A New Era in Pain Management: Non-injectable Anesthesia for Scaling & Root Planing Procedures

by Jo-Anne Jones, RDH

As dental professionals, we would all agree upon the importance of the regular removal of bacterial pathogens in order to minimize the risk of developing or aggravating periodontal disease. In the absence of regular care, chronic inflammation in the tissue leads to pathologic anatomic changes clinically detectable as periodontal pockets and alveolar bone loss.1 Our professional community is keenly aware of the burden placed on the body by a chronic inflammatory condition as the science continues to support the negative impact of periodontal disease on systemic health. A wide array of inflammatory cytokines, prostaglandins and destructive enzymes are the culprits of critical interest to both the medical and professional communities.

Periodontal therapy advances continue to emerge, even as periodontal disease remains the number one cause of adult tooth loss. Poor compliance and adherence to routine dental care may be to blame. About 40% of the population is apprehensive about dental visits, 20% is highly fearful, and 5% avoids oral health care completely. Getting an injection, having dental radiographs taken, the use of scalers and curets, and the sight of the needle were identified as the dental stimuli evoking the highest negative perceptions.2 The resulting failure in compliance remains the main barrier to achieving excellence in treatment outcomes. From a patient and practice perspective, the exposure to negative and feared stimuli must be reduced to increase adherence to treatment protocols such as periodontal therapy and maintenance. Furthermore, periodontal maintenance is a strong contributor to practice success and income flow.

Since the lack of compliance is a contributory risk factor, we then have the ethical responsibility of modifying this potential risk wherever possible. Chairside technologies have changed the way we practice dentistry and dental hygiene, tending to a commitment to a minimally invasive dentistry which affords greater patient comfort. Whether compliance with treatment recommendations is a causal or contributory risk factor, it warrants our attention. We are in a new era of pain management; an opportunity to accomplish clinical periodontal scaling and root planing while addressing the vitally important issue of patient comfort with a novel approach. The emergence of non-injectable anesthesia has gained attention and rapid integration into the chairside armamentarium.

Previously, the only Health Canada and FDA-approved anesthesia for dental procedures has been injectable anesthetic. (Figure 1) We now have a non-injectable anesthetic that delivers a degree of anesthesia that makes scaling and root planing comfortable for the majority of patients procedures. One of these products is liquid Cetacaine, a well known and efficacious topical anesthesia. (Figure 2)

Cetacaine is a topical anesthetic comprised of a triple action formula Benzocaine 14.0 %, Butamben 2.0 %, Tetracaine Hydrochloride 2.0 %. Cetacaine’s unique triple formula delivers a fast-acting, long-lasting prescription topical anesthetic at the required site. Cetacaine produces anesthesia of all accessible mucous membranes except the eyes.

The recent Canadian introduction of liquid Cetacaine was in response to a strong need for alternative anesthesia for scaling and root planning. The liquid form is the first non-injectable anesthesia to contain the long studied combination of active ingredients of benzocaine (14.0%), butamben (2.0%) and tetracaine hydrochloride (2.0%). Benzocaine is a fast acting widely used topical and local anesthetic with relatively shallow penetration. It is commonly used as a topical pain remover and is an active ingredient in many over-the-counter anesthetic ointments. It is complemented by butamben, an intermediate-acting and penetrating agent and by tetracaine, which is long-acting and more deeply penetrating. The combination of active ingredients allows for fast onset anesthesia in the periodontal pocket (30 seconds) and extended continuing activity (30 – 60 minutes).

Benzocaine is an ester, a derivative of the organic acid PABA p-aminobenzoic acid and the alcohol ethanol.1 Pain is caused by the stimulation of sodium entering free nerve endings causing depolarization of the nerve toward the central nervous system resulting in interpretation of pain. The esters of PABA work as a chemical barrier to pain stimulation by stopping the sodium from entering the nerve ending.

Cetacaine may be utilized for a number of different procedures including scaling and root planing, (Figure 3) laser procedures (Figure 4) and as a pre-injection topical. (Figure 5) The advantages and benefits are numerous including:

Reduced patient anxiety and increased compliance;

Rapid onset of anesthesia (30 – 60 seconds) and sustained effects (30 – 60 minutes);

Reduced chair time;

Reduced interruption in DDS schedule for administration of topical anesthesia;

Site specific and easy to deliver;

Clinician has control over amount dispensed – 0.4 ml may be used at one visit;

Minimal waste with unique luer-lock dispensing cap;

Ability to complete full mouth debridement supporting one stage approach to periodontal therapy;3

Affordability of product takes lead over competitors — approximately $3 for full mouth application. Cetacaine liquid is available in either a 14g (included in the kit) or a 30g bottle yielding 34 and 73 full mouth applications respectively.4,5

Product evaluators noted that the level of anesthesia was adequate for most patients and 88% rated it excellent or good and worthy of trial by colleagues.6 Dr. Tenenbaum, Professor of Periodontology, Toronto, Ontario states, “With Cetacaine, I have reduced my use of local anesthetic injections for recall and initial therapy scaling and root planing treatment by at least 80%. Cetacaine is really efficient.” As with any anesthesia, there are contraindications which may preclude Cetacaine from being utilized on certain individuals. Dental professionals are always encouraged to be prudent in their research and investigation of pharmokinetics, properties of active ingredients and contrainidications.

Cetacaine has an ability to enhance your dental practice by providing a non-injectable, safe and cost-effective anesthetic alternative for the majority of patients resulting in elevated comfort and increased compliance. Providing a positive experience has a very powerful and sustaining effect on practice success. OH

Ms. Jones is the owner of RDH Connection Consulting & Training. RDH Connection is a practice management and clinical training company delivering results-oriented solutions for today’s dental hygiene practice with a focus on delivering excellence and quality care. Ms. Jones remains active in clinical practice and also serves on the Advisory Board of Dentistry Today. Ms. Jones will be a featured speaker at the 2010 World Aesthetic Conference in the UK. She may be reached via email at jjones@rdhconnection.com

Clinical photography courtesy Dr. George Freedman. Oral Health welcomes this original article.


1. Guidelines for the Management of Patients with Periodontal Diseases. J Periodontol September 2006

2. Doebling S, Rowe MM. Negative perceptions of dental stimuli and their effects on dental fear. J Dent Hyg. 2000;74:110-6.

3. Mongardini, C. One Stage Full-Versus Partial-Mouth Disinfection in the Treatment of Chronic Adult or Generalized Early-Onset Periodontitis. Long-Term Clinical Oberservations. J Periodontol June 1999. Vol 70:632-45.

4. http://www.cetylite.com/cetacaine_liquid_kit.html

5. http://www.cetylite.com/pdf/CetyliteAGDHotProduct.pdf

6. Signif
icant anesthesia without injection for minimally painful procedures. Gordon J Christensen Clinicians Report. Vol 2: Issue 6, June 2009 p 1,4.