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  • Dear Dr. Lieberman,
    Thank you very much for your interested lecture. Please have me your presentation.
    Yours,
    phanaihung@yahoo.com
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China PPT

  1. 1. Local Anesthesia for Patients <br />Pediatric<br />Dr. William H. Lieberman D.D.S., M.B.A.<br />
  2. 2. Brief Bio.<br />Dr. William H. Lieberman D.D.S., M.B.A.<br />Private pediatric practice in New Jersey <br />Past-President American Society of Dentistry for Children<br />MBA, Healthcare<br />Coordinator Dental Continuing Education, Monmouth Medical Center<br />Assistant Clinical Professor at New York University<br />
  3. 3. 1975-2011Then & Now<br />Electronic Charts<br />Paper Charts<br />
  4. 4. 1975-2011Then & Now <br />X-Ray Film<br />X-Ray Sensors<br />
  5. 5. 1975-2011Then & Now <br />Composite (RMGI) Restorations <br />Amalgam Restorations<br />
  6. 6. 1975-2011Then & Now <br />Curing Light<br />LED Light<br />
  7. 7. 1975-2011Then & Now <br />The Wand / STA - Single Tooth Anesthesia<br /> System Instrument<br />Syringes<br />
  8. 8.
  9. 9. Table of Contents<br /> Set Up<br /> Basic operation<br /> Injection Techniques<br /> Maintenance <br /> Advanced options<br />www.STAis4U.com<br />
  10. 10. 1884<br />1904<br />
  11. 11. Drug choice and Volume<br />4% Articaine HCL<br />Adult: ½ cartridge<br />Child: ¼ cartridge<br />Preferred Vasoconstrictor Concentration<br />1:100,000 epinephrine<br />2% Lidocaine HCL<br />Adult: ¾ cartridge<br />Child: ½ cartridge<br />Preferred vasoconstrictor concentration<br />1:100,000 epinephrine<br />
  12. 12. What do you see ?<br />
  13. 13. Agras, et al. 1979<br />Prevalence of Dental Fear?<br />20%<br />
  14. 14. Technology ?<br />1853 <br />1904 <br />2010<br />150+ years<br />
  15. 15. 1997<br />“New Innovation”<br />Computer-Controlled <br />Local Anesthetic <br />Delivery System<br />“C-CLAD”<br />
  16. 16. Computer Controlled Local<br />Anesthetic Delivery System <br />1997 – 1stGeneration<br />2007 – 3rd<br />Generation<br />
  17. 17. Disruptive Technology<br />An innovation that alters a product or service in ways the market does not expect<br />
  18. 18. Allows you to <br />do something you <br />can’t do any other way!<br />
  19. 19. Simple mechanical system<br />
  20. 20. Dynamic Pressure Sensing Technology - DPS™<br /><ul><li>Monitors “Exit-Pressure”
  21. 21. Real-Time, continuous information
  22. 22. Visual and audible feedback
  23. 23. System control: “Exit-Pressure”</li></li></ul><li>Total<br />Feedback <br />No<br /> Feedback<br />FPO<br />
  24. 24. Hochman M, Chiarello D, Hochman C, Lopatkin R, Pergola S.<br />Clinical Research<br />Computerized local anesthesia vs. traditional syringe technique: Subjective pain response.<br /> NYS Dental Journal – 1997<br /> Method & Material<br /> 50 patients (dentists) <br /> Palatal injection<br /> Each patient served as a control<br /> Subjects blinded to technique<br /> VAS scale, subjective pain scoring<br /> 3 examiners performed testing<br /> CCLADS: Fixed flow-rate = 0.005ml/sec = 2 minutes<br /> Handheld syringe: Maintained injection for 2 minutes<br />
  25. 25. Number of Subjects = 50<br /><ul><li>RESULTS:
  26. 26. Wand group - 82% reported No Pain or Minimal Pain
  27. 27. Placebo group – 10% reported No Pain or Minimal Pain</li></li></ul><li>Froum, Tarnow, Caiazzo, Hochman <br />J. Periodontology 2000,71:1453-59<br />Histology: PDL injection<br />METHODS & MATERIALS<br />3 subjects / 32 sites;<br />Control site<br />1 hr, 1 day, 4 days, 7 days, 21 days & 49 days<br />Dosage Volume = 1.0 ml<br />
  28. 28. Hochman, Friedman, Williams, Hochman<br />Data on Different Tissue Types and Dental Injections<br />Interstitial Tissue Pressure Associated With Dental Injections: A Clinical Study<br />Quintessence Int 2006; Vol 37: 469-476.<br />200 dental injections (50/group)<br />Group 1 – PDL<br />Group 2 - Palatal injection<br />Group 3 - Buccal infiltration<br />Group 4 - Mandibular block<br />Measured pressure in “real-time”<br />Fixed flow-rate: 0.005ml/sec<br />
  29. 29. Validation<br />Prof. Stanley Malamed<br />Prof. Bassett<br />Prof. DiMarco<br />Prof. Naughton<br />Prof. J. Meechan<br />Prof. Dionne<br />
  30. 30. Lesson 1 Set Up and Basic Operation<br />
  31. 31. Step - 1<br />FRONT<br />Attach Foot Control<br />Tighten Securely<br />BACK<br /> Attach Power Cord<br />Turn Power Switch On<br />Wait 5 seconds for STA to Self-calibrate<br />
  32. 32. Step - 2<br />ANESTHETIC CARTRIDGE<br />Insert cartridge into holder<br />Press firmly until spike punctures the diaphragm<br />
  33. 33. Step - 3<br />Wand Handpiece & Needle<br />Attach Luer-Lock needle to <br />handpiece, if necessary <br />Tighten securely<br />Place needle and cap into holder on either side of STA<br />
  34. 34. Step - 3<br />Shorten length of Wand Handpiece<br />Remove tubing handpiece<br />Shorten by “breaking” the length of the handle<br />Mark the bevel<br />
  35. 35. Step - 4 <br />Insertion of Cartridge Holder<br />Insert wings of holder into top of STA<br />Turn counter-clockwise <br /> ¼ turn<br />STA activates and purges handpiece of air<br />Lights are activated<br />
  36. 36. Step - 4b <br />Removal of Cartridge Holder<br />Push cartridge out using finger slots at top of cartridge holder<br />Remove cartridge and continue<br />Turn clockwise ¼ turn<br />
  37. 37. Step - 5<br />Easy Learn: Training Mode<br />The Training Mode provides an audible explanation of the various functions of the STA<br />Allows one to become familiar with operating the STA<br />Enable Training Mode by pressing and holding the “Hold to Train” button for 4 seconds<br />
  38. 38. Step – 6 System is Ready<br />
  39. 39. Learn the Injection of Your Choice<br />Lesson 2:Performing the STA-Intra-ligamentary Injection<br />Lesson 3:Performing the AMSA – (Palatal) Injection<br />
  40. 40. Lesson 2 Tools needed to perform STA-IL Injection<br />What you need to perform this injection:<br />Bonded - 30-g ½ inch STA-Wand® Handpiece<br />The STA drive-unit set to “STA” mode<br />Activate Training Mode feature (optional)<br />
  41. 41. Lesson 2 Performing STA-IL Injection<br />What you need to learn:<br />How to use Cruise-control feature<br />Understand how DPS® works<br />How to use STA aspiration to prevent back-spray of anesthetic into patients mouth<br />
  42. 42. Performing STA-Intra-ligamentaryInjection<br />
  43. 43. Easy Learn: Cruise Control<br />Step - 1<br />What is the Cruise Control feature:<br />The feature allows you to deliver anesthetic solution without the need of continuously depressing the foot pedal, it’s analogous to cruise-control in your car in which you release the accelerator and continue to drive.<br />How do you activate:<br />Start injection by depressing pedal<br />After 3 seconds voice prompt will say “Cruise”<br />Immediately release foot off pedal to remain in cruise mode<br />How do you de-activate:<br />Tap foot-control pedal to stop<br />
  44. 44. Easy Learn: STA-IL Insertion Site <br />Step - 2<br />Area effected:<br />Single Tooth Anesthesia<br />Injection site:<br />Start on distal<br />Bend needle, if necessary, to gain access<br />It is best to maintain a direct view of the needle and it’s entrance to the sulcus at all times<br />It is important for the shaft of the needle to be parallel with the surface of the root<br />
  45. 45. You need a slight bend to the needle to allow proper access.<br />
  46. 46.
  47. 47. Incorrect<br />Correct<br />Unbent needle<br />Bent needle<br /> (allows proper angle and access to PDL)<br />NOTE: You cannot access the distal of the lower molars properly without bending the needle slightly.<br />
  48. 48. Buccal Approach <br /><ul><li> Important to maintain direct vision of proper needle angle and needle entrance into the sulcus when using either approach
  49. 49. Distal-buccal requires needle to be bent as well</li></li></ul><li>Mesial Approach<br />Correct<br />Incorrect<br />Incorrect needle<br />angle and entrance<br /><ul><li> Proper angle and entrance can be achieved with bent or straight needle </li></li></ul><li>Easy Learn: Needle Insertion<br />Step - 3<br /><ul><li>Objective of Insertion:</li></ul>Needle tip to entrance of PDL<br /><ul><li>Angle of Insertion:</li></ul>30 to 45 degrees<br />Bend needle, if necessary<br />Direct vision of needle<br />Needle shaft parallel to root<br /><ul><li>Movement of Insertion:</li></ul>Very SLOWLY advance needle producing Anesthetic Pathway<br />Needle is inserted like a “Periodontal Probe”, gently<br />30º<br />
  50. 50. Easy Learn: Dynamic Pressure Sensing<br />Step - 4<br />What is the DPS feature:<br />This feature provides real-time audible and visual feedback to indicate when the needle is properly positioned when performing the STA-Intra-ligamentary (PDL) injection. <br />How to use:<br />In STA-Mode only<br />Start injection<br />Insert needle into “assumed” correct PDL injection location <br />Wait approximately 10-15 seconds in “assumed” correct location<br />Listen & Watch, “ascending tone” & Increase of Pressure Scale through “orange” LED zone<br />Maintaining the High “orange” or the “green” LED zone throughout confirms proper needle location<br />
  51. 51. Easy Learn: DPS® technology<br />Step - 5<br />Trouble Shooting:<br />Problem:<br /> Pressure not building:<br />Insufficient hand pressure on STA/Wand handpiece<br />Did not wait 10 -15 seconds to allow pressure to build<br />Incorrect needle position <br />Over-Pressure Alert:<br />Excessive hand pressure on STA/Wand handpiece<br />Blocked needle tip with excessive hand pressure into PDL tissue<br />Incorrect needle position<br />
  52. 52. Lesson 3 Tools needed to perform AMSA - Injection<br />What you need to perform this injection:<br />30-g ½ inch – Bonded STA-Wand® Handpiece<br />Cotton-applicator with wooden-handle required<br />The STA drive-unit set to “STA” mode<br />
  53. 53. Lesson 3 How to Perform AMSA- Injection<br />What you need to Learn:<br />How to use Cruise-control feature<br />How to perform Pre-Puncture Technique<br />How to perform Anesthetic Pathway Technique<br />How to use STA-aspiration to prevent back-spray of anesthetic into patients mouth<br />
  54. 54. Easy Learn: AMSA Insertion Site <br />Step - 1<br />Area effected:<br />The AMSA can produce pulpal anesthesia from the Central Incisor to the 2nd Premolar and the associated hard and soft palatal tissues. <br />Injection site:<br />Imagine a line located between the 1st and 2nd Premolar<br />Mid-way along an imaginary line from the palatal suture to the free gingival margin<br />Approach this site with the hand-piece from the contra-lateral premolars <br /><ul><li>Bisect premolars
  55. 55. Midway between the free gingival margin and mid-palatine suture</li></li></ul><li>Easy Learn: AMSA Insertion Site <br />Step - 1<br />Injection site:<br />Imagine a line located between the 1st and 2nd Premolar <br />Mid-way along an imaginary line from the palatal suture to the free gingival margin<br />Approach this site with the hand-piece from the contra-lateral premolars <br />
  56. 56. Clinical Technique: AMSA Injection<br />
  57. 57. AMSA Injection <br /> A new technique that enables us to anesthetize a maxillary quadrant in the primary dentition with one injection.<br />
  58. 58. Referances<br />Friedman MJ, Hochman MN. The AMSA injection: A new concept for local anesthesia of maxillary teeth using a computer-controlled injection system. Quintessence Int. 1998; 29:297-303<br />Gibson RS, Allen K, Hutfless S, Beiraghi S. The Wand vs. traditional injection: A comparison of pain related behaviors. Pediatric Dent. 2000;22:458-462<br />
  59. 59. Lesson 4 Performing P-ASA Injection<br />What you need to Learn:<br />How to use Cruise-control feature<br />How to perform Pre-Puncture Technique<br />How to perform Anesthetic Pathway Technique<br />How to use STA-aspiration to prevent back-spray of anesthetic into patients mouth<br />
  60. 60. Clinical Technique: P-ASA Injection<br />
  61. 61. Easy Learn: P-ASA Insertion Site <br />Step - 1<br />Area effected:<br />The P-ASA can produce pulpal anesthesia of the Central and Lateral Incisors and the associated hard and soft palatal tissues<br />Injection site:<br />Entry point is the incisive groove surrounding the incisive papilla<br />Final needle tip position is within the incisive canal <br />
  62. 62. Easy Learn: Anesthetic Pathway<br />Step - 2<br />What is the Pre-Puncture technique:<br />The technique allows you to penetrate and advance the needle through the palatal gingiva with minimal discomfort to the patient<br />How to perform:<br />Place bevel against surface with cotton-applicator on-top<br />Wait 8 seconds- then rotate and penetrate surface 1 - 2 mm <br />Advancement Pace: 1 - 2 mm then wait 4 seconds to allow anesthetic to proceed needle <br />Advance needle until bevel contacts surface of bone<br />
  63. 63. Clinical Technique: P-ASA Injection<br />
  64. 64. Lesson 5Tools needed to perform IA Block Injection<br />What you need to perform this injection:<br />Smaller Children: 30-g 1 inch – Bonded STA-Wand® Handpiece<br />Adolescents : 27-g 1 ¼ inch – Bonded STA-Wand® Handpiece<br />Normal Mode<br />
  65. 65. Lesson 5Performing IA Block Injection<br />What you need to Learn:<br />How to change to Normal Mode<br />How to use Cruise-control feature<br />How to perform Anesthetic Pathway Technique<br />How to use Bi-Rotational Insertion Technique<br />How to use STA-aspiration<br />How to use 2 speed operation<br />
  66. 66. Easy Learn: Bi-rotation Insertion<br />Bi-rotation Insertion technique:<br />This technique allows you to minimize needle deflection during insertion.<br />How to perform:<br />Rotate needle in a back-n-forth fashion<br />
  67. 67. Insertion Techniques<br />RotationalInsertion<br />Linear<br />Insertion<br />X<br />X<br /> Deflection<br />Linear <br />Rotational<br />
  68. 68. Easy Learn: 2-Speed Operation<br />Step - 1<br />Using “Normal” mode 2-speed operation:<br />You can more effectively and efficiently perform the IA Block using the 2-speeds <br /> How to use:<br />Depressing the foot control lightly allows you to start the injection using the ControFlo (slower) flow rate – Use for the first ¼ cartridge of IA Block<br />Depressing the foot control all the way down allows the second, more rapid rate to administer the remaining volume of anesthetic<br />1<br />2<br />
  69. 69. Easy Learn: Aspiration<br />Step - 2<br />Using Aspiration to prevent intravascular needle placement:<br />You can prevent needle placement into a vessel by use of aspiration <br /> How to use:<br />After completion of needle placement:<br />Press and then release foot-control pedal to activate aspiration, which is six beeps for the complete cycle<br />If you see blood in the needle hub, re-position needle and re-aspirate until negative observation<br />1<br />2<br />3<br />
  70. 70. Easy Learn: Anesthetic Pathway<br />Anesthetic Pathway technique:<br />This technique allows you to penetrate and advance the needle through the mucosa and soft-tissues with minimal discomfort to the patient. <br />How to perform:<br />Penetrate mucosa<br />Advancement Pace: 1- 2 mm then wait 4 seconds to allow anesthetic to proceed needle <br />Advance needle until contact against surface of bone<br />
  71. 71.
  72. 72. Lesson 6Performing Multi-Cartridge Block<br />
  73. 73.
  74. 74. Multi-cartridge<br />technique<br />Single insertion<br />Multiple Cartridges<br /><ul><li> Safe
  75. 75. Effective
  76. 76. Efficient</li></li></ul><li>Lesson 7Tools needed to Perform Supraperiosteal/Buccal Infiltration Injection<br />What you need to perform this injection:<br />30-g 1-inch Bonded STA-Wand®Handpiece<br />Normal Mode<br />
  77. 77. Lesson 7Performing Supraperiosteal/ Buccal Infiltration Injection<br />What you need to Learn:<br />How to change to Normal Mode<br />How to use Cruise-control feature<br />How to perform Anesthetic Pathway Technique<br />How to use STA-aspiration<br />How to use 2 speed operation<br />
  78. 78.
  79. 79. Easy Learn: Anesthetic Pathway<br />Anesthetic Pathway technique:<br />The technique allows you to penetrate and advance the needle through the mucosa and soft-tissues with minimal discomfort to the patient.<br />How to perform:<br />Penetrate mucosa<br />Advancement Pace: 1 - 2 mm then wait 4 seconds to allow anesthetic to proceed needle <br />Advance needle until contact against surface of bone<br />
  80. 80. Lesson 8Maintenance<br />What you need to Learn:<br />How to change to Lubricate and Service Plunger<br />How to clean and care for STA Drive Unit<br />
  81. 81. Advanced Features<br />What you need to Learn:<br />How and Why to use Multi-cartridge feature<br />How to change to Manual Plunger Operation<br />How to change de-activate Aspiration<br />How to adjust the Sound Volume control<br />How to change Mode of operation<br />
  82. 82. Advanced Lesson<br />A - Anesthetic Level Indicator<br />B - Auto Purge/Retract/Hold to Retract<br />C - Multi-Cartridge/Hold to Train Mode<br />D - Dynamic Pressure Indicator<br />E - STA Mode<br />F - Select Mode (Normal or Turbo)<br />G - Aspiration Button<br />H - Volume Control<br />I - Power Light<br />A<br />C<br />B<br />D<br />E<br />F<br />H<br />G<br />I<br />
  83. 83. Multi-CartridgeUsed for 2nd or 3rd Cartridge on Same Patient<br />While plunger is retracted, press Multi-Cartridge/Train Button<br />Indicator light turns ON<br />Remove empty cartridge; replace with new one<br />Insert cartridge holder onto top of STA; continue injection<br />STA defaults to Multi-Cartridge OFF after injection<br />
  84. 84. Auto Purge / Manual Purge<br />Auto Purge: default setting and will automatically purge air from the system when set up is complete<br />Manual Purge: press the Auto Purge Button B then depress the foot pedal to purge air from the system<br />B<br />
  85. 85. Plunger Retraction<br />Plunger Retracts Automatically:<br />When Auto Purge/RetractLight(A) is ON<br />When cartridge is emptied or when cartridge holder is removed<br /> Plunger Retracts Manually:<br />Push and hold Retract<br /> Button(B) for4+ seconds <br />A<br />B<br />
  86. 86. Aspiration<br />If not needed, Aspiration can be turned OFF, by pressing Aspirate button<br />After purging, STA defaults to Aspiration ON<br />
  87. 87. Cartridge Volume<br />LED lights indicate amount of anesthetic solution remaining<br />STA “bongs” once when ¼ cartridge is expressed, twice when ½ is expressed, and three times when ¾ is used<br />
  88. 88. Sound Volume Control <br />To Change Audible<br />Volume:<br />Press up arrow to increasevolume<br />Press down arrow to decrease volume<br />
  89. 89. Modes of operation:STA, Normal, Turbo<br />“Select” button change<br />A- STA Mode– 1 speed<br />ControlFlo only<br /> DPS® (Dynamic Pressure Sensing) <br />B - Normal Mode– 2 speedControlFloand RapidFlo<br /> C- Turbo Mode- 3 speed<br />ControlFlo, RapidFlo, and TurboFlo<br />A<br />B<br />C<br />
  90. 90. Foot Control and Mode Selections:<br />Depress Pedal Slightly<br />ControlFlo Speed <br />Used for Palatal and PDL injectionsexclusively<br />Start of all injections during the first ¼ cartridge <br />Depress Pedal Moderately<br />RapidFloSpeed<br />Infiltration & Mandibular Block<br />After first ¼ cartridge only<br />Depress Pedal Firmly<br />TurboFloSpeed<br />After first ½ cartridge only<br />
  91. 91. DPS® - Dynamic Pressure Sensing<br />Informs the Dentist of Correct Injection Site (PDL Space) with Ascending Lights and Sounds<br />Informs the Dentist if the Needle has Left the Correct Site<br />Informs the Dentist if the Needle has been Blocked<br />All Feedback Information in Real Time<br />
  92. 92. STA-Intraligamentary Injection Technique: DPS - Dynamic Pressure Sensing<br />Hold needle steadily in place with minimal pressure for approximately 15 seconds <br />Ascending tones and lights will indicate the needle is in the correct injection site, the periodontal ligament space<br />If ascending tones and lights are not initiated after 15 seconds, move needle slightly until the correct position is attained and lights and tones are seen and heard<br />
  93. 93. THE ROLE OF ccladIN Pediatric dentistry<br />
  94. 94. Behavioral Management <br />CCLAD technology has improved the overall acceptance of the anesthetic injection in the pediatric population leading to less disruptive behavior.<br />
  95. 95. References<br />Lieberman, William H. Clinical Session: The Wand. Pediatric Dent. 1999;21:2<br />Allen KD, Kotil D, Larzelere RE, Hutfless S, Beiraghi S. Comparison of a computerized anesthesia device with a traditional syringe in preschool children. Pediatric Dent. 2002 Jul-Aug;24(4): 315-20<br />
  96. 96. Pediatric <br />Restorative Dentistry<br />
  97. 97. Painless & Predictable<br />
  98. 98. Bi-Lateral<br />Restorative Dentistry<br />Efficient<br />
  99. 99. No Soft Tissue Numbness<br />No Lip Biting<br />
  100. 100. STA-IL Anterior Teeth<br />
  101. 101. Bevel orientation<br />
  102. 102. Mark the Bevel<br />
  103. 103. Patient Compliance<br />
  104. 104. Lack of Disruptive Behavior<br />
  105. 105. Prevent “Dripping”<br />
  106. 106. HAPPY PATIENTS<br />
  107. 107. Cooperative Patients<br />
  108. 108. Dr. Bill’s Helpful Tips<br />Needle choice <br /><ul><li> 30 gauge for all
  109. 109. 1” for older children mandibular blocks
  110. 110. ¾” for infiltration and blocks in younger children
  111. 111. ½” for STA (periodontal ligament injection)</li></li></ul><li>Dr. Bill’s Helpful Tips<br />Break the Wand for any injection to better “cup” the needle<br />Mark the bevel with a permanent marker <br />Bend the needle with caution, as needed, for a better angle<br />
  112. 112. Dr. Bill’s Helpful Tips<br />Instrument location - LED’s should be clearly visible to operator & within reach<br />Start instrument prior to injection to avoid startling the patient<br />Use cruise control- NEVER turbo w/ pediatric patient<br />
  113. 113. Dr. Bill’s Helpful Tips<br />Avoid dripping the anesthetic in the mouth - the bitter taste is the easiest way to lose a compliant patient<br /> Develop a consistent pattern of injection site (distolingual is best due to anatomy if manageable)<br />
  114. 114. Rule of 2’s for STA: <br /><ul><li>20 seconds MAXIMUM time to be in one location
  115. 115. 2 minute window to begin procedure
  116. 116. 20 minutes to complete treatment</li></ul>Watch the videos on the website…very helpful! www.STAis4U.com<br />Dr. Bill’s Helpful Tips<br />
  117. 117. Timeliness <br />
  118. 118. Summary<br /><ul><li>Audible & visible assurance of pulpal anesthesia
  119. 119. Painless- minimizes disruptive behavior
  120. 120. Immediate onset of anesthesia
  121. 121. no delay is important for a child’s short attention span
  122. 122. saves chair time
  123. 123. Multiple quadrants at the same visit
  124. 124. No soft tissue numbness - no risk of lip biting</li></li></ul><li>Thank You Dr. Mark Hochman!<br />
  125. 125. Our office mission statement includes “to create an atmosphere that allows the pediatric patient to succeed”. Nothing helps more than successful, painless anesthesia with no risk of collateral soft tissue damage from lip biting.<br />

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