you know if you want good success with the id blocks you need to look and study the anatomy you know even if it’s on a skull and then relate that to your patient you know to a living patient. George on that note because one you know i know you’re gonna you’re gonna give us a guideline for success of course learn the anatomy but two things to reflect on what you said there on the patient in front of you because i had this thing in the beginning where if someone was overweight versus someone was super skinny that anatomy difference how it presents to you can can really throw you off when you’re learning the technique and and i think every dentist maybe has this George i mean correct me wrong but you sometimes go through a bad patch of your id blocks not working i certainly had it a few times in my career in my you know eight years so far where i just went through a bad patch where for some time my four id blocks in a row were just not successful i was giving three of them to get to work at that point obviously it’s definitely technique at the time and a lack of skill, lack of expertise but i’ve heard this from a few dentists speaking to them actually they just been through a bad patch sometimes and obviously it’s the same mistake that you’re making over and over again. So when that happens it’s important what you do next if you’ve got an issue you would, you should ideally then reflect on on what the issue is and how can you improve it so look at your anatomy books look at the skull look at techniques even you know this day and age we’ve got youtube and a whole bunch of things showing correct techniques of id blocks that’s what you should do sometimes colleagues will think you know what this isn’t working for me i’ll move on to another technique or keep trying three times or four times instead of looking at where they’re going wrong and it’s really having that thought process of where am i going wrong? How can i improve as opposed to not actually finding out what the problem is and that’s the most important message here you know everyone will have failures everyone but then if you have a failure what do you do? Are you the type that just doesn’t you know reflect and try and learn from it? or are you the type to learn from it improve and then move on going forward? So yeah it’s always a technique thing as well as anatomy don’t get me wrong you could have a perfect technique but then you’re assuming that the nerves are where they should be and they’re not always where they should be. So you know there could be a difference in anatomy. The other aspect is on the patient i mean you just mentioned a skinny patient and a patient who could be a little bit more larger in size and often if you’ve ever encountered patients who are really quite overweight you know they’ve got a large amount of fat in the cheek you may not get into the area where you want or the mouth opening may be limited or you know for whatever reason or you may need to actually advance the needle all the way into the hub actually goes just by the mucosa which obviously we’re taught not to do and that is scary when you have to do that but that’s the only way you’re going to get through that fat tissue yeah unless you’ve got extra long needles which you know they’re standard needles but i mean even with those kind of patients to get through the tissue you know the patients who can’t open if they have trismus or whatever you know have you looked at gow gates? Have you looked at akinosi? These are all variants of achieving the same outcome as an id block they’re just different techniques i’d probably say they’re moderate to advanced techniques they’re not your standard id blocks they’re not as commonly performed but if you’re doing more complex stuff or patients who are a little bit more trickier or differences anatomy i would look towards those techniques as welL. I mean the standard thing i do is if i have a block that’s not work my default thing that was always taught is just go again just maybe a sending me a higher and that’s my default is that an accepted practice i think that is i think if you go you know a little bit higher sometimes it depends on where you are right i mean if you go if you’re already high and you’re going highest well that’s not going to work but if it really depends on where you started off so you could say you could go higher you could go more further back in the mouth you could go you know more outside you know a bit more closer towards you or a bit lower down but then you won’t know if you need to go higher or lower or wherever you need to go if you don’t have a basis of where the correct anatomy should be in the first place if that makes sense? It does so i guess the main message here is If you’re going through that bad patch as described really hit the natty books again related to your patient, go back and watch those videos like you said then they’re widely available i’ll link a few in the blog post below for those who to click onto there’s some good ones that we can share for sure. Hitting bone yay or nay? do it i i was taught that but that was a long time. Nor do i by the way but i was gonna hear your what why you think? What you do? So you don’t hit bone because? Because theoretically whether it’s true or not but theoretically there’s a small deformity to the tip of the needle and as you withdraw it back out you can get more trauma and you know especially on a patient who may be you know on certain blood thinners or whatever it is that can cause more of an impact so i i don’t tend to do it and to be honest i’ve not done it for a long time my id blocks are pretty successful so if i needed to do it i would be doing it but i’ve not needed to do it yeah exact same reason so i used to do in fact when i was a new grad it was like i love the feeling of hitting bone because i know i’m there kind of thing it was a hip bone because that’s what we were taught right and then i stopped doing it because i’d seen a few slides i think it might have been Radoslaw is that polish implant guy what’s his name? Yeah Radoslaw. I can’t i know who you’re talking about. I think a lot of people know he’s quite well-renowned Europe though for implant dentistry and i believe he shared a a slide and showing this and used like gloves or something where when you have a needle versus when you’ve hit bone and it does damage that needle a bit and then that can cause more trauma so that’s yeah same reason for is why i don’t hit bone anymore so that’s some food for thought there I mean. That’s not to say i do use the tip of the needle to hip bone and other techniques so other more advanced local anaesthetic techniques so something my dad taught me was a thing in plastic surgery called hydrodissection where they use some sort of fluid to separate tissue and i tend to do that for not for blocks but for infiltrations especially if i’m raising a flap. I will ensure that the needle has hit the bone because at that point i know that the tip of the needle is under the periosteum and then as i inject it will lift the periosteum off the bone so even before i start cutting i know that periosteum is going to fall off the bone. That is genius. Yeah so it makes my flap raising extremely simple so anyone who’s done my courses or who i’ve mentored will often use that technique. It makes the local anesthetic more effective as well because obviously the local anaesthetic is close to bone something like articaine needs to diffuse through the bone so i know it’s not going to just be in the soft tissue well away from where i’m going to work as well so it depends on what i’m doing so i will use the needle tip and hit the bone for those kind of techniques but certainly not for id blocks and it’s not just id blocks obviously we’ve got infraorbital block and other blocks you know mental nerves and things like that i would never advance the needle to try and hit the bone around the nerve because i know it could potentially cause trauma. Brilliant i’m so glad you shared that, amazing. Now we were talking earlier now obviously in the theme of back to basics let’s talk about a really common scenario the hot pulp, the lower molar that’s in severe pain and it’s difficult to numb and i’ve been that scenario where you try everything you first try the id block then maybe you give a second id block then you give an articaine infiltration buccally then you do a bit of periosteal then you put some in the attached gingiva then you go a little bit lingual right? And you’ve like injected in every single site possible yet the patient is still not numb right? So you were telling me an interesting story about a patient in Reading just share that with everyone please don’t worry. Yeah i completely forgot you’re based in Reading i should have sent him to see you to have a go before he came to see me. So this patient had a hot pulp lower six your classic hot pulp lower six but it could also be upper molars as well it kind of you know it’s the same learning outcomes or points that we can learn from so a patient who had a hot pulp on the lower left six he had seen as dentist to attempt extirpation, dentists couldn’t get anywhere near this tooth. They had tried double id blocks infiltrations all the way around you know as you said lingual and intra-ligamentary and all kinds still couldn’t touch the tooth you know even the gentlest touch of the drill sent him off in pain and he saw another gdp in the same practice who had a bit more of an endo interest again same scenario multiple id blocks, multiple local couldn’t touch it. They gave him antibiotics, anti-inflammatories you know for a number of days i think it was for a week to try and see if it settled down, attempted again still no joy. So this is his third attempt, they then referred him out to endodontic specialist and again he went there the endodontist attempted still no joy. As his mum who was a patient of mine and i’ve treated for advanced restorative work reached out to me because she lived in the i think she lived in North wales you know explaining her son lives in Reading, he’s had i think it was coming up to three weeks of no sleep. He couldn’t work, it was really affecting his quality of life. Now she knew i don’t do root canal especially multi rooted teeth i certainly don’t do root canal but would i be willing to see him to try and help i said fine and i spoke to the patient you know checked medically fit well and all the rest of it and he came up to see me while i was working in a clinic in Manchester again same thing man, if you know when a patient comes to see you start to get a little bit cocky you know i can manage this patient, this is fine you know i’ll easily do it look at the work that i do anyway patient came in double id blocks, intra-ligamentaries, mental you know the full works lingual everything. Started to drill the tooth it was going okay i was getting you know i was getting much further than the previous dentist and then i got to the pulp and yeah again just couldn’t cope with this extreme extreme pain. Couldn’t go anywhere near it and unfortunately you do come across these situations it doesn’t matter how much local you’re using and i had already given an intraosseous as well. So i’d given him double id blocks, i’ve given him intra-ligamentary, had given an intraosseous which i don’t often do but i do that in the odd occasion still nothing touched it and you do get these kind of cases and and sometimes i think colleagues think well you know these people can do it and it’s magic actually it’s not. It’s a case of then setting the patient up and saying “Look this is not going to be comfortable whatever i do is not going to touch it but if you give me a few seconds i can sort this out for you but you will be in discomfort for the one maximum two seconds, are you okay with that?” Now this trap he was an adult you know he’s had pain for well over three weeks and we’d already got further than you know at this point i was already beyond the main pulp chamber i was going to the different canals he was more than happy to give it a go because he knew i’m doing the main bulk of work here and it literally is a case of putting that needle in the pulp chamber down those canals and for that one second maybe two seconds really you know pressing into that canal with the local anesthetic it’s not actually the local anesthetic that just does the work it’s also the pressure you know just ripping that nerve apart and at that point it’s fine and that’s essentially what i did so i got to the point of you know removing up to the pulp and that’s when you know he could feel the pain and that’s all i did, it was an intra-pulpal you know for that one or two seconds and once that was done he was fine, no pain and i could continue to carry on with a full extirpation put the calcium hydroxide down there, temporize and sent him away and you know he was in he was so appreciative over the following days that he you know gave a really nice hamper because it was the first time he could get sleep for you know for three weeks and that’s really you know if anyone’s had toothache that’s really quite debilitating. I have had severe toothache my friend my lower incisors, all four of them root failed, tooth fractured so we think orthodontics cause my lower four incisors to necrose so first time present first year of uni severe throbbing ache i was in tears, first year uni dental school in sheffield. We go up randomly to take a pa and this is huge apricot pathology all around my lower incisors. Anyway so yes i’ve definitely been there the worst thing ever but you know what i was smiling throughout that story you were saying George because i was actually expecting you to say he came up to see me and we got him numb through one id block and this is how i did it right? But i just love the human side that you showed there the real, the reality that you know what no matter what you do the hot pulp is a hot pulp okay and you get, you do the best you can and then it’s about getting that intra-intra-pulpal so i’m actually really pleased and i really appreciate the humility and sharing not a failure in any way you know you’ve got hamper, you got someone out of pain but in an ideal world you would have loved to given one id block and you know pull up your collars yep done that but it’s sometimes just not possible. So it’s great that you share that because a lot of young dentists listening we’re gonna encounter this scenario every six months or something on that or maybe more frequent if you’re emergency setting or you know whatever depending on what kind of practice you’re in but it’s a scenario we must face and that communication gem you gave George is key that you just have to say to the patient look this is a situation give me a little bit of time we will get you out of pain but it’s not going to be a joyful ride for those 10, 20 seconds in that scenario a painless experience unfortunately it’s just not possible. Yeah exactly and you really do have to sit the patient up. Give him the you know give them the options look this will take literally one to two seconds it will be uncomfortable but it will sort you out or i can just stop here put some leather mix or whatever where i’ve gone up to temporize you know give it another week or you know this patient had already been on a week’s worth of ibuprofen in advance just to settle things down before my attempt as well but you know it works you know there’s no real magic technique, it’s just a case of look this is what we need to do this is the reality we can either go down this path or this path and that’s it and you know i’ve had i’ve had really bad toothache as well so during covid i don’t know if you know this but during covid i had severe acute pulpitis from my lower left six and that was on good Friday during covid. Now i knew that i knew the guys in the liverpool dental school treating the covid pulpitic you know that service all they were all they could offer was extraction at that point because of covid. It’s very early on so dental treatment was very very much limited to take teeth out that’s it and i didn’t want to burden them i know quite a few endodontics i work with quite a few endodontics. I’m really really slick operators this was this was 7 p.m on friday because i thought i’d just persevere with it just got worse and worse and worse and by 7 p.m i couldn’t actually close my mouth it was that bad it was it was severely affected because i had to get my wife get the kids in the car drive to my practice. I’ve got a practice as well i put them in the waiting room and then in front of a mirror i had to give myself an id block i had to give myself i had to give myself an interligamentary.. -An id block not even like an infiltration? You gave yourself an id block? An id block, intra-ligamentary started to extirpate it was a hot pulp so as soon as i started getting into near the pulp chamber i experienced exactly what this lad I treated experienced which was acute pain you know as i was getting close and again i had to give myself an intra-pulpal and i’ve recorded this because i was using my phone as the mirror while i was treating myself amazing i know yeah and as i gave the intro but i didn’t realize the sound was being recorded but as i gave myself an intra-pulpal as i was reviewing back the videos all i could hear was myself grunting going because it was that painful to keep my i had to keep my mouth open while i’m numbing myself up through the pulp but honestly after that was done it was like magic i could you know i found all four canals, extirpated done. You obturated with sip being obtura you did your own crown prep I didn’t obturate. I did put a decent enough restoration over the teeth but honestly that night i had the best sleep that i’d had for about a week because this constant like acute pulpitic pain that was experienced you know it was coming in waves of pain you know that classic textbook you’d experience waves of pain that’s what i was experiencing and it was it was horrifying I mean i can’t believe you gave yourself an idea blocking. You did all that hats off to you and i was thinking in my head wait i couldn’t even bring yourself to do that but you know what i do remember the time when i had the severe pain we’ve only just been taught as entering second-year dental school at that point in Sheffield, we get early exposure to extractions and we’ve only just been taught how to extract your teeth and you know what i it crossed my mind you know that i have some pliers dental pain as you experience is the worst thing ever as we know as we experience. So it’s great you shared that story i’m actually amazing at that’s really impressive. So final question George i think a lot of a lot of great gems, a lot of varied gems we’ve covered today i think everyone find this really useful but just give us a flavor of you know i said to you earlier when we’re planning this episode like you don’t know what you don’t know and i probably have no idea that these advanced techniques even exist but what kind of moderate and advanced techniques do you do to to use utilize to be able to do the kind of density you do what do you teach on your courses in terms of technique wise? I suppose because of the surgical techniques that i’m teaching or implant techniques that i’m teaching require really good adequate anesthesia like ultra good you know a lot of the times we’re doing this just with local anaesthetic alone, we may have some Midazolam mixed in there but you know sedation is not a substitute for achieving local anesthesia. If the patient is not numb and they’re sedated it can actually bring them out of the sedation and make the procedure even worse because they’re not comfortable. So it’s really really important to have really good you know adequate anesthesia achieved and a comfortable patient and these kind of techniques that we we tend to use will be for example we we teach blocks to the posterior superior alveolar nerve blocks, for the middle superior alveolar nerve, the blocks to anterior superior alveolar nerve, the nasopalatine block or incisive nerve block, a greater palatine block which is really quite important for things like crown lengthening on the palatal aspect to even just reduce bleeding or harvesting connective tissues or lifting up large palatal flaps you need to now to you know adequately achieve anesthesia there mental nerve blocks of course but also lingual blocks. So these are the kind of range but then also extra oral techniques i think as dentists we’re commonly taught how to numb up the patient from the inside of the mouth and not from the outside of the mouth so i tend to do a lot of blocks from the outside. So if it’s an infraorbital block that i need to achieve i will do an extra oral infraorbital block if we’re doing work on the zygomatic, we will do extra oral blocks for the zygomatic region sometimes we do a full maxillary block so you can achieve a block for the whole one side of the maxilla in one go and you can do that through two methods, you can go through the greater palatine foramen and achieve anesthesia to the whole maxilla through that root or you can go extra orally into the Pterygomaxillary fissure and deposit the local through the extra oral approach. So these are quite you know a bit more advanced complex techniques. It’s not just a case of you get your normal dental local and start sticking things wherever you can do some real damage doing these types of techniques incorrectly as you can you know as you can imagine you know for example if you’re incorrectly taught or shown how to do an extra oral infraorbital block you can cause blindness to the eye so you can really do some damage but these are the more advanced techniques that we would cover in our courses. I mean maybe i’m just showing my ignorance but yeah i just didn’t appreciate them the role of extra oral blocks. I’ve never seen one being done before. I have seen and i’m on a course learning about it at the moment extra oral tmj sort of anesthesia and that kind of stuff that’s my kind of interest i’m developing but i’ve never seen it for maybe because maybe you see this on maxfacts positions and i didn’t hold one for long enough to see that kind of stuff but yeah you kind of forget sometimes in dentistry that there are extra oral blocks available and as well as all the others that you said so that’s really fascinating i can’t believe i didn’t ask you this my friend any tips on getting painless palatal um injections now what i do at the moment lately here i do at the moment i just put i just push really hard with the handle my mirror is there anything above and beyond that that i could be doing yeah i think that’s that’s probably the best way i would also suggest not just pushing really hard but making a little bit of vibration to it as well um so it’s not just pushing hard but pushing and and vibrating in a remote area where you’re providing the local anesthetic i would also while at the same time if you’re going to do that just deposit a few drops of anaesthetic first so you don’t give the full cartridge give a few drops then come out give it a minute or a minute and a half and then you can go back and then slowly give the local when you know when we’re talking about techniques i i you know i’ve seen dentists where they’re pressing really hard and giving the local but it’s everything isn’t it it’s not just pressing hard it’s also giving the locals slowly you know i’ve seen people just pump that local and often the pain is not just a needle tip going in it’s the expansion of the tissues and if you’re expanding the tissues very quickly and stretching it very quickly it will cause pain and why you know if you can avoid it why would you why would you not look to avoid it so i would suggest pressing hard vibrating on the handle of of your mirror remotely in a different area and then dropping a little bit of local anaesthetic in the palette you know a good a good small amount but enough to achieve uh a decent amount of anesthesia withdrawing giving it a minute or so then going back in and and slowly providing that local you know very very slowly the slower the better actually depending on what you’re doing if it’s a single tooth you’ve got all the time in the world the other alternative is you’re giving your buccal articaine first then after the buccal articane you can then go in politely because often the buccal articaine can go through the bone onto the palatal side but what i tend to do is i’ll give the buccal out articaine first and then i’ll numb up the crest with articaine and then once the crest is numbed up you can then slowly go down the palate while moving the mirror and doing all the other stuff i think in an ultra nervous patient that’s how i know you’ve got the luxury of as much time as you can yes i would be doing it i think that way as well buckle then papilla area then the palatal of the papilla area and then progressive that’s the the you know the way i’ve achieved the most painless palatal that’s the best way and i do well with all that as well. I think this has been a really valuable episode George but at least if you’ve got anything else to? Yeah i was going to say if you’re really looking at the the full process if you’ve got a patient who’s really nervous about numbing up um and you know they’re still not really suitable for or you can’t provide station for whatever reason obviously give the topical on the cottonwool roll on the buccal aspect once the topical’s been there for you know a good three four five minutes then take it out and you insert the needle by only one to two millimeters only within the mucosa not the gingiva, not the fixed gingiva but high up in the mucosa give you know again like the palate give a small amount of local wait for that to kick in then you can go back give it a little bit more local again with articaine, wait for that local to kick in this is all in the mucosa once that’s kicked in you should be able to anesthetize the the papilla and the attached and once that’s kicked in, you can then go to the papilla on the lingual or palatal aspect wait for that to kick in and then on the palate. So you know there is a progressive route now in saying that i would often do that in single teeth type work or maybe multiple teeth type work you know when you’re doing things like zygomatics and full arch and you know a whole bunch of more complex stuff often the patient may be sedated but generally you don’t have that time because the local anesthetic has a certain period of time that it’s effective for so once the locals in you know you you’re really starting a you know a bit of a countdown that that brings me on to another subject as well often colleagues will put the local in give it a few minutes and then crack on with the work and that’s not how things should be done you know you put your local in whether it’s an id block or infiltration that local anesthetic takes a specific time for it to diffuse into the tissues adequately and often more often than not dentists will start doing the work doing the treatment before that’s fully kicked in and ideally what you should do is you give your local check the time so for example you know the times 3 30 you finish your local i would then on my clock even for big mouth even for zygomatics more, so for zygomatics but i would start a timer i want 10 minutes to have passed before i start treating the patient, before i start cutting the patient, before i start drilling the patient you’ve got to have adequate time for that anesthesia to become you know to be effective because if you’ve not given adequate time it could still be in the soft tissues it may not have diffused into the bone into the nerves or wherever you’re going to you know you’re going to work so that’s a really important aspect of trying to provide successful local anesthetic. So a great point and often something that the easiest thing to skimp on is the time like if you’re in a rush or you’re trying to you know be you know the time is the easiest thing to just skip on and yeah a couple of minutes later you started but whenever i do have a a particularly nervous patient or someone with a history of being difficult to numb for whatever reason they’re the kind of patient i’ll be booking in just for anesthesia and then see a checkup while they’re waiting outside because they need that time because not often the technique is just about giving them enough time as well and you you’re so right with that George please tell us for you know if we you do lots of implant courses and stuff a lot of the the audience that listen and watch this are various various levels of their career what kind of a dentist, the kind of dentist who’s going to be learning implants from you and what kind of stuff do you have available for them what kind of resources courses do you run? I’m not sure where to start so i suppose most people know me for courses on more complex advanced techniques so generally my courses involve learning zygomatic implants and i’ve got a great, so for every course i have a great co-instructor so for zygomatics i have someone called Guy McClellan who teaches the zygomatics on that course i teach the pterygoids we both will teach the trans-sinus so that’s one course but it’s not just implant courses we teach bone grafting so big bone grafts we teach gum soft tissue grafting and you’ve mentioned Amit Patel. Amit Patel runs a course with me and we teach on cadavers because we feel pig’s heads aren’t really appropriate to learn true techniques you know pigs soft tissue or bone or anatomy bears no resemblance or similarity to a human so why learn from a pig when we have you know really good quality cadavers about these days. So Amit Patel heads up the soft tissue grafting course. We have Sanjeev Bhandari who heads up the apical micro surgical course and again that’s on cadavers. We have Sami Stagnell we’re talking about local anaesthetic so Sami Stagnell is a consultant oral surgeon he heads up the local anaesthetic course and again that courses on cadavers and we will be teaching more advanced intraoral techniques. So whether that’s Gow gates or akanosi or just normal good quality id block techniques or mental nerve block techniques or good quality infiltration techniques and then if if there are some advanced practitioners out there we will teach extra oral techniques to those colleagues and then of course i teach full arch implants and that’s a hands-on course so all of these courses are hands-on they’re not theory again i teach a hands-on course for large implants and so that’s not just for fixed bridges we have a new course coming out in next year that’s with someone called Harpal Chana who’s a restorative consultant based in London and that will be again another hands-on implant over denture course. So there’s a number of courses that i run quite a few i think next year there’s something like 24 courses they’re all hands-on busy. All with various specialists in their field teaching that subject but yeah so yeah. If you can just leave me your if you can email me the website because you know every episode i like to share what presenters have because a lot of time people resonate with what you said and they’ll usually message me on instagram saying, how do i get hold who? What’s the email address for this person? How do i get on to learn more from this speaker? So i know that what you spoke about today will it’s such a fundamental topic right and then those who may need help with grafting whatever may be looking for a course like yours so if you send me the website i’ll put on the protrusive website for those to see how they can learn from you George. So i really appreciate if you do that. -Yeah i’ll definitely do that i mean most people i think find me on facebook as implant dude but that friendship number has it has kind of maxed out so i’m a bit behind the times. I’ve just kind of started instagram i’m a bit rubbish at instagram but again you know i’m trying i’m on there as implant dude but the courses are under the website advanced implant training but i’ll put it up, i’ll send you a text where you can. Actually share it with me and i’ll stick it on protrusive.co.uk for everyone wanting to see Protruserati, thank you so much for joining me and George today i hope you found that as useful I did. George thanks so much for your time that was really awesome i think lots of from communication gems to patient management to a cool few stories in that which I enjoyed. Thanks so much for giving up your time today. That’s great. Thank you so much for having me on Jaz.
Jaz’s Outro: There we have it guys i hope you enjoyed that episode with George lots of stories exchanged there, lots of bigger themes you always like to focus on the bigger picture on these episodes. I hope you found value from that hope you’ll find that the next time you’re going through a bad patch of giving id blocks or the next time you’re struggling to anesthetize someone’s molar which is a hot pulp you’ll just relax and just explain to the patient what the scenario is what’s going on and you won’t always be successful. Hot pulps are one of those things you will not always be successful so don’t beat yourself up over it if you can subscribe on the youtube i really appreciate that and i’ll catch you in the next episode back to basics. It’s gonna be a huge one, it’s all about extractions you absolutely cannot miss the next episode it is gonna be probably the most profound episode i’ve ever done. So i’ll catch you in the next one with Chris Waith.