Offering Anesthesia-Free Minimally Invasive Dentistry

When considering opportunities to improve a practice's bottom line, clinicians should be exploring both those to increase revenue and those to reduce expenses in order to improve profitability. Practice leaders could consider adding expanded suites of services and referring out less dentistry but should not overlook efficiency gains that can be achieved within current service offerings while still ensuring predictable and quality dental care. A prime example of this is the introduction of "anesthesia-free restorations."

When indicated, clinicians should feel great confidence in attempting restorative care without anesthesia because this is reflective of the movement in dentistry toward minimally invasive treatment of early caries lesions.¹ There are several clear benefits for both patients and clinicians. Dentistry that is minimally invasive enough to permit restorative treatment without anesthesia preserves tooth structure and limits potential damage to the pulp. In addition, complications associated with the administration of anesthesia, such as the occurrence of paresthesia or medical emergencies, are eliminated.² The greatest and perhaps most obvious benefit for patients is being able to leave the practice at the end of treatment without being numb. They can quickly resume normal activities like speaking and eating that anesthesia often impedes. Furthermore, the shorter treatment times improve clinical efficiency, which allows practitioners to see more patients per day. Given that clinicians allow an average of 5 to 10 minutes for the administration and successful onset of profound hard-tissue anesthesia,³ consider how advantageous it would be to accomplish restorative care without waiting on anesthesia.

Case Selection and Considerations

The process of placing anesthesia-free restorations begins with proper patient selection. The dentist should feel confident in his or her ability to achieve an ideal outcome without causing pain for the patient. Likewise, the patient should feel equally reassured and encouraged to attempt the procedure without anesthesia. It is important for dentists to provide patients with education regarding this new approach using clear communication. This may require some practice prior to discussing it with a patient for the first time. Because research has shown that pain can be as much a psychological phenomenon as it is a physiological phenomenon, patients who present as extremely anxious or report experiencing significant dental trauma in their past may not be appropriate candidates for this technique.⁴

Beyond proper patient selection, placing an anesthesia-free restoration requires fully understanding the preparation requirements for the case in order to best manage pulpal irritation.⁵ It is well understood that a significant amount of the pain experienced during tooth preparations is a result of the heat generated by the handpiece as the clinician modifies the tooth structure.⁶ Although the use of laser techniques has been associated with generating less pulpal heat response, in the absence of a laser, a clinician can still create low heat generating preparations by using specific techniques and managing the heat with cool water. The success of such preparation techniques depends on the clinician's expertise as well as the depth of the preparation. In addition, a preparation's proximity to the pulpal tissue may also be a predictor of the amount of pain associated with the restorative procedure. Therefore, when considering caries lesions for anesthesia-free restoration, clinicians should attempt to identify those that are minimally invasive with limited extension into the dentin, which most commonly present as Class I and Class V lesions. Appropriate Class I cases include those involving pit and fissure discoloration with some widening of the fissures and localized areas of cavitation⁷ as well as lesions identified under failing sealants that demonstrate discoloration, voids, or vacancies.

Preparation Techniques

When performing an anesthesia-free procedure, proper isolation of the tooth is ideal to protect both the cheek and tongue from potential trauma. It is critical for the dental team to remember that an unanesthetized patient may feel discomfort solely from aggressive tissue retraction mechanisms.

Once the tooth is isolated, a fissurotomy bur is then used to open the pits and fissures for Class I preparations and the lateral walls for Class V preparations. The initial preparation follows the anatomy of the fissures or walls to best assess the depth and breadth of the cavitation. As the caries is removed, the preparation is extended laterally to expose the extent of the lesion and confirm a clean dentinoenamel junction. Next, using the bur in a slow sweeping motion with water spray, the preparation is extended to a depth that conservatively removes the caries on the pulpal floor. These slow sweeping motions facilitate removal of the deeper caries with less discomfort. The removal of pulpal caries can also be achieved with a slow-speed round bur of appropriate size, which will not generate as much heat as a high-speed bur. To protect sound dentin when removing caries in these anesthesia-free preparations, studies have shown the advantages of using a ceramic or polymer round bur.⁸

After the caries has been fully removed, the clinician can then proceed with his or her preferred preparation cleansing methods and bonding protocols. Keep in mind that vibration and pressure can create discomfort for the patient, so low speeds and light touches are critical to achieving success with this procedure.

Restorative Materials

Additional consideration should be given to the restorative materials chosen for anesthesia-free procedures. Oftentimes, clinicians prefer to use a flowable composite material in these conservative preparations. Flowable materials are available in a range of viscosities that make them easier to place and help them stay where they are applied. In addition, the materials selected for minimally invasive anesthesia-free restorations should provide not only a predictable long-term bond to tooth structure but also ideally a bioactive relationship with the oral environment.⁹ The anesthesia-free restorations shown in Figure 1 and Figure 2 were completed with a flowable nanohybrid composite (Beautifil Flow Plus^®, Shofu). This material was selected for its bioactive Giomer Technology, which releases and recharges fluoride. In addition, the variety of available shades enables natural-looking, long-lasting esthetic results. Materials with Giomer Technology offer the advantages of both composite resins and glass ionomers,¹⁰ and research has shown that they are able to withstand and perform in caustic environments for many years.¹¹ Figure 3 and Figure 4 show pretreatment and posttreatment views of two Class V lesions that were prepared without anesthesia and restored with a self-adhesive flowable composite restorative
(FIT SA^™, Shofu), which was also selected for its bioactive Giomer Technology. In addition, Shofu's resin composites, including their flowable options, are often 30% less costly than comparable resins on the market.

As dentists navigate today's challenging economic waters, many have to innovate and adapt for the survival of their small businesses. One approach is to look at the procedures being performed each day to see if there are ways to make them more efficient or to reduce the cost of materials or steps required for delivery without compromising the quality of the dentistry. Providing anesthesia-free minimally invasive restorations meets all of those requirements and can simultaneously win fans in a dental practice.

Jennifer Bell, DDS
Fellow
Academy of General Dentistry
Private Practice
Holly Springs, North Carolina