Dear Dr. DiTolla,

With how many ounces and for how long do you have the patient swish with Cyclone?

– Dr. Mitchel L. Friedman
Lincroft, NJ

Dear Mitchel,

Thanks for the Cyclone question. For those that don’t know, Cyclone is a powerful liquid topical anesthetic that we use in the office. My assistants use it with patients who are concerned about gagging prior to taking study models or final crown and bridge impressions, especially if they are full arch impressions. I have also seen them use it before an FMX on patients who are concerned with gagging to help them get all the necessary views.

On the hygiene side, my hygienists use Cyclone when someone doesn’t need root planning but still has sensitive prophies, and we’d like them to be more comfortable. I have also seen it used prior to perio probing a sensitive unanesthetized patient. We fill up a Dixie cup two-thirds of the way and ask the patient to swish for 60 seconds prior to spitting into a hand-held cuspidor. It gives good anesthesia on all oral tissue including the buccal and lingual gingival, the tongue and the soft palate. Cyclone is available from Steven’s Pharmacy at 800-352-3784 or stevensrx.com.

– Dr. DiTolla

Dear Dr. DiTolla,

This past week has not been great for me in obtaining adequate anesthesia on the mandibular molars using the block. I use the X-tip often, but it causes discomfort unless a lower block and long buccal are already somewhat working. I remember an issue of Chairside^® in which you mentioned you were planning to go to a course featuring anatomy that would help you with lower block anesthesia success. I am curious if the course proved valuable and if it has helped with mandibular anesthesia success. Also, do you have any recommendations as to good courses to take for improving the techniques for lower blocks? I find this part of dentistry the most frustrating.

– Dr. Julian Drew
Raleigh, NC

Dear Julian,

I feel your pain! I have experienced missing blocks in batches, too, and the more dentists I talk to the more I realize we are not alone.

The course I attended was designed to teach the Gow-Gates technique, which is a great way to anesthetize a quadrant. However, a couple of things got in the way of me becoming a Gow-Gates convert.

The first was the realization that the Rapid Anesthesia Technique (outlined in the last issue of Chairside) could be trusted to reliably anesthetize mandibular molars at a 99.9 percent success rate. I suppose this isn’t surprising, as this is the type of injection I always go to when my lower block isn’t working.

The second thing, which goes hand-in-hand with the Rapid Anesthesia Technique, was the discovery of the STA™ System from Milestone Scientific (Livingston, N.J.; stais4u.com). In addition to being designed specifically for PDL injections (like the one I use in the Rapid Anesthesia Technique), it also has the ability to give multiple carpules of anesthesia without removing the needle. That is a big deal for me! I always wondered why the standard carpule was 1.8 cc and no one could give me a good answer. I have heard Dr. Stanley Malamed say for years than one carpule is not sufficient for the average adult when giving a lower block!

When using the STA System for a lower block, I use the first carpule to painlessly get the 27-gauge needle to the hub. Without having to remove the needle from the tissue, my assistant exchanges the empty carpule for a full one. Many times I will have put a third carpule in while I continue to tap the tip of the needle against the bone. My success rate has gone way up since I started this technique, in no small part to being able to give more anesthetic with “just one shot” from the patient’s point of view. I hope that helps, Julian!

– Dr. DiTolla

Dear Dr. DiTolla,

Do you have a DVD on Profound topical (Steven’s Pharmacy; Costa Mesa, Calif.) and the injections that might follow for molars? Thanks!

– Dr. Tina Donahue
San Francisco, CA

Dear Tina,

Here is a link for the online video: glidewelldental.com/dentist/education/clinical-education-materials.aspx. It is the “Rapid Anesthesia, Reverse Preparation & Two-Cord Impression Technique” video. Also, I just did a photo essay detailing the technique in our Chairside magazine, which should be arriving in your office any day now. It can also be viewed online at chairsidemagazine.com.

– Dr. DiTolla

Dear Dr. DiTolla,

I keep hearing stories about it being difficult to cut off zirconia-based restorations. Is this true, and what is the best way to cut them off?

– Dr. Mike Hamm
Minneapolis, MN

Dear Mike,

Compared to cutting off a PFM, cutting off a zirconia crown (e.g., Cercon^® from DENTSPLY Ceramco [York, Pa.], 3M™ ESPE™ Lava™ [St. Paul, Minn.], or Prismatik Clinical Zirconia™ from Glidewell Laboratories) is quite challenging. I have cut many units off as part of our material testing at the laboratory, and I have learned a few things.

First of all, you better have the right burs on hand. I prefer the Zir-Cut™ burs from Axis Dental (Coppell, Texas), and chances are it will take more than one bur to get through the zirconia coping. I use the biggest tapered Zir-Cut bur Axis makes to help get through the tenacious coping.

Secondly, it helps to have an electric handpiece — there is no such thing as too much torque when cutting through zirconia. Cut with plenty of water and air to keep the tooth cool.

Lastly, be careful while putting pressure on the bur to cut through the coping. It is natural to lean into the bur since it is cutting so slowly, but you need to be careful since once you break through the zirconia you can go flying into the tooth.

Cutting off zirconia-based bridges is even worse, so for now I am sticking with PFM bridges unless a patient absolutely demands otherwise. I hope this helps!

– Dr. DiTolla

Dear Dr. DiTolla,

Can veneers be removed with a laser without damage and then rebonded? I have a patient whose original veneers keep popping off because they were not bonded properly at delivery. I have rebonded three of six and was hoping to rebond the remaining three veneers prior to her going off to college. If time permits a brief conversation, email and/or referral to a journal article, it would be greatly appreciated.

– Dr. William Lucas
Richmond, VA

Dear William,

Unfortunately, no. I know of no way to remove a veneer without destroying it, unless they fall off like the three you mentioned. The laser shatters the veneers into many pieces as it pops them off the teeth. It sounds like your best alternative is to let the other three veneers fall off, which admittedly is not a great option. Short of replacing the veneers, I am afraid I have no solution.

– Dr. DiTolla