Testing the Tools

Buffer the Pain Away

BufferPro™

Premier®

premierdentalco.com

There are many ways to deliver local anesthesia, and every practitioner finds a style that they believe delivers the most “painless” injection. Few marketing phrases are as effective as a patient testimonial saying, “The shot didn’t hurt.” Absence of pain leads to absence of fear, which leads to more patients in my practice. My father was an early champion of bicarbonate buffering with the Onpharma system, and the literature support for the effectiveness of buffering anesthetic is solid. Neutral or basic pH anesthesia injections burn or tingle less than acidic ones, and they deliver more profound anesthesia at a faster rate. This occurs because a neutral pH allows for faster diffusion of anesthetic across cell membranes and is, therefore, more effective at infiltration delivery. The basic nature of sodium bicarbonate at an average pH of 7.8 balances the acidic nature of lidocaine that has an average pH of about 5. Articaine typically has a higher pH around 7.3 and so is already significantly closer to the physiologic pH of 7.4 that leads to speedy pulpal anesthesia. Since I primarily use articaine, I felt like I couldn’t justify the additional cost of buffering every anesthetic carpule when the effectiveness wasn’t as significantly different. Premier® and Septodont have partnered to deliver a new product that eliminates the need to use an opened bicarbonate cartridge quickly or on every anesthetic carpule because its BufferPro™ delivery system is single-use for a single carpule, and it has a two-year shelf life. You can store it at room temperature in your supply closet and dispose of it in a sharps container. The cost per carpule is about $3 compared to $5+ for others. To use, there are no calculations or additional hardware involved — simply open the sealed package, slip the bicarbonate delivery cartridge onto your anesthetic cartridge of choice, and press it down to push bicarbonate buffering solution into your anesthetic. It will mix on its own to some extent, but spin it around slowly a few times or give it some gentle shakes for good measure. You will notice that the plunger has moved back slightly, so be careful when loading it into your syringe in case it has pushed beyond the glass, since that can snag on the plunger. Once loaded, use immediately to avoid formation of precipitates. Personally, I like to keep BufferPro on hand for when I am going to block a patient that I know has a history of not getting numb easily. While I know that recent studies — like those from Jason Goodchild, DMD — have shown that articaine is perfectly safe as an initial block anesthetic, I still often block with lidocaine first. Using buffered lidocaine increases my successful block percentage to a similar rate as with articaine, and I have even noticed a faster onset time when buffering articaine. BufferPro isn’t an all-the-time product for me, but it is super easy to use and definitely effective enough that it has found an important role in my practice.

The Softer Side of Hemostasis

Ceramic Soft Tissue Trimmer

Eagle Dental

eagle-dental-burs.com

In most situations, when I cut gingiva with a handpiece, I have very little expectation that I will gain hemostasis quickly. Bur gingivectomy is quite common during crown preparations, and, when possible, I use a red stripe finishing diamond as I approach or go below the gingival margin to minimize tissue tearing and the prolonged bleeding that follows it. When I plan ahead to do a gingivectomy, such as with anterior exposure cases or implant uncoveries, I have used a scalpel or diode laser. However, I have found that tissue is significantly more likely to remain where I placed it after healing if I use a ceramic soft tissue trimmer from Eagle Dental. While they are expensive at $75+ per bur, they last a long time since they are only encountering soft tissue — these burs should not be used for contouring hard structures such as tooth or bone. Postoperative healing and bleeding is significantly less than with other strategies because the tissue has been trimmed so finely that capillary beds are less disrupted and there is minimal surface area affected that needs tissue regrowth. I prefer the football-shaped bur for working on the buccal aspect of a prep and for doing implant uncovery because the shape allows for a nicely sloped graduated bevel when directed at a 90-degree angle to the tissue. You can run the bur at full speed on a high-speed handpiece without worrying about it breaking apart, but I typically trim at about half speed to ensure that I’m not being too aggressive and am following a smooth path. Ceramic burs do not generate as much heat as metal or diamonds, so water-cooling is unnecessary for protecting the tissue from burns and should only be used if you need it for debris removal. The flame-shaped bur is useful for interproximal trimming or for following the margin around a prep in subgingival margin situations if I need more exposure or coagulation for a scan. While I still prefer my laser for quick hemostasis, I am becoming increasingly fond of conservative tissue preparations with ceramic soft tissue trimmers from Eagle Dental.

Easily Prevent OIL Formation

Liquid Strip

Ivoclar

ivoclar.com

Freehand composite sculpting and the associated bonding and curing processes are among the most technique-sensitive that general dentists perform. Especially when considering the cosmetic success of composite veneers or anterior restorations, I often feel like my surface finish is imperfect. Typically, I will address the finish and shine by overbuilding a veneer and then polishing it back to eliminate voids and any trace evidence of the oxygen-inhibited layer (OIL). Depending on your polishing system of choice, this may or may not be a time-consuming process. The only way to prevent the presence of the OIL is to create an absence of air, such as when a mylar matrix strip is wrapped around a Class IV. In situations where you don’t want the pressure of a physical strip affecting your recent contouring and sculpting work, you could utilize a glycerin gel like Liquid Strip from Ivoclar. This material is shelf stable at room temperature for multiple years and is easy to dispense with a viscosity similar to most etchants. It is a clear gel composed of glycerine, water and highly-dispersed silicon dioxide and aluminum oxide. Indications for use include as an indirect restoration try-in aid, a barrier for use in lab-etching processes, and a cover for preventing OIL formation during final curing of composites or resin cements. I am typically unsatisfied with my composite placement during veneer creation, so I significantly polish and recontour. Because of this, I usually am removing the OIL with a polishing system, even when I don’t use Liquid Strip. The OIL is important for increased bond strength between layers of composite because the OIL adapts readily to the new layer and allows for a copolymerization reaction at the interface. So if you plan to stack layers for color blending, anatomy and translucency, this product should not be used until your final layer has been placed. Also, if you are using a low-viscosity flowable, make sure to tack cure before placing Liquid Strip so that the materials do not mix. If you are using a chameleon-style composite, such as Omnichroma, and doing the majority of work with a single layer that just needs contouring, glycerine-curing can help increase the beauty, shine and hardness of the most-exterior layer of your restoration with less polishing, less post-cure reduction and less soft resin to clog your bur flutes. While I personally haven’t found a critical need for it in daily workflows beyond freehand veneering as an additional step after tack-curing, Liquid Strip by Ivoclar is a high-quality dental-grade glycerine gel and is really good at its intended purpose of preventing formation of the OIL and being easily rinsed away afterward.