In the medical world, there are two ways to go about things: there is the “book way” and there is the “hospital way”. The book way is how it is supposed to be done; the hospital way is the more realistic method that actually works.
Each hospital tends to develop their own methods, based on their resources and patient populations. Take for example, eye injuries. The book way states that a foreign body can be removed with a burr or the tip of a needle. My hospital has an ophthalmologist literally across the street so anyone with a foreign body is just sent over to the specialists. In the 14 months I have been with the hospital, I have never seen anyone remove a foreign body.
Another concept that varies from hospital to hospital is the use of dental blocks. At my hospital, we tend to prescribe antibiotics and oral pain medications. Although some hospitals routinely use dental blocks, they aren’t commonly used in my hospital.
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When I was doing my emergency medicine rotation, we didn’t really use dental blocks either; therefore, my knowledge on the performance of dental blocks was very little — but after watching it being performed once, I was hooked for life.
All it takes is one patient to change the way you practice medicine. For me, it was a patient who had such bad dental pain they were sobbing. In fact, they were sobbing so much that they were squeezing the hand of their significant other, and their significant other was almost crying, too.
The patient had already taken a lot of pain medicine before they came to the emergency department (ED), and it was evident that oral pain medications were not going to take care of this patient’s pain; this was when the attending decided that a dental block was in order.
After watching a supraperiosteal block performed, I was amazed at how simple and effective it was and I questioned why I had never done it before. I decided right then and there that I would dental block all patients that presented with complaints of tooth pain.
Before I embarked on my ambition, I decided to do research on the subject: dental blocks are commonly performed using a 1:1 ratio of lidocaine and bupivicaine. The lidocaine will allow for initial pain relief within several minutes while the bupivicaine allows for longer acting relief up to several hours. It is often suggested that lidocaine with epinephrine be used to cause vasoconstriction and prevent the spread of the anesthesia out of the target area.
More research indicated after the administration of anesthesia, the patient hold gauze to their face in that area to aid in keeping the anesthesia localized. Interestingly, nerve blocks can also be used to gauge how badly the patient is in pain and whether or not a patient is drug-seeking.
I have often times looked into the mouths of tooth pain complaints only to find beautiful teeth and gingiva staring back at me. If a patient is truly suffering from the horrors of mouth pain, he or she will often jump at anything that will offer relief, even if it involves having a needle stuck somewhere in his or her mouth. If a patient is not actually experiencing mouth pain and is drug-seeking, he or she will often think twice about the needle.
During my research, I was surprised at how few the contraindications were. The biggest contraindication is that you should never inject into infected tissue. Because antibiotics are often administered for tooth complaints, the risk of infection due to injection with a needle is very low. Because of the relatively small amount of anesthesia that is administered, almost everyone qualifies for the block.
One thing to mention is to always make sure you aspirate when you insert the needle to avoid injecting lidocaine straight into a vessel. After watching endless videos on the internet and reading various articles on the best methods to dental blocking, I decided I was ready.
Of course, as soon as I decided that I was going to start dental blocks, we went through a streak where we had an unusual dry spell of no one complaining of dental pain. Finally, a young man came in with tooth pain. When I asked him if he wanted a dental block, he enthusiastically agreed.
I drew up the anesthesia, found my anatomic landmarks and dove in, performing the supraperiosteal just as I had seen it done. I gave him gauze and had him press it on his face right where I had injected. After a few minutes I went back to check on the patient and the look of relief on his face told me it was a success.
In medicine, it is always exciting to find simple procedures that will cause immediate and immense relief for your patients. As for me, dental blocks have excitedly been added into my repertoire and I plan to use them on every dental pain patient that walks through the door.
Jillian Knowles, MMS, PA-C, is an emergency medicine physician assistant in the Philadelphia area.
