Paradigm shift: past-present-future
Update/Summary: I have been using the TNN technique consistently for 10 months in full-time practice. I use it every day. I start with it as primary anesthesia on every case on which I can possibly use it - this is different from when I only used intraosseous injection for patients who absolutely wouldn't get numb from IAN. I have fewer complaints of injection pain and post-injection soreness. My team promotes it, of their own volition. My patients talk about it with family and friends. I am able to do dentistry more efficiently and more comfortably, as a result of using TNN. There may be a modification of this technique, or another that comes along in the future to make it even less technique sensitive to do IO anesthesia. I'm not going to wait for another device that may be sold along with that; I am going to seize this opportunity to take extra good care of my patients, to be more efficient with my time and theirs, and to have something that makes my practice stand out from those who would wait around for their Schein or Patterson rep to tell them how to do dentistry. Past: I was first introduced to Dr. Greg Tuttle's anesthetic technique several years ago, when he brought it up in a brief conversation during a family event (Greg is my uncle). He is always eager to share and discuss the products, techniques, and advances that are currently working best for him (in fact, one of those discussions 21 years ago caused me to consider dentistry as a career path). At that family event, Greg told me in adequate detail how he approached this technique, and he encouraged me to try it out. I must admit, my first attempts at the technique were guarded, biased, and not very patient. First, I assumed that I was going to hurt my patient by sticking the needle directly in the attached gingiva, after only an application of topical. Therefore, I would generally infiltrate the area before trying. Secondly, I beaked the ends of my needles much too frequently because I would get impatient and apply too much pressure, trying to penetrate the bone. I thought it was just the force of the needle that pushed it into the space, so I did not get a good result from this approach. Thirdly, I don't feel like I retained all of the important parts of the technique in order to be confident that anesthetic was being delivered, and would be effective. I tried the technique, off and on, for about two years; I only used it 6-8 times over that period, and many of those were as a secondary technique to an ineffective IA block. Present: Dr. Greg Tuttle approached me again about trying the technique, because it had been extremely successful for him, and he was eager to find out if it was something that could be taught and reproduced by someone else. He gave me another tutorial, and I was attentive to the differences that I missed the first time. I got the proper equipment, briefed my team on the new technique, and dedicated an entire week to using the technique on any accepting patient that needed work on lower posterior teeth (I presumed that this area would be the most effective to know whether it was effective vs an IA). My team and I also recorded some patient testimonials, immediately after treatment during the first 2 days. Getting the feel of how much pressure to apply and how to know when a needle penetration is successful is the most challenging part of doing this. I would often be unsure of the bone penetration, but having delivered the proper amount of anesthetic under pressure, and being careful to watch that it wasn't just draining out somewhere else, I achieved profound anesthesia nearly every time with one injection. I was also apprehensive that the needle-stick directly in the gingiva after only applying topical would be extremely uncomfortable to the patient. I had it done on myself by Dr. Greg Tuttle, before I tried it on a patient. The pain and pressure were less than an infiltration or IA; my patients tell me that they like the technique for this reason as well as the limited spread of anesthesia, the more profound anesthetic effect, and that the numbness seems to wear off much more quickly. The most challenging part of the technique, as I continue to use it now, every working day, for almost a year, is to slow down and concentrate on following the steps properly and without excessive haste. I have to remember that the incredible amount of time I save by getting to work right away with profound anesthesia is worth a slightly longer injection time. I think that this method will only work consistently for the clinician who is willing to learn and practice the proper technique, and continue to renew the ability through case selection and focused study. The most valuable change that I made by learning the TNN technique is the paradigm shift that encourages me to use intraosseous infiltration as my primary mode of anesthesia, rather than blocks or traditional infiltrations. I believe this makes my injections more effective, safer, and more pleasant for the patient. It allows for much quicker onset, and the after-effects of anesthesia resolve much more quickly. Future: The most beneficial aspect of using this technique in practice, by far, has been the ability to immediately start treatment on lower molars, premolars, and canines with already-profound anesthesia. I have consistently beat my normally-scheduled treatment time for several fillings in a quadrant or crown preps by 30 min. I could now confidently shorten these appointments by 15-30 minutes and still stay on time, while still performing excellent dentistry. I still do not very often use the technique for upper teeth. I haven't had the confidence in my ability to perform the technique in the different positions and angles required vs the lower teeth. I also don't find much wait time when I anesthetize upper teeth to make a large difference for anesthesia onset. Therefore, I have stuck with doing infiltration for most upper tooth work. However, If I was to focus more on the benefit to the patient of a more concentrated numbness (tooth, gingiva, and bone rather than also cheek and face and eye), I would concentrate on using TNN for upper teeth more consistently. I see the benefit - I just have yet to make the modifications to my own technique. My patients rave about the benefits of TNN. They are much more comfortable during and after the procedures, and so far none have complained excessively about the gingival injection. The profundity of anesthesia has not always been perfect, but even on those cases where the patient could still feel something, he or she said it was slight, and I was able to deliver more anesthetic with the same technique. I believe that an IA or infiltration would have had the same incidence of sensitivity, because I had about the same percentage of patients need a "boost" of anesthesia after starting work on them. My patients are also excited about the fact that we are one of the few offices in the country, and perhaps the world, offering this sort of progressive anesthetic technique as a primary anesthesia method. With and without my prompting, they share this information with family and friends.