Topical Anesthesia in Dentistry - Improving Patient Comfort

TOPICAL ANESTHESIA
IN DENTISTRY:
IMPROVING PATIENT COMFORT
AN INDEPENDENT CE/CME STUDY COURSE

FOR DENTAL PROFESSIONALS
By
HAZEL KERR, RDH, MS
File Name: amelogo and usage.eps

As of Date: 04/2004
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TOPICAL ANESTHESIA IN DENTISTRY ARCMESA EDUCATORS
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ABOUT THE AUTHOR
Hazel received her Associate of Science Dental Hygiene degree

from Palm Beach Community College and later earned her
Bachelor of Science and Master of Science degrees from the
University of North Florida in Jacksonville.
Ms. Kerr has fourteen years of experience in private practice and
twenty-five years of experience as a Dental Hygiene educator in
both Florida and Mississippi. As a faculty member, she specializes
in courses such as Oral Anatomy, Dental Radiology, Clinical Dental Hygiene, and
Community Dental Health. More recently Hazel is teaching online courses in
Advanced Ethics and in Leadership in Dental Hygiene in the Baccalaureate Degree
program at St. Petersburg, Florida.
Hazel received the Outstanding Faculty Award in 1997 and reached the capstone
of her full-time career in education by serving as the Program Director of Florida
Community College’s Dental Programs. In 2004, after early retirement from full-
time work, she earned her Online Professor Certification. Hazel currently develops
and teaches online dental hygiene courses for two colleges in Florida.
Recognized as a leader in her field, she has served as an officer in her professional
association at both the local and state levels and is currently involved as a Florida
delegate to the national association. Hazel was appointed to the Board of Directors
of a prominent health agency in Jacksonville in 2001-2003 and has also been
privileged by having a student award named for her. The “Hazel Kerr
Professionalism Award” is presented annually to a student graduate chosen by the
faculty at the Dental Hygiene program in her community.
AUTHOR’S STATEMENT AND ACKNOWLEDGEMENTS

This course is a review of current information published in the dental literature on
topical anesthetic preparations, their characteristics, and use in pain control for
dentistry. The author would like to acknowledge Dr. Alan Fetner, Periodontist, and
Dr. Darryl Field, Periodontist, of Jacksonville, Florida, for their valuable suggestions
in editing the first draft of the manuscript.
© 2006 – ArcMesa Educators, LLC/Hazel Kerr

All rights reserved. This CE/CME course,
or any part thereof, may not be duplicated
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or reproduced without the permission of the authors.
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COURSE OBJECTIVES
Upon successful completion of this course, the participant will:
1. Compare the use of topical anesthesia with four other methods of pain
control in dentistry.
2. Explain why topical anesthesia has varied rates of absorption in different
areas of the mouth.
3. List and compare the chemical agents found in topical dental anesthesia.
4. Identify the precautions for preventing toxic reactions and identify the
chemical agent that is most toxic.
5. Compare the properties, concentrations and delivery methods for a variety
of topical dental anesthetic products.
6. Describe the step-by-step techniques for applying topical anesthetic agents
to oral tissues prior to injection and during scaling procedures.
By reviewing the course content and completing the post test at the end of this continuing medical education
activity, you are entitled to receive 3 credit hours if you achieve a score of 70% or greater. Estimated time to
complete this activity is three hours.
ArcMesa Educators, LLC is an ADA CERP Recognized Provider for Dental

Continuing Education, an Academy of General Dentistry Accepted National
Sponsor (#90564) for FAGD/MAGD Credit, a Florida Board of Dentistry Provider
(#BP-00246), and a registered provider with the Dental Board of California (RP
4365).
ArcMesa requires disclosure and resolution of any real or perceived conflict(s) of interest regarding the content or
subject matter of this activity. Hazel Kerr has indicated she has nothing to disclose relative to this activity. ArcMesa
Educators, LLC staff has nothing to disclose relative to this activity.
Date of original release: June 2006 Medium used: Monograph

Date of most recent review/approval: N/A Expiration Date: June 2009
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TABLE OF CONTENTS
ABOUT THE AUTHOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i
COURSE OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ii
TABLE OF CONTENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iii
COURSE INSTRUCTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iv
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
USES IN DENTISTRY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
SUPERVISION LEVELS FOR DENTAL AUXILIARIES . . . . . . . . . . . . . . . . . . . . . . . .4
EFFECTIVENESS ON TISSUE TYPES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
DELIVERY SYSTEMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
CHEMICAL AGENTS USED FOR INTRAORAL TOPICAL APPLICATION . . . . . . .10
SPECIAL PATIENT CONSIDERATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
TOXICITY, ALLERGIES AND OVERDOSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
APPLICATION TECHNIQUES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31
COURSE EXAMINATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35
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COURSE INSTRUCTIONS
FOR INTERNET AND HOME STUDY PARTICIPANTS!

• Read the course material carefully. Internet participants may study online or print a copy
of the course for off-line study. Start when you are fresh and take your time.
• This course includes an "open book" exam. You may review the text at any time as a learning
aid or to check the accuracy of your responses before submitting your completed exam.
• Be sure to answer each exam question; blanks are counted as incorrect answers.
A minimum score of 70% is required for successful completion of this exam.
• The processing fee for this course entitles only one person to receive a certification of com-
pletion. A history of courses taken and certificates earned can be found in your "Member
History" section of our online program and/or available traditionally by contacting our cus-
tomer services department.
• After successful completion of the course exam, Internet users are returned to their
"Member History" page where you may view and/or print your Certificate of Completion.
Please note that each certificate is uniquely identified with an ArcMesa "Certificate ID
Number". Numbers may be used for certificate validation by various authorized organiza-
tions. Mailed or faxed exams and evaluations are processed within 48 hours of receipt.
Certificates are posted for return by 1st Class U.S. Mail the next day.
• If you fail an on-line exam, you may retest immediately by selecting the "Repurchase Exam"
link found directly across from the course title within your "Member History" page.
Note: Traditional users will be notified by ArcMesa and may retest upon purchasing a
new exam.
• Please complete the brief course evaluation form at the end of the exam. Your responses
and suggestions will allow us to upgrade our procedures and course materials to serve you
more effectively in the future.
PROBLEMS OR QUESTIONS?
If you have any questions about your examination or your Certificate of Completion, please call
ArcMesa at 1-800-597-6372
Your Certificate of Completion will reflect the following data:
Date of completion, name, profession/occupation, license number (if provided), course title,
CE/CME hours awarded, provider name and approval number (if applicable). Internet users receive
an online grade report. Home study users may request a grade report.
Thank you for choosing ArcMesa Educators!
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INTRODUCTION
Topical anesthesia is defined by Stedman’s Concise Medical Dictionary as “superficial

loss of sensation in conjunctiva, mucous membranes or skin, produced by direct
application of local anesthetic solution ointments, or jellies”. Sulcular anesthesia is
a term used in this course to refer to local dental anesthesia induced by application
of a topical agent in the gingival sulcus.
Where does topical anesthesia fit into the big picture? It is one of the five methods
of pain control available in dentistry:
1. Psychosomatic pain control is a technique you use all the time. It is the
soothing voice you use with your patients, you reassure them, you may
touch their arm or shoulder, you smile, you have a calming effect and your
are good at it.
2. Another technique is Local Anesthesia, a critical component in providing
pain management. It works by preventing the nerve impulse from reaching
the brain. Local anesthetic also provides hemostasis during the procedure.
Over 50% of states in the U.S. allow hygienists to administer injections.
Florida does not. You must be familiar with your individual state dental
practice act to determine the level of supervision for this procedure.
3. Nitrous Oxide Oxygen sedation has enjoyed a long and successful history for
the management of pain and anxiety since 1844. It is safe and effective.
4. General Anesthesia includes loss of consciousness and is a central nervous
system depressant.
5. Topical Anesthesia is application of an anesthetic drug directly to the soft
tissue surface. The drug penetrates the mucosa and diffuses to the treatment
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site. It works by blocking the nerve impulse to the brain and has been
found effective on oral soft tissue and to a minimum degree on hard tissue.
Topical anesthesia is an important component of pain control in both dentistry
and medicine. This topic has become one of renewed interest to many dentists,
dental hygienists, and dental assistants because of the variety of products being
marketed for clinical use and the decision on the best product to select for specific
dental procedures.
This course focuses on intra-oral topical chemical agents used for pain relief in
dentistry. The final section of the manuscript will describe delivery methods and
step-by-step techniques for achieving successful pain control when applying topical
anesthetic agents for prior to injection and scaling.
This knowledge will enable the dental professional to make an educated decision
when selecting topical anesthetic products and to apply them safely and effectively.
A greater effectiveness can be achieved for pain control with topical agents by
selecting the best delivery method for the procedure and by improving operator
technique. Patient comfort can be enhanced more than has traditionally been
expected for both scaling and prior to injection.
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USES IN DENTISTRY
There are six indications for using topical anesthesia in the dental office:1, 2, 3
1. to provide anesthesia of soft tissue sites prior to injections to prevent the
pain of needle penetration.
2. to aid in non-invasive examination procedures by minimizing gagging
during taking of radiographs or impressions.
3. to ease discomfort and reduce anxiety during suture removal
4. to provide sulcular anesthesia during scaling & root debridement when a
local injection is not indicated or as an alternative to a local injection.
5. to ease the pressure of the rubber dam clamp during sealant placement.4
6. to supplement local injections in pulpectomies and provide a degree of
pulpal anesthesia in endodontics. 5,6,7
A secondary consideration for using a topical agent is one of psychological benefit
in reducing anxiety in patients. Some apprehensive patients who are informed and
counseled that the agent will be of benefit, experience less discomfort because they
believe it will work. Although this advantage may be slight, it should not be
disregarded in the overall attempt to provide pain-free dental care.
A less known use of topical agents in dentistry is with oral facial disorders, such as
trigeminal neuralgia and cancer related neuropathy. Researchers found topical
agents effective in reducing neuropathic pain when applied to the trigger zone on
the oral tissue surface. Topical agents are faster acting than systemic medications.
The trigger zone of trigeminal neuralgia can be desensitized with 20% Benzocaine
to decrease neuronal firing and relieve the pain. The viscous gel or sticky ointment
provides longer contact and better comfort than the liquid. 8
Traditionally, the two most common indications for use are prior to injections and
during probing and scaling procedures. This course will focus on these two
common in-office uses.
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SUPERVISION LEVELS FOR DENTAL AUXILIARIES
Topical agents are often applied by the dental hygienist or assistant, instead of the
dentist. Therefore, it is important to recognize that the Dental Practice Act
identifies this procedure as an important function for the dental auxiliary and that
the supervision level will vary from state to state. Dental assistants and dental
hygienists apply topical more often than the dentist. Since supervision
requirements vary state-to-state, each individual taking this course should review
their dental practice act for supervision requirement.
A review of permitted functions and supervision levels according to U.S. state
revealed that 27% DO require the physical presence of the dentist and 73% DO
NOT when the dental hygienist applies a topical agent.10
In Florida, the dental assistant may apply topical anesthetic agents under direct
supervision (requires presence of dentist) and the dental hygienist may apply
topical under general supervision (does not require presence of dentist.)9
The Florida Board of Dentistry, at the Jan 7, 2005 meeting, determined that a new
product, Oraqix®, which is a local anesthetic thermosetting gel applied with a blunt
tipped syringe, can be administered under general supervision by the dental
hygienist, just as any other topical anesthetic for adults.
The Florida Board of Dentistry also restricts the use of spray topical anesthetics to
the dentist only,rather than permitting their use by auxiliaries. Each individual
needs to review your state’s dental practice laws to determine the supervision
requirement with the specific use of spray or other forms of topical anesthetic
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At the time of publication, the American Dental Hygienists’ Association identified

31 out of 50 states in the US that allow local anesthesia (local injection) to be
administered by the dental hygienists.11 In the twenty states where the dental
hygienist cannot administer local injection, topical anesthetic agents are the sole
source of pharmaceutical pain control, when the dentist is unavailable to administer
a block or infiltration injection.
Another consideration in controlling the pain induced by subgingival scaling
during periodontal therapy, is that the use of local injection anesthesia itself is a
cause of discomfort. 12, 13 Alternative techniques to injection are needed, especially
when only a few teeth in each quadrant are involved. This course will offer
improved techniques and alternatives to injection as methods of pain control.
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EFFECTIVENESS ON TISSUE TYPES
Topical anesthetic agents work by desensitizing the terminal nerve endings and
blocking initiation and conduction of nerve impulses. It penetrates 2 to 3 mm deep
when applied to the soft tissue surface.1, 2 The mechanism of action is to decrease the
neuronal membrane’s permeability to sodium ions which results in inhibiting
depolarization and blocking nerve conduction.14 Some topical agents, such as
lidocaine, are systemically absorbed and do appear measurable in blood plasma
samples following application to the oral mucous membranes.15,16,17,18,19
Recognizing tissue type is an important consideration when applying topical. If

stippling is present the tissue is keratinized. An example of keratinized tissue is
attached gingiva shown here. The palate is also keratinized.
Alveolar mucosa (sometimes called lining mucosa), is smooth and shiny and is
non-stippled. It will absorb at a faster rate.
The effectiveness of a drug applied topically is dependent on absorption rate of the
tissue and concentration of the agent being applied. Absorption rate varies with
thickness of tissue and amount of keratinization and tissue permeability. Non-
keratinized tissue is more permeable and absorbs the agent at a faster rate. This
tissue is found in locations such as the gingival sulcus lining, the vestibule, the
throat, and abraded tissue. In contrast, the masticatory mucosa contains keratin on
the surface layer and absorbs at a slower rate. Keratinized tissue is found on the
palate, tongue, and attached gingiva. Palatal mucosa was found to be more resistant
to the effects of topical anesthetics than other intraoral sites investigated. 20
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Additionally, the topical agents have no effect on discomfort for deep regional block
injections.
When topical is indicated for scaling and probing procedures, it is important for
the operator to understand that in order to effectively provide anesthesia, the agent
should flow into the sulcus rather than applying it to the attached gingiva only.
New delivery methods such as utilizing a gel administered with a blunt syringe
inserted into the sulcus, can be very advantageous as a delivery method to reach this
non-keratinized soft tissue site. 21,22
Chemical agents that are used for topical application have a greater concentration
than the same agent administered by injection. Many of the chemical agents used
for local anesthetics via injection are not suitable to be used on the surface tissues
because a high concentration would create the potential for overdose and local
tissue toxicity. 23 For example, mepivacaine anesthetic agent is not useful as a topical
agent since injected at a 2% to 3% concentration but would requires a 12% to 15%
concentration if applied topically. However, lidocaine anesthetic agent is injected at
a 2% concentration and is also effective as a topical agent at 2% to 5%
concentration.
Unlike local anesthetic agents, topical anesthetic agents contain no added
vasoconstrictor drugs, such as epinephrine. Vasoconstricting drugs increase
duration of anesthesia and reduce systemic toxicity by delaying absorption into the
cardiovascular system. Because topical agents contain no added vasoconstrictor,
topical agents have the potential for being absorbed systemically.
Amide types, such as lidocaine, increase risk of serious reactions. Stanley F.
Malamed, D.D.S., author of Handbook of Local Anesthesia, states, “application of an
amide topical to a wide area would require a large quantity of the agent and increase
the likelihood of overdose”. 23 He further recommends limiting lidocaine to 3 or 4
teeth if applied topically to minimize the risk of overdose. Maximum
recommended doses (MRD) will be discussed later in this course.
In comparison, an ester such as benzocaine is less likely to cause systemic overdose
reaction since it is not absorbed into the central vascular system as rapidly, if at all.
The ADA, in ADA Guide to Accepted Dental Therapeutics, 2003, reports that
“benzocaine in particular is safe for topical use even on abraded or lacerated tissue.”
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DELIVERY SYSTEMS
Topical anesthetic agents are available in a variety of forms for in-office use. The
most common forms of topical anesthetics are gels, liquids, sprays, and adhesive
patches. Other delivery forms are available for at-home use such as rinses,
ointments, sprays, and creams. The spray form is not recommended for intra-oral
use because of the high concentration of the agent and the inability to control the
amount and/or confine the area of use. The potential exists for overdose with this
high concentration. 1, 18 The metered dose spray is the only form recommended for
oral use, if at all, since it delivers a small measured amount each time the nozzle is
depressed. Another problem with spray is in keeping the spray nozzle sterile, since
not all sprays come with a disposable nozzle.23 The application of topical anesthetic
agents, by dental professionals, also varies from state to state. In Florida, the rules
of the Board of Dentistry specify that a spray topical anesthetic cannot be
administered by either the dental hygienist or the dental assistant.9 All dental
professionals are recommended to refer to individual state dental practice rules if a
spray topical agent is being considered for in-office use by dental auxiliary.
Traditional delivery methods for gels include administering with a cotton tip
applicator and via a cotton ball held with forceps for liquids. Some liquids are
supplied in the form of a pre-moistened unit dose swab (Beutlich, Hurricaine®)
which is easy to apply and is an excellent alternative for preventing accidental cross
contamination.6 Topical agents for clinical use are also available in other delivery
systems such as a transoral adhesive strip delivery system, a blunt tipped applicator
delivery system, or a gel patch which dissolves in the mouth. Please refer to Table
1 for brand names and descriptions.
Cost is a consideration in product selection. Any alternative delivery method will
have an additional cost over the traditional delivery method and this factor must be
considered in each individual dental practice. 24
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Table 1 – Contemporary Delivery Systems for Topical

Anesthetic Agents
Delivery System Brand & Manufacturer Anesthetic Agent
Transoral Adhesive Patch DentipatchTM by Noven 20% Lidocaine

Pharmaceuticals
Gel Patch that dissolves in Topicale® by Premier 18% Benzocaine gel

mouth
Unit Dose cotton swabs Hurricaine® Single-dose 20% Benzocaine liquid
containing liquid agent swabs by Beautlich, L.P.
Pharmaceuticals
Syringe with soft microtip Ultracare by Ultradent 20% Benzocaine gel

prefilled with gel Products, Inc.
Blunt-tip Subgingival Oraqix® by Dentsply 2.5% Lidocaine with

syringe & cartridge Pharmaceuticals Prilocaine in a
thermosetting gel
Cream applied alone or EMLA® (off-label oral use) 2.5% Lidocaine with 2.5%
mixed with oral adhesive by Astra-Zeneca Products Prilocaine in a cream
such as Orabase
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CHEMICAL AGENTS USED FOR INTRAORAL TOPICAL APPLICATION
Certain anesthetics suitable for topical application are not suitable for injection
and vice versa. For example, benzocaine is the most popular topical agent but is not
available as an injectable. Mepivacaine is marketed as an injectable but is not
effective for topical application.
The American Dental Association1 lists only five drugs for topical anesthetics:
benzocaine, cocaine, dyclonine, lidocaine and tetracaine with ranges of duration
from 10 to 60 minutes. Of these five agents, dyclonine is no longer marketed in
solution form in the US, and another, cocaine, is rarely used in dentistry. In
addition, Prilocaine has recently been marketed as a topical agent.
Cocaine
Cocaine is available in concentrations of 2% to 10% as a powder, tablet or solution.
Since it is a Schedule II drug under the Controlled Substances Act it is seldom used
in dentistry. If cocaine is used in the mouth it is recommended that the
concentration not exceed 4% for topical application to oral mucous membranes.1, 23
Safer alternatives are available.
Dyclonine
Dyclonine is neither an amide nor an ester, but a ketone. Previously
manufactured by Astra Pharmaceuticals in a 0.5% solution for oral use, it is no
longer marketed in the U.S. in the liquid form. Its potency is equal to that of
cocaine. It has an onset time of 10 minutes and duration of one hour.20 Dyclonine
can still be found in the form of a throat lozenge, Sucrets®.1 It is possible that
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dentistry may see a re-appearance of dyclonine in the future because of its history
of effectiveness, long duration time, and low systemic toxicity.
Tetracaine
Tetracaine is an ester and is 5 to 8 times more potent than cocaine. It is
available only in combination with other drugs, and is most popular in the form of
a controlled-dose spray. 23 Caution is recommended with intra-oral use of this agent.
It is the most toxic of the dental topical agents and is rapidly absorbed. It has an
onset time of 2 minutes and lasts 20 to 60 minutes.3
Benzocaine
Benzocaine is an ester and is the most frequently used oral topical agent. It is
insoluble in water but its solubility in alcohol and glycol make it suitable for topical
use. It is marketed in percentages ranging from 14 to 20% in the form of a gel,
liquid or spray. Benzocaine is also available in a pump system, or unit dose swabs.
A unique delivery system of benzocaine gel is marketed by Ultradent® in an easy to
use disposable syringe that includes a micro-capillary tip.22 This micro-tip is
designed for inserting the gel strategically at the gingival margin which is ideal to
use for scaling procedures. Since topical benzocaine is not water soluble or absorbed
systemically, allergic reactions are very rare. If they occur they are confined to the
site of application. 23 Localized allergic reactions may appear as redness, edema,
itching or hives. Mild allergic reactions are delayed, occurring 60 minutes or more
after exposure. This type of delayed onset is non-life threatening. In some cases,
a delayed mild onset can become systemic. It occurs after absorption on a
previously sensitized individual. With this delayed systemic reaction, the patient
would be flushed and experience itching from hives. 24
Lidocaine
Lidocaine is an amide that is used as a topical agent. Lidocaine has two forms: (1)
lidocaine base, a 5% concentration poorly soluble in water, and (2) lidocaine
hydrochloride, a 2% concentration that is water soluble. Aerosols are of a higher
10% concentration.2, 23 Lidocaine is marketed in an adhesive patch, in solution, as
a spray or ointment or in combination with other agents dispensed with a blunt
syringe. 25 As previously mentioned, the risk of overdose with an amide such as
Lidocaine, is greater than that of an ester, such as Benzocaine. The risk increases
when a large area is applied, such as an entire quadrant or half the mouth. 23
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DentipatchTM , manufactured by Noven Pharmaceuticals, is a delivery system for

lidocaine in the form of a transoral adhesive patch. It is especially effective for
sensitive palatal injections and for scaling and root planning procedures. The patch
must be applied to dry mucosa and stay in place for 15 minutes before removal. It
has been shown to achieve 40 minutes of anesthesia with this technique.26
DentipatchTM has been found to be more effective than benzocaine gel in preventing
pain of the needle and in scaling and root planning with 40 patients in a double-
blind study.27 A second study found the same results and effectiveness when
researched with 60 subjects. 28 Other impressive studies regarding the effectiveness
of DentipatchTM can be found in the dental literature.
One difficulty of the transoral patch is the technique for application which
requires specific steps. The results are technique sensitive. The tissue must remain
dry for 30 seconds and the patch held in place for 30 seconds with finger pressure
before releasing. The patch should then stay in place for 15 minutes prior to
removal for the greatest benefit. Successful application is a skill that can be learned
and if so, will result in highly effective pain relief for both scaling procedures and
pain caused by the needle. 28
Prilocaine is new on the topical agent list in its uncharged base form and marketed
as a topical only in combination with lidocaine. Prilocaine is 40% less toxic than
lidocaine. 23 Prilocaine hydrochloride (the injectable) is marketed as Citanest‚, 4%
plain or with epinephrine. Prilocaine without vasoconstrictor (the injectable) can
effectively provide anesthesia equal in duration to lidocaine or mepivacaine with a
vasoconstrictor.23 Prilocaine hydrochloride, however, does not have topical
anesthetic action in clinically acceptable concentrations. Only its base is available
as a topical agent in a combination with lidocaine and marketed in two products for
topical application, in EMLA® and more recently in 2004 in Oraqix®.
Eutectic Mixture of Local Aesthetics (EMLA) is not approved for intra-oral use (at
the time of publication) but remains the most widely used topical anesthetic agent
in the medical field rather than the dental profession.29 Eutectic refers to a “mixture
of two or more substances with melting point lower than that of any of its
constituents.” 31 It is a mixture of 2.5% prilocaine and 2.5% lidocaine. Although
the EMLA product is not FDA approved for intra-oral use, it is applied on intraoral
soft tissues by the dentist as off-label use. Dental research has revealed that EMLA
can possibly be used for intra-oral use. EMLA was compared with lidocaine 5% for
effectiveness during probing of pocket depth and was found to be advantageous in
providing anesthesia.32 When EMLA was compared with benzocaine 20% and each
was mixed with an oral adhesive (Orabase) for a procedure involving palatal
infiltration anesthesia, the results showed no difference in pain response between
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the two agents.33 However, the cream was difficult to apply and required longer
onset period than the benzocaine. Its use in children was investigated and no
difference was found when compared to lidocaine ointment for maxillary buccal
infiltration injections.34 EMLA was also found to be effective in reducing the
discomfort of the rubber dam clamp during sealant placement. 4
A new product on the market containing prilocaine, Oraqix® , is approved by the
Food and Drug Administration for intra-oral use. It is a combination of 2.5%
prilocaine and 2.5% lidocaine (like EMLA) but is in the form of a thermosetting gel
rather than a cream. It is recommended for insertion into the sulcus to reduce
discomfort of scaling. The agent is a liquid in the dispenser but becomes a gel when
applied in the mouth. The advantage of Oraqix® when compared to EMLA is the
delivery system. The gel preparation is specifically intended for scaling and root
planning procedures. It is designed with a blunt-tipped dispenser for application to
the subgingival area. The product was an effective pain control agent during scaling
and root planning and a possible alternative to infiltration anesthesia. A study
investigated 122 patients in eight different centers. The waiting period for onset of
Oraqix®‚ was 30 seconds to 2 minutes. 35 A second study was done in 2003 by with
113 patients and confirmed the efficacy of the lidocaine/prilocaine gel over the
placebo in anesthetic benefit during scaling and root planing.36 Another study
concluded that Oraqix® provided anesthesia during scaling and root planning after
an application time of 30 seconds with an average duration time of 17 to 20
minutes. This study reported two additional advantages to the delivery system of
Oraqix® as (1) the tongue and tissues were not numbed indicating the agent
remained at the treatment site, and (2) the advantage of no unfavorable taste. 16
Oraqix® may be safe for use with children but it cannot be recommended at this
time since all product studies were performed with adults.21
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Product Comparison - Table 2 Comparison of Characteristics of

Topical Anesthetics Used in Dentistry
Chemical Percent Brand Name Manufacturer Onset Duration
Agent Concentration or Distributor
Benzocaine 20% Topex gel*, spray* Sultan Dental 1 min. 10-20 min.
& liquid Products
20% Hurricaine spray*, Beutlich L.P. 1 min. 10-20 min.
gel*, liquid* & sin- Pharmaceuticals
gle-dose swabs
18% Topicale gel*, gel Premier Dental 1 min. 20 min.
pumps, get Parch* Products
20% Topicale Xtra

Patterson Brand Patterson Dental 1 min. 20 min.
gel* Co.
Superdent gel Darby Dental 1 min 20 min.

Supply Co.
20% Gingicaine® gel* & Gingi-Pak (Belport 1 min. 20 min.
liquid* Gingicaine® Co., Inc.)
One
20% Ultracare gel w/ Ultradent Products, 1 min. 20 min.
syringe dispenser Inc.
Benzocaine, 14% Benzocaine & Cetacaine* Cetylite Industries, 1 min. 20 min.
tetracaine, plus 2% Tetracaine Inc.
other agents
Lidocaine 5% Xylocaine Topical Astra 3 to 5 min. 10-20 min.
liquid*
10% Xylocaine Spray

5% Lidocaine Gel* Premier Dental
Products
Lidocaine & 2.5% Lidocaine Oraqix® gel w/ Dentsply Fast onset 30 min.
Prilocaine 2.5% Prilocaine syringe Pharmaceuticals
Lidocaine Lidocaine 20% DentipatchTM (lido- Noven 2.5 min. 45 min.

Transoral 46.1mg/unit caine transoral) Pharmaceutical
Cocaine Schedule II Drug 1 min. 20-40 min. or up to

liquid, powder, rarely used in den- 2 hours.
tistry
tablets
Dyclonine 0.5% No longer marketed less than 10 min. 20-40 min.
liquid in U.S.
Tetracaine 2% tetracaine in Supracaine in Marketed as Slow onset 45 min.

spray or gel combination with Canada only. Supracaine in
other ingedients Canada only
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*Approved by the ADA Council on Dental Therapeutics
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Dosage Recommendations
Table 3 : Comparison of Injectable Anesthetic Drug with Same Topical
Anesthetic Drug and the MRD
(Maximum Recommended Dosage)*
Drug MRD as INJECTABLE MRD as TOPICAL
Benzocaine NO INJECTABLE AVAILABLE Benzocaine (20% Gel)
1 ml=20 mg of drug
No MRD
Systemic toxic reactions virtually
unknown.
Local allergic reactions rare.
Lidocaine Lidocaine HCI 2% without Lidocaine Topical (5%)

Epinephrine 1 ml = 40 mg drug
1 cartridge = 36 mg drug MRD is 200 mg
Absolute MRD is 300 mg
MRD is 2.0 mg per lb. body weight Lidocaine transdermal patch (20%)
1 patch = 46.1 mg drug
Prilocaine CitanestTM without Epinephrine Oraqix®

1 cartridge = 72 mg drug Prilocaine (2.5%) & Lidocaine (2.5%)
Absolute MRD is 400 mg MRD = 5 cartridges at one
MRD is 2.7 mg per lb. body weight appointment.
Each cartridge contains 42.5 mg of

Prilocaine and 42.5 mg of Lidocaine
Tetracaine NO INJECTABLE AVAILABLE MOST TOXIC OF ALL TOPICALS

Topical solution Tetracaine 2%: Max.
Dose is 20 mg or 1 ml
Topical spray: Max. Dose is 2
metered sprays
CAUTION RECOMMENDED
Cocaine NO INJECTABLE AVAILABLE Max Dose = 400 mg as topical
SCHEDULE II DRUG 4% used as topical
Not recommended in dentistry
because of abuse potential.
Dyclonine NO INJECTABLE AVAILABLE Topical agent 0.5% solution
Max. Dose = 200 mg or 40 ml of solu-
tion
Solution no longer available in U.S.
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It is important to consider the total dose a patient receives when more than one
agent is used.2, 17, 23, 37 For example, if an individual patient is receiving a block
injection of lidocaine for the lower right quadrant, and at the same appointment
will receive topical anesthetic for scaling the upper right quadrant, the total dose of
the injection and topical must be considered. In some cases, two different agents
will be used and the question arises of how to determine the MRD. It is
recommended that “ the total dose of both anesthetics should not exceed the lower
of the two maximum doses for the individual agents.” 23
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SPECIAL PATIENT CONSIDERATIONS
Overdose is more likely to occur in young children because of their small size.
Lowering of doses will give an extra margin of safety for children. Reducing doses
should also be considered for geriatric patients, those who have debilitating illness
(i.e.: HIV/AIDS patients), patients who have medical conditions (i.e.:
methemoglobinemia) or are taking drugs that alter responses to topical anesthetics,
such as chemotherapy.1
Pediatric Patients
In a survey examining the use of topical agents by Pediatric dentists, most use
the brand Hurricaine® which is a 20% benzocaine gel.38 The researchers added that
the perception of effectiveness varied among dentists and there is a need to develop
a better mode of topical anesthetic delivery system for the pediatric dental
population.38 Vision-Gel‚ was the most effective in a 20% benzocaine concentration.
The pain response of 120 children, ages 10 to 15, was measured using a visual analog
scale when rating the pain of a local anesthetic injection. 39 The DentiPatchTM‚
transoral patch (lidocaine 20% ) did create higher plasma levels in children than in
adults. Blood plasma did not reach the toxic level. Inclusion in the calculation of
the patient’s total lidocaine should be considered when using DentiPatchTM‚ prior to
injection. 17
Contrasting these studies, others observed that a Lidocaine transoral patch was
more effective in reducing the pain of the needle. There was a significant difference
between the lidocaine patch (20%) and the benzocaine gel (20%) in reducing pain
of palatal injections. The patch was left in place for 15 minutes and the benzocaine
gel was left in place for one minute. This duration was the manufacturers
recommendation for both products. The significant difference favoring the
lidocaine was observed by researchers in reporting the pain sounds elicited during
the injection, however the children’s ranking of pain on a visual analog scale did
not show a difference in the two products. 40
Another study involved forty children ages 7 to 15 years old. They found that
Hurricaine‚ (20% benzocaine) was preferred over EMLA because the children's
comfort and taste levels were better. In this study, EMLA was mixed with an oral
adhesive paste prior to applying as an intra oral agent. This is an off-label use of
EMLA since it is not approved by the FDA for intraoral use at the time of this
writing. 41
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The safety of the lidocaine patch was investigated with adult patients. The use of
a lidocaine transoral patch (DentipatchTM) did not add appreciably to the blood
levels, however, it was reported that “low systemic lidocaine absorption is of
particular importance in the pediatric dental population, where excessive local
anesthetic blood levels have led to disastrous effects.” 42
Pregnant Patients
Consideration should be given for using topical anesthetic when a patient is
pregnant, because once absorbed into the system, topical anesthetics can cross the
placenta to enter the circulation of the fetus. Local anesthetics can cross the
placenta and cause fetal depression. It is advisable to limit the dose to the minimum
in order to provide effective pain control and protect the fetus. The dental
professional must determine whether the potential benefits of therapy outweigh the
risks to the fetus. Recent evidence shows that periodontal infections are associated
with delivery of low-birth-weight babies.43For safe dental treatment and
maintenance of a pregnant woman’s oral health, dental care must involve selecting
the safest agent, limiting the duration of the drug, and minimizing the dosages.
No complications with childbirth after the use of topical anesthesia, however, have
been documented. Considerations of risk/benefit may suggest that purely elective
treatment be delayed until after delivery and that other dental care should be
performed, if possible, during the second trimester. 1
It is not clear in the research as to whether benzocaine, prilocaine, and other
topical drug agents have been shown to be present in breast milk following topical
administration of anesthetic. The ADA does state that “Lidocaine and probably
other topicals are distributed into breast milk at low quantities with no problems
documented in humans.” 1
It is prudent to be conservative in administering any drug to a pregnant patient. 23
A consultation with the patient’s physician prior to starting any treatment provides
the safety margin needed in the case of pregnancy. The American Academy of
Periodontology recommends consideration of consultation with the pregnant
patient’s obstetrician to ascertain risk factors such as gestational diabetes or high
blood pressure and to advise the obstetrician of any proposed treatment. 44
The U.S. Food and Drug Administration developed a table and a rating system to
aid health care providers for drugs that affect the fetus. 1 Topical and local anesthetic
agents are not teratogenic in humans and are considered safe for use during
pregnancy. 43 A teratogen defined is a drug or other agent that produces a
congenital anomaly or raises the incidence of an anomaly in the population.
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The FDA “Class C” category includes drugs for which teratogenic risk cannot be
ruled out and should be used with caution. The FDA “Class B” drugs show no
evidence of risk in humans and are considered appropriate for use during
pregnancy. These use-in-pregnancy ratings can be found in drug information sheets
and in the Physicians Desk Reference.
Table 4 -
U.S. FDA’s Pregnancy Classification With Topical Anesthetic Drug
Class Definition Topical Agent
A No risk demonstrated to the fetus in any
trimester.
B No adverse effects in animals; no human Lidocaine, lidocaine
studies available. hydrochloride, & prilocaine.
C Only given after risks to the fetus are consid- Benzocaine, tetracaine,
ered; animal studies shown adverse reac- cocaine, dyclonine.
tions; no human studies available.
D Definite fetal risks; may be given in spite of
risks if needed in life-threatening situations.
E Absolute fetal abnormalities/ not to be used

at any time during pregnancy.
History of Methemoglobinemia
Although benzocaine is not absorbed systemically, the ADA indicates a
contraindication of benzocaine for patients reporting congenital or acquired
methemoglobinemia. 1,23 “The topical anesthetic benzocaine can induce
methemoglobinemia, however, only when administered in very large doses.” 23
Caution is recommended in the use of benzocaine with patients presenting this
medical history.
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Box 1: Definition of Methemoglobinemia
Methemoglobinemia is when methemoglobin (a form of hemoglobin) is present

in the blood. This form of hemoglobin cannot carry oxygen. It is defined in
Taber’s Cyclopedic Medical Dictionary, 19th ed, p.1343, as “the clinical condition
in which more than 1% of hemoglobin in blood has been oxidized to the ferric
form and cannot transport oxygen, ….more than 30% produces dizziness,
headache, and severe neurological symptoms, ….more than 55% may produce
coma, seizures and cardiac arrhythmias”. The most common sign is cyanosis.
Methemoglobin in the blood may be caused by toxic substances such as aniline
dyes, potassium chlorate, or nitrate-contaminated water and to atypical responses
to benzocaine-like analgesics.
Congenital methemoglobinemia, as found in Taber’s, p. 1343, is the result of

“hereditary deficiency of methemoglobin reductase in the blood. Reductase is an
enzyme found in erythrocytes.” Affected persons may appear cyanotic but are
usually not symptomatic.
Methemoglobin, when present in blood, causes the blood to appear dark and a
chocolate brown color and this is the strong clinical sign of methemoglobinemia.
The brown color in the blood, along with cyanosis, which does not respond to
oxygen therapy would alert the health professional of the presence of
methemoglobinemia. The condition is confirmed by a co-oximetry lab test. The
history of anemia, coronary heart disease, and pulmonary disease are also factors in
causing methemoglobinemia.
Benzocaine induced Methemoglobinemia is the only life-threatening condition
related to the use of Benzocaine as a topical agent. The onset of benzocaine-induced
methemoglobinemia is usually within 20 to 60 minutes of drug exposure. In a
healthy person, methemoglobin level in the blood is below 2%. A level of 30% may
produce no symptoms or minimal symptoms (headache, lightheadedness and
fatigue.) Levels between 30% and 50% produce moderate symptoms affecting the
cardiovascular and central nervous system (weakness, headache, rapid pulse, rapid
breathing, and mild shortness of breath). Levels between 50% to 70% cause severe
symptoms (impaired consciousness, irregular or slow heartbeat, respiratory
depression, convulsions, and acidosis). It was reported that “levels above 60% can
be fatal and levels above 70% usually are not compatible with life.” 45
Treatment for drug-induced methemoglobinemia, once diagnosed, is with 1 to
2 mg/kg of methylene blue in low concentration. A 1% solution administered
intravenously over five minutes is the recommended dose. Cyanosis usually
subsides in 15 to 30 minutes. 45
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If methemoglobinemia worsens, a blood transfusion may be required to increase

the patient’s level of functioning hemoglobin. Patients should be screened for any
history of reactions to benzocaine or hemoglobin disorders. Benzocaine induced
Methemoglobinemia rarely occurs, but when it does, treatment depends on prompt
diagnosis and action. Benzocaine appears to cause the condition by acting as an
indirect oxidant, causing the hemoglobin in the red blood cells to undergo
oxidation. “This oxidation alters the cell membrane, resulting in the heme iron
converting from the ferrous to the ferric form, leaving the hemoglobin unable to
bind with oxygen.” As the level of methemoglobin in the blood increases,
symptoms of the condition increase. 46
Two local (not topical) anesthetic injectables, articaine and prilocaine, can also
produce methemoglobinemia in patients with subclinical methemoglobinemia, if
administered in large doses. 23
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TOXICITY, ALLERGIES, AND OVERDOSE
Allergic and toxic reactions can occur with the use of topical anesthetics. Research
indicates that low blood plasma levels are achieved with the use of topical
anesthetics15,16,17,18,19 and that systemic reactions, although rare, may also occur with
topical anesthetics.1 Allergic responses to topical anesthetics can either be localized
to the site of application or can be systemic if topical is applied to an area of the
mucous membrane where absorption takes place. 23 If an individual receives another
exposure to an affected allergen, it can produce a greater reaction or exaggerated
response.
In general, allergic reactions are of two types, either mild (non life-threatening) or
severe (life-threatening). Severe life-threatening reactions are termed anaphylaxis,
for example from bee stings or penicillin. This type of allergic reaction affects
respiration and/or the cardiovascular systems and requires immediate emergency
intervention.
If the response to the allergen is immediate, developing within minutes of
exposure, it is most likely to be life threatening. The more rapidly the signs and
symptoms occur following exposure to the allergen, the more likely the reaction
will be intense.
A mild non life-threatening response is delayed, occurring 60 minutes or more
after exposure. The symptoms of mild allergic skin reactions to products such as
topical anesthetic agents include hives, itching, edema and flushed skin. Mild
delayed onset reactions are either localized to the area of exposure or they can
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become systemic. It occurs after the allergen is absorbed into the system of an
individual that was previously sensitized. With delayed systemic reactions, the
patient would be flushed, with hives and itching all over the body. 24
In the case of topical Benzocaine, the allergic reaction is always localized to the
area of application, since Benzocaine is not water soluble and therefore not
absorbed into the cardiovascular system. The localized tissue reaction usually
appears as edema, redness, and burning. 21,23,24,26
Allergic reactions are more likely with the amide type of topical anesthetic such as
Lidocaine, since it is absorbed into the cardiovascular system and benzocaine is not.
The risk increases with the area that was covered with the topical anesthesia.
Lidocaine absorption was investigated in one study, following its topical
application in the form of a 2% solution used as a 1-minute mouth rinse. Minor
systemic absorption was found with blood plasma levels lower than the therapeutic
amount. 47
A rare case of toxic reaction of lidocaine was reported following an oral topical
spray that was used preoperatively in preparation for general anesthesia.48 Other
researchers found that there is a risk of lidocaine toxicity with frequent use of
viscous lidocaine.49
Localized mucosal irritation may appear with Lidocaine topical as minimal,
moderate, or severe. Minimal symptoms are slightly reddened mucosa, moderate
symptoms are beet redness; and severe symptoms are blister formation and necrosis.
None displayed severe localized reaction to the topical lidocaine (in a study of 100
adult patients). Only 3% of the patients displayed local irritation in the mild to
moderate range. 50
The practitioner must be aware of the action and characteristics of the agent
selected for use and possible allergic or toxic reactions. Benzocaine (ester) is not
absorbed into the cardiovascular system while lidocaine (amide) is absorbed into the
cardiovascular system from the site of application. There is a greater chance of an
overdose (systemic) with an amide such as lidocaine, while there is a greater chance
of allergic reactions (localized to site) with an ester such as benzocaine. The risk of
either allergic reactions or systemic reactions increases with the size of area being
treated and the quantity of agent used. Generally, topical agents are considered a
low risk. 1, 23
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It is wise to be reminded of precautions for an extra margin of safety in order to

avoid allergic or systemic reactions. The following is recommended:
w Use as small amount as possible for the procedure.

w Always review the medical history for previous allergies or for any condition
which contraindicates use of benzocaine, lidocaine, or tetracaine, or other
anesthetic agents. If a patient claims to be allergic to a local anesthetic, do
not use any form of anesthetic including topical until the allergy is either
ruled out or is confirmed. Patients may report an allergy to a local
anesthetic when it is actually an epinephrine reaction rather than a true
allergy. 23
w Limit the area of use, especially if using lidocaine which is systemically
absorbed into the CV system. Since lidocaine is more rapidly absorbed, if
lidocaine is used for scaling, limit the use to 3 or 4 teeth at a time. 23
Applying lidocaine to the entire quadrant is not recommended during
scaling.2, 3
w Do not use a spray topical intra-orally since sprays are of a higher
concentration and are difficult to confine to the desired site.
w Overdose is more likely to occur in young children because of their small
size. Lowering of doses will give an extra margin of safety for children.
Respiration, cardiovascular status and state of consciousness are to be
monitored in pediatric patients.1
w Adverse localized effects may appear as transient redness, edema, and
burning sensation at the site of application.21, 23, 26
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w The quantity of agent and the integrity of the tissue surface must always be
considered when applying a topical agent.1, 23 Absorption is greater if the
underlying connective tissue is exposed and less topical agent should be
used when removing sutures or applying to a mouth ulcer.
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APPLICATION TECHNIQUES
Application Technique Prior to Injection

The dental assistant or dental hygienist must
have knowledge of the intended injection site in
order to apply the agent at the correct location.
Diagram 1 identifies locations for common block
and infiltration injections:
Diagram 1 – Location for Placement of Topical Agent Prior to

Injection
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w First, dry the injection site with one or two gauze squares to remove saliva
so that the topical agent will remain in the proper location and not be
flushed away or diluted with saliva. A saliva ejector may be used to aid in
isolation.
w Then, apply a small amount of topical gel on the end of cotton tipped
applicator and place directly to the tissue over the injection site. A large
amount is not necessary and may combine with saliva and be swallowed by
the patient making the throat numb and giving an unpleasant taste.
w Allow a minimum of 1 minute for maximum effectiveness before injection.
Some manufacturers claim effectiveness after 30 seconds; however research
has shown that at least one minute provides more effective results with
topical agents.1,2 Research has shown that effectiveness is no more than
that of a placebo if left in place only 10 to 15 seconds as recommended by
some product manufacturers.23
w Allow patient to rinse following injection.
Applying Topical During Scaling

The use of topical agents during scaling can reduce
discomfort by two mechanisms. There is both a
psychological and a pharmacological effect. It has been
shown that subjects who are informed they are to receive
a topical anesthetic for comfort, anticipate less injection
pain than those not offered the topical agent. This may
decrease apprehension even though the
pharmacological effect is minimal. 20
Three sources of discomfort were identified in an article

by Barry McCardle, DMD, with his patients in private
practice. The sources were (1) the transient
inflammation induced by scaling, (2) the exposure of cementum during healing and
the discomfort of the injection site itself when a local injection is administered. The
latter source of discomfort could be eliminated in some cases by using a topical
rather than a local agent when only a few teeth need treatment. 13
Select a product that has long duration and low toxicity. Two techniques and
products are recommended: (1) Ultracare gel (benzocaine 20%), which is marketed
in a disposable syringe with a microtip22, (2) any benzocaine gel of choice, that is
applied at the gingival margin with a “Microbrush”51 .
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Technique for Sulcular Anesthesia During Scaling

w First isolate area to be treated with cotton rolls or Dri-Aids and place a saliva
ejector in the mouth.
w Next dry soft tissue in area to be scaled to prevent dilution of topical agent.
w Apply a small amount of gel with a microbrush or microtip to the gingival
margin of the teeth that are being treated. A curet can also be dipped into
the topical agent in order to deliver the agent to the sulcus during scaling.
The objective is to allow the agent to flow interproximally and subgingivally
for achieving sulcular anesthesia.
w Important: “The clinician should avoid swabbing topical anesthetic
throughout the mouth with a cotton applicator. Swabbing does not
provide effective anesthesia, and more importantly, dosage cannot be
documented well.”2
w Always allow sufficient time for effectiveness before beginning procedure.
The wait time will vary with the product, but is a minimum of 1 minute up
to 5 minutes.
w Patient records should always be documented with the name of the
chemical agent and the amount applied.
Oraqix® Applied with Blunt-tip Syringe (lidocaine & prilocaine)

Oraqix® appears very promising with its unique application feature and
thermosetting characteristics. Oraqix® is viewed by this author as having a definite
advantage in both effectiveness (numbing ability) and application technique. It is
recommended that the dental professional reading this paper try the product to
gain a clinical comparison.
w To prepare Oraqix® for use, three parts are assembled: the blunt-tip
applicator, the dispenser tip & body, and the Oraqix® cartridge. Detailed
instructions are available on the product website http://www.oraqix.com 52
Once the product is properly assembled Oraqix ® can be applied to the site
by depressing the paddle on the dispenser body.
w First, apply Oraqix® on the gingival margin around the selected teeth.
w Wait 30 seconds, then fill the periodontal pocket with Oraqix‚, using the
applicator until the gel becomes visible at the gingival margin.
w Wait another 30 seconds before starting treatment.
w Effective anesthesia is obtained for a duration of approximately 20 minutes.
w Typically, one cartridge is enough for one quadrant. However, Oraqix®‚
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may be reapplied if needed, up to 5 cartridges maximum, according to the

manufacturer.
w Oraqix® may be safely applied to the periodontal pocket without first
applying to the gingival margins, however all studies on its effectiveness
were performed by first applying to the gingival margin.
w Note: Oraqix® should be a liquid when administered with the applicator.
It has thermosetting properties forming a gel in the mouth. If it has formed
a gel in the cartridge before use, it should be placed in a refrigerator until it
becomes a liquid again. When it is a liquid the air bubble is visible in the
cartridge and will move when tilted.52
Technique for Application of DentipatchTM (lidocaine)

Step 1 - Isolate area using cotton rolls and suction. Dri-Aids53 are excellent or All-
DriTM or other dry angle type product.
Step 2 – Dry area for 30 seconds with air syringe (less time for palate).
Step 3 – Open the DentipatchTM strip(s), peel off protective liner.
Step 4 – Apply DentipatchTM to mucosa of both buccal and lingual side of the area
being treated. Apply with firm finger pressure and hold in place for 30
seconds with steady pressure. Note: A good way to remember this is “dry
30 seconds, apply 30 seconds.”
Step 5 – Leave in place 15 minutes for maximum effectiveness. Onset of
anesthesia may occur in 5 to 10 minutes. The scaling procedure can
commence after 5 to 10 minutes. However, remove patch after 15 minutes.
Step 6 – Remove patch using cotton pliers or fingers.
Note: With a 15 minute application period, 40 minutes of anesthesia can be
achieved.26
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CONCLUSION
This course has addressed characteristics of chemical agents used in dentistry for
in-office topical anesthesia and pain control. The technique for application of
various products has been reviewed and the following conclusions made:
1. For use prior to injection, select a topical agent that has fast onset with low
toxicity. Benzocaine gel or lidocaine gel are both proven effective topical
agents. In the very sensitive palatal region, a transdermal lidocaine patch or
EMLA cream may be more effective than benzocaine gel.
2. Always wait at least 1 minute after application before injection, even though
the product brochure may indicate onset occurs in less time.
3. Use the smallest amount possible in order to avoid toxic reactions, although
reactions are rare. Be cautious with all topical agents when using on
children, pregnant women, geriatric populations, or patients with
compromised health. Do not apply topical agents to abraded or traumatized
tissue.
4. All techniques for applying topically require drying of tissue before
application. Do not skip this step because it is important in overall
effectiveness.
5. For scaling procedures and achieving sulcular anesthesia, the blunt tip
dispenser provided with Oraqix® has an advantage over traditional cotton-
tip applicator methods. DentipatchTM and Oraqix® are probably the two
agents for scaling that provide a longest duration combined with excellent
effectiveness. An 18% to 20% benzocaine gel applied with a microtip or
microbrush has the advantage of both proven safety and effectiveness but
has a shorter duration period. Benzocaine may also be the most cost
effective topical anesthesia for scaling when compared to newer products.
6. This course contains limited discussion on cost, which is a consideration
that must be addressed in product selection for each individual office.
7. The use of topical anesthesia may have a psychological benefit for the
patient as well as pharmacological effect and can reduce overall anxiety for
the apprehensive or hypersensitive patient.
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3. Wilkins E. Anxiety and Pain Control. Clinical Practice of the Dental
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Med. 1999; 28:170-2.
16. Friskopp J, Huledal G. Plasma levels of lidocaine and prilocaine after
application of Oraqix, a new intrapocket anesthetic, in patients with
advanced periodontitis. J Clin Periodontol. 2001; 28:425-9.
17. Leopold A, Wilson S, Weaver JS, Moursi AM. Pharmacokinetics of lidocaine
delivered from a transmucosal patch in children. Anesth Prog. 2002; 49: 82-
7.
18. Mehra P, Caiazzo A, Maloney P. Lidocaine toxicity. Anesth Prog.1998 Winter;
45: 38-41.
19. Vickers ER, Marzbani N, Gerzina TM, McLean C, Punnia-Moorthy A, Mather
L. Pharmacokinetics of EMLA cream 5% application to oral mucosa. Anesth
Prog. 1997 Winter; 44: 32-7.
20. Meechan JG. Effective topical anesthetic agents and techniques. Dental
clinics of North America; 2002. 46(4): 759-66.
21. Oraqix® (lidocaine and prilocaine periodontal gel) Product brochure. 2004;
Dentsply Pharmaceutical. York, PA. 1-866-273-7846.
22. Ultradent Products. Ultracare® product instructions. MSDS information.
Available at http://www.Ultradent.com/products. Accessed on 2/18/05.
23. Malamed SF. Handbook of Local Anesthesia, 4th ed. Mosby; 1997.
24. Malamed SF. Emergency medicine: beyond the basics. J Am Dent Assoc
1997; 128: 843-854.
25. Blanton PL, Jeske A.H. Dental local anesthetics: alternative delivery methods.
J Am Dent Assoc. 2003; 134: 228-34.
26. DentiPatch® Lidocaine transoral delivery system. Product brochure. Sept.
1997; Noven Pharmaceuticals, Inc., Miami, FL. 1-888-55NOVEN.
27. Carr MP, Horton JE. Clinical evaluation and comparison of two topical
anesthetics for pain caused by needle sticks and scaling and root planning. J
Periodontol. 2001; 72: 479-84.
28. Carr MP, Horton JE. Evaluation of a transoral delivery system for topical
anesthesia. J Am Dent Assoc. 2001; 132: 1714-9.
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29. Friedman PM, Mafong E, Friedman E, Geronemus R. Topical anesthetics

update: EMLA and beyond. Derm Surg 2001; 27,no.12:1091-26.
30. EMLA® cream (lidocaine2.5% and prilocaine 2.5%). AstraZeneca
Neuroscience Products. Product description & full prescribing information.
Available at: http://www.Astrazeneca-us.com. Acessed on 2/28/05.
31. Venes D, ed. Taber’s Cyclopedic Medical Dictionary, 19th ed FA Davis Co.;
2001.
32. Donaldson D, Meechan JG. A comparison of the effects of EMLA cream and
topical 5% lidocaine on discomfort during gingival probing. Anesth Prog.
1995; 42: 7-10.
33. Primosch RE, Rolland-Asensi G. Comparison of topical EMLA 5% oral
adhesive to benzocaine 20% on the pain experienced during palatal
anesthetic infiltration in children. Pediatr Dent. 2002; 23: 11-14.
34. Meechan JG, Donaldson D. The intraoral use of EMLA cream in children: A
clinical investigation. ASDC J Dent Child, 1994; 61:260-2.
35. Jeffcoat MK, Geurs NC, Magnusson I, MacvcNeill SR, Mickels N, Roberts F,
Robinson P, Salamati A, Uukna R. Intrapocket anesthesia for scaling and root
planning: results of a double-blind multicenter trial using lidocaine
prilocaine dental gel. J Periodontol. 2001; 72: 895-900.
36. Magnusson L, Geurs NC, Harris PA, Hefti AF, Mariotti AJ, Mauriello S, Soler
L, Offenbacher S. Intrapocket anesthesia for scaling and root planning in
pain-sensitive patients. J Periodontol. 2003; 74: 597-602.
37. Kreider KA, Stratmann RG, Milano M, Agostini FG, Munsell M. Reducing
children’s injection pain: lidocaine patches versus topical benzocaine gel.
Pediatr Dent. 2001; 23; 19-23.
38. Kohli K, Ngan P, Crout R, Linscott CC. A survey of local and topical
anesthesia use by pediatric dentists in the United States. Pediatr Dent. 2001;
23: 265-9.
39. Tulga F, Mutlu Z. Four types of topical anaesthetic agents: evaluation of
clinical effectiveness. J Clin Pediatr Dent. 1999 Spring; 23: 217-20.
40. Kreider KA, Stratmann RG, Milano M, Agostini FG, Munsell M. Reducing
children’s injection pain: lidocaine patches versus topical benzocaine gel.
Pediatr Dent. 2001; 23: 19-23.
41. Primosch RE, Rolland-Asensi G. Comparison of topical EMLA 5% oral
adhesive to benzocaine 20% on the pain experienced during palatal
anesthetic infiltration in children. Pediatr Dent 2001 23:11-14.
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42. Hersh EV, Houpt MI, Cooepr SA, Feldman RS, Wolff MS and Levin LM.
Analgesic efficacy and safety of an intraoral lidocaine patch. J Am Dent
Assoc 1996; 127: 1626-34.
43. Moore PA. Selecting drugs for the pregnant dental patient; J Am Dent Assoc
1998; 129: 1281-1286.
44. J Periodontol, Acacemy Report, American academy of periodontology
statement regarding periodontal management of the pregnant patient. Jan
2004. Available at: http://www.perio.org/resources-products/posppr2.html
Accessed on 06/01/06.
45. Sachdeva R, Pugeda JG, Casale LR, Meizlish JL, Zarich SW. Benzocaine-
induced methemoglobinemia. Tex Heart Inst J 2003; 30:308-10.
46. King CR. Benzocaine-induced Methemoglobinemia: a rare, potentially fatal
reaction to common anesthetics. Available at: www.endonurse.com/articles.
Accessed 5/24/06.
47. Elad S, Cohen G, Zylber-Katz E, Findler M, Galili D, Garfunkel AA, Or R.
Systemic absorption of lidocaine after topical application for the treatment
of oral mucositis in bone marrow transplantation patients. J Oral Pathol
Med 1999; 28: 170-2.
48. Mehra P; Caiazzo A; Maloney P. Lidocaine toxicity. Anesth Prog 1998; 45:
38-41.
49. Yamashita S, Sato S, Kakiuchi Y, Miyabe M, Yamaguchi H. J Pain Symptom
Management 2002; 24: 543-545.
50. Hersh EV, Houpt MI, Cooepr SA, Feldman RS, Wolff MS and Levin LM.
Analgesic efficacy and safety of an intraoral lidocaine patch. J Am Dent
Assoc 1996; 127: 1626-34.
51. Microbrush® International, Available at: http://www.microbrush.com.
Accessed on: 3/28/05.
52. Oraqix® Dispenser, Directions for use. Available at: http://www.oraqix.com.
Accessed on: 2/10/05.
53. Young dental products. Available at: http://www.youngdental.com. Accessed
on: 3/28/05.
54. Torres & Ehrlich, Modern Dental Assisting, 4th ed 1990; Saunders
publishing, 185.
v 34
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COURSE EXAMINATION
Traditional Completion: To complete the examination, please circle the appropriate answer for
each question on the “Examination Answer Sheet” provided and return to ArcMesa customer service.
Online Completion: We suggest using this page to prepare for the online examination. If you have
purchased the program, and are ready to complete the online examination, select the “Take Exam” link
located directly across from the program title within your online ArcMesa “Member History” section.
1. Topical anesthetic agents are indicated in dentistry for all of the following
procedures except one. Which is the exception?
a. All new patient exams
b. Prior to injection
c. During scaling and root debridement
d. Application of rubber dam clamp in sealant placement
e. Suture removal
2. The effectiveness of an anesthetic agent applied topically depends on which

of the following characteristics?
a. Concentration of agent
b. Type of tissue
c. Absorption rate of tissue
d. All of the above
3. Which of the following locations in the mouth are LEAST likely to absorb
the topical agent due to presence of keratin?
a. Tongue
b. Gingival sulcus
c. Buccal vestibule
d. Both “a” and “c”
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4. Which of the following statements is true regarding the supervision level for
dental auxiliaries applying topical agents in the dental office?
a. All states require the dentist to be present in the office.
b. All states require the dentist must authorize the procedure but need
not be present.
c. All states require the dentist must check the patient following the
procedure.
d. State supervision levels vary and there is no national standard
regarding application of topical agents.
5. What is the name of the ester type of topical anesthetic agent that is more
potent than cocaine, is rapidly absorbed, and caution is recommended
during its use?
a. Dyclonine
b. Tetracaine
c. Lidocaine
d. Prilocaine
6. Local tissue reactions occur occasionally to topical anesthetic agents and

include all of the following symptoms except one. Which is the exception?
a. Redness
b. Edema
c. Hemorrhaging
d. Burning
7. Of the following topical anesthetic agents, which is least likely to be

absorbed into the cardiovascular system because it is insoluble in water?
a. Tetracaine
b. Cocaine
c. Lidocaine
d. Benzocaine
e. Prilocaine
8. Topical anesthetics are more concentrated when compared to injectable

anesthetics and topical anesthetics contain no vasoconstrictors.
True False
v 36
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9. “Eutectic” refers to a mixture of two or more substances with a melting

point lower than its constituents.
True False
10. Lidocaine is marketed as a topical anesthetic agent in which of the following

delivery methods?
a. In combination with other agents dispensed with blunt syringe.
b. Transoral adhesive patch
c. Liquid or solution
d. Spray
e. All of the above
11. Of the following agents, which is NOT recommended for intra-oral use in
dentistry?
a. Gel
b. Spray
c. Liquid or solution
d. Transoral adhesive
12. When benzocaine is used for topical anesthesia for a healthy adult, what is
the maximum recommended dosage for one appointment?
a. 1ml of gel
b. 40 mg of the drug
c. 200 mg of the drug
d. No MRD is established, use the smallest amount as possible to achieve
results
13. Allergic local reactions, although rare, are more likely to occur from
excessive or extended use of which classification of topical anesthetic
agents?
a. Amide type
b. Ester type
c. Ketone type
d. Prilocaine
14. All drugs that are topical anesthetic agents can also be found as an injectable
anesthetic agent.
True False
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15. When administering an injection, which of the following times is the

MINIMAL waiting period after applying the topical agent?
a. 30 seconds
b. 1 minute
c. 3 minutes
d. 5 minutes
16. Overdose rarely occurs with use of topical anesthetics, however caution
should be exercised with which of the following individuals?
a. A 6 year-old male
b. A frail 80 year-old female
c. A female on cancer chemotherapy
d. A patient diagnosed with AIDS
e. All of the above
17. A condition where a form of hemoglobin is present in the blood that

cannot transport oxygen because it has been oxidized to the ferric form is
known as methemoglobinemia.
True False
18. Topical anesthetic agents are safe to use with all pregnant women because
the agent, if absorbed, does not cross the placenta to enter the bloodstream
of the fetus.
True False
19. When applying topical anesthetic in the oral cavity, which of the following
locations would have the fastest rate of absorption?
a. Attached gingiva
b. Tongue
c. Gingival sulcus
d. Hard palate
20. Which of the following topical agents can cause a serious life-threatening
incident if used on a patient with a history of acquired
methemoglobinemia?
a. Lidocaine
b. Dyclonine
c. Cocaine
d. Benzocaine
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21. Which of the following is NOT a symptom of the condition known as

methemoglobinemia?
a. Chocolate color of blood
b. Cyanosis
c. Headache
d. Flushed skin
22. Prilocaine hydrochloride in its base form is combined with which of the
following drugs and marketed as a topical anesthetic agent in the US?
a. Lidocaine
b. Benzocaine
c. Tetracaine
d. Dyclonine
23. Pregnancy is an absolute contraindication for using local or topical

anesthetic for dental treatment.
True False
24. Which of the following topical agents are safe to use in moderation with the
pediatric dental patient?
a. Benzocaine gel
b. Lidocaine patch
c. EMLA cream
d. All of the above
v 39
ARCMESA EDUCATORS
www.arcmesa.com
Examination Answer Sheet
If completing the exam traditionally, please remove the Examination Answer Sheet and Evaluation page and
return to ArcMesa when completed.
Important Note: Please retain a copy or be sure to mark your answers on the examination page(s) for your own records.
TOPICAL ANESTHESIA IN DENTISTRY

Use a dark pen or pencil to circle the appropriate answer for each of the questions from the examination.
If you wish to FAX your answer sheet back to ArcMesa, it is best to use a dark pen.
1. A B C D E 13. A B C D
2. A B C D 14. True False
3. A B C D 15. A B C D
4. A B C D 16. A B C D E
7. A B C D E 19. A B C D
8. True False 20. A B C D
9. True False 21. A B C D
10. A B C D E 22. A B C D
12. A B C D 24. A B C D
Credit Card Information (For online users completing traditionally):

If you have not yet purchased this course, and would like to complete the course traditionally, Mail or Fax both
the Answer Sheet and Evaluation form with your credit card information to:
ArcMesa Educators, 615 Hope Road, Bldg 1, Eatontown, NJ 07724 or Fax to: 732-380-1104.
ONLINE USERS PLEASE NOTE: Your account will be charged an additional $5.00 processing and grading fee
for traditional completion, and a certificate of completion will be mailed upon receipt of a passing grade.
Method of Payment:
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Signature: Date:
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THIS Required information for proper certification and individual record retention.
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Validation: I certify that I have studied the course materials and have
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Course Evaluation
COURSE TITLE: TOPICAL ANESTHESIA IN DENTISTRY: IMPROVING PATIENT COMFORT
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TOPICAL ANESTHESIA

AN INDEPENDENT CE/CME STUDY COURSE

File Name: amelogo and usage.eps

ABOUT THE AUTHOR

Hazel received her Associate of Science Dental Hygiene degree

AUTHOR’S STATEMENT AND ACKNOWLEDGEMENTS

© 2006 – ArcMesa Educators, LLC/Hazel Kerr

Upon successful completion of this course, the participant will:

ArcMesa Educators, LLC is an ADA CERP Recognized Provider for Dental

Date of original release: June 2006 Medium used: Monograph

ABOUT THE AUTHOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i

COURSE OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ii

TABLE OF CONTENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iii

COURSE INSTRUCTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iv

SUPERVISION LEVELS FOR DENTAL AUXILIARIES . . . . . . . . . . . . . . . . . . . . . . . .4

EFFECTIVENESS ON TISSUE TYPES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

CHEMICAL AGENTS USED FOR INTRAORAL TOPICAL APPLICATION . . . . . . .10

SPECIAL PATIENT CONSIDERATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

TOXICITY, ALLERGIES AND OVERDOSE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

APPLICATION TECHNIQUES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

COURSE EXAMINATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

FOR INTERNET AND HOME STUDY PARTICIPANTS!

Topical anesthesia is defined by Stedman’s Concise Medical Dictionary as “superficial

SUPERVISION LEVELS FOR DENTAL AUXILIARIES

At the time of publication, the American Dental Hygienists’ Association identified

EFFECTIVENESS ON TISSUE TYPES

Recognizing tissue type is an important consideration when applying topical. If

Table 1 – Contemporary Delivery Systems for Topical

Delivery System Brand & Manufacturer Anesthetic Agent

Transoral Adhesive Patch DentipatchTM by Noven 20% Lidocaine

Gel Patch that dissolves in Topicale® by Premier 18% Benzocaine gel

Syringe with soft microtip Ultracare by Ultradent 20% Benzocaine gel

Blunt-tip Subgingival Oraqix® by Dentsply 2.5% Lidocaine with

CHEMICAL AGENTS USED FOR INTRAORAL TOPICAL APPLICATION

DentipatchTM , manufactured by Noven Pharmaceuticals, is a delivery system for

Product Comparison - Table 2 Comparison of Characteristics of

20% Topicale Xtra

Superdent gel Darby Dental 1 min 20 min.

10% Xylocaine Spray

Lidocaine Lidocaine 20% DentipatchTM (lido- Noven 2.5 min. 45 min.

Cocaine Schedule II Drug 1 min. 20-40 min. or up to

Tetracaine 2% tetracaine in Supracaine in Marketed as Slow onset 45 min.

Lidocaine Lidocaine HCI 2% without Lidocaine Topical (5%)

Prilocaine CitanestTM without Epinephrine Oraqix®

Each cartridge contains 42.5 mg of

Tetracaine NO INJECTABLE AVAILABLE MOST TOXIC OF ALL TOPICALS

SPECIAL PATIENT CONSIDERATIONS

E Absolute fetal abnormalities/ not to be used

Box 1: Definition of Methemoglobinemia

Methemoglobinemia is when methemoglobin (a form of hemoglobin) is present

Congenital methemoglobinemia, as found in Taber’s, p. 1343, is the result of

If methemoglobinemia worsens, a blood transfusion may be required to increase

TOXICITY, ALLERGIES, AND OVERDOSE

It is wise to be reminded of precautions for an extra margin of safety in order to

w Use as small amount as possible for the procedure.

Application Technique Prior to Injection

Diagram 1 – Location for Placement of Topical Agent Prior to

Applying Topical During Scaling

Three sources of discomfort were identified in an article

Technique for Sulcular Anesthesia During Scaling

Oraqix® Applied with Blunt-tip Syringe (lidocaine & prilocaine)

may be reapplied if needed, up to 5 cartridges maximum, according to the

Technique for Application of DentipatchTM (lidocaine)

14. Wynn R, Meiller T, Crossley H. Drug Information Handbook for Dentistry,