Eugene R. Casagrande discusses
The Wand STA, an efficient practice builder and timesaver
What dentist does not want to save time during patient visits and build patient referrals? Answer: None, unless you are independently wealthy and practice dentistry as a hobby!
The Wand STA featuring the Wand handpiece (Milestone Scientific, Inc.), a computer-controlled injection system for the administration of local anesthetics below a patient’s pain threshold, was first introduced in October 1997 as The Wand. Although painless injections are achievable at times, predictably, painless injections for all intra-oral locations, in all patients, are an unrealistic expectation using a conventional hypodermic syringe. The use of the Wand STA now makes this a realistic possibility, but only if dentists are willing to enact a serious consideration of the way they approach the administration of local anesthetics.
Many clinical studies, articles, and textbook references have been published on new techniques and injections using The Wand STA.1-7 The purpose of this article is to help you complete the ‘paradigm shift’ necessary to properly incorporate the use of The Wand STA into your dental practice and to show you how it can promote better patient care, efficiency, and profitability.
The first and foremost part of a shift in thinking must be to admit that, in fact, dentists do cause discomfort at times with conventional syringe injections. Why do many dentists avoid giving palatal injections, even though they know there will be some discomfort when they complete a crown preparation palatally, pack cord, or place a rubber dam clamp? Many rationalise that the discomfort of these procedures is less than the discomfort of a palatal injection. Why should a patient experience any discomfort?
An early study with the Wand showed that over 90% of patients were at least somewhat bothered by conventional injections. After only a single exposure to an injection delivered with the Wand, these patients’ fear levels were decreased by 75-80%. This type of response from patients clearly demonstrated the strong preference for a computer- assisted injection versus a conventional syringe.
Attention to detail
Careful attention to technique details must be adhered to in order to realise the many advantages of computer-assisted injections over dental syringe injections. The ergonomic design of the pen-like grasp of The Wand handpiece allows the user significantly improved aim at reaching the target site successfully. The anaesthetic solution will dissipate in all directions once injected, so if the needle is closer to the target site, more anaesthetic will reach the nerve and less will go into collateral tissues. This advantage will result in not only the use of less anaesthetic from a pharmacological standpoint, but reduce the need for multiple injections, which can be a significant time saver.
The bi-directional rotation technique during insertion of the needle is another change that needs to be incorporated when one begins to use The Wand STA versus a conventional syringe.8 This rotation counteracts the deflection pattern that occurs with all mono-beveled needles, once again vastly improving the success rate of locating the target efficiently. Not only will this result in the need for less repeat injections, but also will achieve a much quicker anaesthetic onset time.
The mandibular block injection is the greatest benefactor of these improved techniques, because the target site is furthest away compared to other intra-oral injections. Instead of waiting five to ten minutes for onset of anaesthesia, lip signs of mandibular nerve anaesthesia will often occur in two to three minutes after completion of the injection.
Eugene R. Casagrande DDS, FACD, FICD graduated from and was on the part-time faculty of the USC School of Dentistry and practiced general dentistry in Los Angeles for over 30 years. He is the director of International and Professional Relations of Milestone Scientific, Inc.
Even a simple maxillary posterior infiltration can be more successful because of better ergonomics with The Wand handpiece. The ability to hold the handpiece closer to the needle improves the angulation towards the alveolus. The deflection caused by the musculature of the lips and cheeks, resulting in injection of anaesthetic solution into the facial tissues are greatly diminished with the pen grasp of The Wand handpiece.
The most common objection given by new users of The Wand STA has been that the injection takes longer. This is true, but the controlled flow rate and pressure/volume ratio are the main reasons that this injection is gentler. The paradigm shift must take place here in order to realise that the total significant time saving occurs in the onset of anaesthesia, not in the delivery of the solution. The bottom line is, ‘When can we pick up our handpieces to start producing dentistry?’ With a maxillary infiltration using The Wand STA, a dentist can typically start drilling within one minute after the injection is complete; with a mandibular block, within two minutes; and with an intraligamentary injection there is normally no waiting time. With fewer missed injections, a decreased need for multiple injections, and a quicker onset time, the slight increase in delivery time is more than compensated for.
Let us realistically think of the amount of time a dentist wastes in re-injecting after missed blocks, giving multiple injections or having to interrupt treatment to re-administer anaesthesia if a patient expresses discomfort. Let us also think of the time spent comforting fearful patients in preparation for injections. Once these patients experience a decrease in fear due to The Wand STA, you will find yourself ‘producing dentistry’ only a few minutes into the appointment instead of using the first 10 minutes of each appointment to ‘get through’ the delivery of anaesthesia phase.
With The Wand STA, more advanced specialised injections, such as the intraligamentary injection, AMSA9- 11, or P-ASA,12 can easily be delivered comfortably and can produce significant time saving if treatment is planned appropriately. The ability to administer an intraligamentary injection comfortably enables the dentist to create treatment plans that include bilateral mandibular dentistry. This can preclude the need for additional appointments to complete minor restorations on the opposing side of the mandible. The restoration of an isolated lesion on one side of the mandible or the bonding of a crown onto a vital tooth on the same day as involved treatment on the opposing side saves significant chair time in operatory setup, cleanup, sterilisation, etc. In most cases, an intraligmentary injection using The Wand STA can negate the need to administer the mandibular block with its collateral numbness to the patient’s lip, face, and tongue.
The Wand STA acts like an apex locator in using an innovative technology called Dynamic Pressure Sensing to inform the dentist that the needle has been placed in the proper injection site, the entrance to the periodontal ligament space, in order to give a successful intraligamentary injection. Using light and sound prompts, The Wand STA also informs the dentist if the needle has moved out of the injection site or if the needle has become blocked.
The use of a single AMSA injection will anaesthetise the central incisor to the premolar region. If you are performing veneer preparations or multiple restorative procedures on these teeth, then after about three to four minutes (including administration), you can begin the dental procedure as opposed to spending 10-12 minutes per side to administer individual infiltration injections. Another common scenario is found when a dentist needs to perform multiple composite restorations in the incisors/canine region. Instead of spending 10-12 minutes anaesthetising the incisors and numbing a patient’s lips, nose and face, the dentist can perform a single P-ASA injection to anaesthetise four to six teeth within three minutes without collateral anaesthesia. The use of an AMSA or P-ASA injection as opposed to multiple single infiltrations results not only in a savings in time, but a savings in the material costs of the anaesthetic as well. Because these virtually painless injections do not cause the collateral numbing of the facial structures (lips and cheeks), possible additional appointments for aesthetic evaluation of the patient’s lip-line at try-in visits may be avoided as well.
The elimination of the ‘numbing’ of collateral facial structures probably creates just as much goodwill from the patient as the painless administration of the anaesthetic itself. The most common inquiry from patients post-operatively has always been: ‘How long will this numbing (facially) last?’ Wouldn’t it be nice to hear instead: ‘It’s unbelievable that I had painless dentistry performed and that I can leave your office smiling and speaking normally!’
The ability to avoid this ‘numbing’ effect shows the patient that you are sensitive to their needs and desires. Have you ever had a patient call and cancel an appointment the same day because of a business or social appointment for which the patient states that they cannot be ‘numb’? If we could reassure them that we could avoid this ‘compromised’ state and still accomplish the scheduled dentistry, what would that mean to that day’s production?
Even if the clinical situation demands regional anaesthesia, the use of The Wand STA still communicates to our patients that we are doing everything possible to ensure their comfort. It shows that you are willing to invest in and learn new technologies to benefit your patients. Many of us use virtual reality eyewear, neck pillows, aromatherapy and other distraction or relaxation techniques to maximise our patient’s comfort during treatment. Shouldn’t we first address the most basic cause of discomfort in the dental office?
Since dental injections are universally feared to some degree, isn’t the perception that we are addressing this concern going to position ourselves as unique and caring? Any effort to go beyond the norm in achieving patient comfort during their dental visits will surely stimulate conversation in the workplace and home to increase potential referrals to our offices.
The Wand STA is one such device that gives us the opportunity to improve our patient’s dental experience in so many different ways. The real time savings is significant and the practice building potential in properly using The Wand STA is tremendous. Why stay satisfied with 160-year-old technology (the traditional dental syringe) and injections that are universally disliked by patients, when you can offer a state-of-the-art instrument and techniques that both improve the patient’s experience and allow for better time management?