Anxiety about visiting the dentist prevents many people from getting the treatment they need. Why do patients fear the dentist when the health of their mouth contributes so much to the health of their body? In most cases it can be traced back to previous dental experiences that were negative, discomfort with the tools and injections used, or outright needle phobia. Some patients experience so much anxiety because of the fear of pain from insufficient use of anesthesia. Topical anesthetics are used by dentists and dental hygienists for a variety of common dental procedures. They can significantly reduce patient anxiety, discomfort, and pain and can even sometimes be used instead of injected anesthetics.
Manufactured Topical Anesthetic Options
Topical anesthetics can be purchased from most dental suppliers as well as from compounding pharmacies.
Benzocaine 18%, Tetracaine 15% Gel
Names: Cetacaine, OneTouch Advanced, and other names
Dyclonine 0.5% Rinse
Names: DycloPro
Benzocaine 20% Gel
Names: HurriCaine, Kolorz Topical Anesthetic, and other names
Lidocaine 2% Solution/Gel
Names: Xylocaine or generic name
Compounded Topical Anesthetics
Generally the topical anesthetics made by a compounding pharmacy are much more powerful than anything that can be purchased through a dental supplier. As you can tell from the concentrations of these compounded formulations, the total anesthetic concentrations are higher. These anesthetics produce a more profound anesthesia.
TAC 20 – Lidocaine 20%, Tetracaine 4%, Phenylephrine 2% Gel or Ointment
Profound – Lidocaine 10%, Prilocaine 10%, Tetracaine 4% Gel or Ointment
Topical 12.5 – Lidocaine 12.5%, Tetracaine 12.5% Gel or Ointment
Dyclonine Rinse – Dyclonine 1% Oral Rinse
TAC 20, Profound, and Topical 12.5 are commonly compounded formulations. Profound can be made in different variations including Profound Lite (half the strength of all ingredients) or with the addition of phenylephrine. Phenylephrine is often added to topical anesthetics used in dentistry to prevent the anesthetic from leaving the treatment area – reducing toxicity and improving anesthetic effect. It is also known to help control bleeding.
Compounded topical anesthetics are not FDA approved. However it is important to note that no compounded formulation is FDA approved. All compounded drugs are made according to an FDA exemption outlined in either section 503A or 503B of the Federal Food, Drug, and Cosmetic Act (FD&C Act). That means that they are made within FDA regulations even though they do not go through the drug approval process. Due to the made-to-order, individualized nature of many compounds it would be overly cumbersome to require the approval process for every formulation. However compounding pharmacies must adhere to strict standards of cleanliness, standardization, and quality of ingredients and processes.
What Procedures Benefit from Topical Anesthetic?
Deep cleaning, sometimes known by the more fear-inducing name “scaling and root planing,” is a common treatment to reduce and prevent periodontal disease. It is an effective treatment for many patients to reduce pocket depth and prevent further regression of the gums. This cleaning process can be painful, especially for patients who already are experiencing bleeding when brushing their teeth. Local anesthetic injected into the side of the mouth being treated can effectively numb the area. However this anesthesia can last all day and make it hard for the patient to eat and do their normal activities. A topical anesthetic can be used instead of an injection in many cases where the periodontal disease is mild to moderate.
Pre-injection numbing is a term used to describe numbing of the oral mucosa prior to an injection of anesthetic. This is mainly beneficial for patients with needle phobia who are worried about the pain of the needle insertion. Dentists know that the pain of an anesthetic injection is not just due to the needle stick, but to the pH of the injected solution. However using a topical can offer a profound calming effect for a patient who is nervous about having needles in their mouth.
Orthodontists also can use topical to make placement of devices less uncomfortable. For example the placement of temporary anchorage devices (TADs) can be made easier with the use of a topical anesthetic like TAC 20, Profound, or Topical 12.5. In many cases, a topical is sufficient to numb the mucosal tissue before penetrating with the anchor.
Taking radiographs is another situation where patient comfort is essential to a good outcome. When the patient is comfortable it can prevent the need for multiple retakes. Distraction techniques can be beneficial but the easiest way to maintain patient comfort is usually to use a topical anesthetic. For patients who move around a lot or experience a gag reflex when taking radiographs in certain areas a topical anesthetic can be especially beneficial.
When Can Topical Replace Injected Local?
Dental hygienists know that many common procedures can be more easily done if only topical anesthetic is required. For example, deep cleanings require anesthesia but may not require an injected anesthetic in all patients. Applying a topical can make the cleaning process quicker and lead to a better experience for the patient. They will be numb but they do not have to worry about needles and an extensive numbing effect that lasts all day. Topical anesthetics are strong when applied but their effects tend to dissipate within an hour.
Topical anesthetics can also be used in cases where local injectable anesthetics are not used. For example, dyclonine rinse can anesthetize the entire mouth to prevent a gag reflex. The solution is swished around by the patient similar to a mouthwash and then spit out. The resulting anesthesia is sufficient for reducing discomfort from instrumentation, when taking x-rays, or for cleanings.
Topical Anesthetic Flavors
Topical anesthetics are applied directly to the oral mucosa and their taste can be very apparent. The bitter taste can be extremely unpleasant for some patients. The majority of both manufactured and compounded topical anesthetics are made with an added flavor. A compounding pharmacy can offer a wide range of flavors including grape, strawberry, blueberry, bubblegum, cherry, and more at the dentist’s request. TAC 20, Profound, and Topical 12.5 can all be made in multiple flavors. Typical over-the-counter numbing products usually also have flavor options.
Allergic Reactions and Safety Considerations
Allergic reactions to topical anesthetics are rare though possible. It is more likely for toxicity to occur with misuse or overuse of the topical which leads to a high plasma concentration of the anesthetics. If an allergic reaction is noticed it is important to first remove any topical anesthetic from the application area. Before using topicals, dentists should ask patients if they have a known allergy to amide anesthetics as this type is more likely to cause a reaction. Lidocaine is an amide anesthetic
Toxic systemic levels of anesthetic can occur if it is applied over too large an area at the same time, if too much anesthetic is used, if a large quantity is swallowed, and in other cases of misuse. Initial symptoms of toxic levels of anesthetic include heart palpitations and excitation and can escalate to the patient becoming unconscious. Methemoglobinemia is a rare condition that results in a bluish tint to the skin and is most often caused by prilocaine or benzocaine. It may be accompanied by a shortness of breath, headache, and dizziness.
Sloughing of tissue can occur if a topical anesthetic is left on the oral mucosa too long. Usually 2 minutes is sufficient to produce anesthesia. After that the anesthetic will start to irritate the tissue or migrate outside of the treatment area. Using more anesthetic than is needed will not produce a better effect.
Compounded Topical Anesthetic Instructions
The first step before applying a compounded topical anesthetic like TAC 20, Profound, or Topical 12.5 is to clean the treatment area and make sure it is dry. The topical gel or ointment should be applied so it just covers the area – it should be applied sparingly and not outside the area being treated. Any technique you have to prevent migration of the topical anesthetic to the throat or other areas should be used. Within around 2 or 3 minutes the topical should be rinsed off completely. If left on too long, topical anesthetic can cause sloughing of tissue. A powerful anesthetic effect should occur within only 5 minutes and last up to a half an hour, diminishing up to an hour later.
Another technique that some offices use is to apply a topical anesthetic gel or ointment to gauze which is held against the treatment area. This may help reduce migration of the anesthetic and keep the product contained where the gauze is applied. With any technique, the entire mouth should not be anesthetized at the same time. It is better to anesthetize one quadrant of the mouth and then move to the next area if required for the procedure.
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