Long Island Periodontist presents "The Art and Science of the Painless Dental Injection"

The Art and Science of the Painless Injection Edward Brant DDS, MS St. James, NY

Welcome, Your Patients Thank you 2

Origins of my commitment 3

With all the benefits of LA-Pts hate getting the needle 4

Benefits of a Pain Free Practice • Low stress to pt and operator • Render care comfortably and predictably • Pt loyalty and increased case acceptance • External Marketing

We Really Need Adequate LA

We Really Need Adequate LA 8

Factors Effecting Duration In Perio Cases • Variation in individual response – Different pts will respond differently to any drug. – Hyporesponders and Hyperresponders

Short Acting • Short acting – pulpal anesthesia = approx 30 min. – Soft tissue anesthesia = approx 1.5 hrs • Mepivicaine 3% (54mg per carpule) – (Polocaine, Carbocaine, Scandonest)

• Intermediate Acting Typical LA’s – pulpal anesthesia = approx 60 min. – Soft tissue anesthesia = approx 2.5-4 hrs • Lidocaine 2% with 1:100,000 epinephrine (36 mg per carpule) – Xylocaine with epinephrine • Articaine 4% with 1:100,000 epinephrine (72mg per carpule) – Septocaine with epinephrine • Prilocaine 4% with 1:200,000 epinephrine (72mg per carpule) – (Citanest Forte with Epinephrine

Pharmacology of LA’s • With infilration anesthesia the amounts used can get high in perio cases. – Half mouth root planing and full mouth prophys with LA • We will review side effects we want to avoid. • We will review the maximum dose of individual LA’s.

Systemic Effects of Dental LA’s – Distribution • once absorbed into the blood, LA’s are distributed throughout the body to all tissues. – Higher the blood levels the greater the clinical action – Usual concentrations no effect is noted • amount is so well diluted to have any effect

Pharmacology of LA’s • How they are metabolized: – Liver – Enzymes in the bloodstream • Toxicity depends on [LA] in the bloodstream. • Rate of removal is dependent on the chemical make up of the LA in use – Half-life = 50% reduction in Blood

Maximum Recommended Doses for Typical LA’s • Short acting – Mepivicaine 3% (54mg per carpule) – Carbocaine 5.5 Carpules – Prilocaine 4% (72mg per carpule) – Citanest Plain 8 Carpules • Intermediate Acting • Lidocaine 2% with 1:100,000 epinephrine (36 mg per carpule) – Xylocaine 11 Carpules • Articaine 4% with 1:100K and 1:200K epinephrine (72mg per carpule) – Septocaine 7 Carpules • Prilocaine 4% with 1:200,000 epinephrine (72mg per carpule) – Citanest with Epinephrine 8 Carpules

Half-Life of Dental LA’s

General Rule for Avoiding Toxic Doses • One Carpule for every 20 pounds 18

Toxicity depends on how much LA is in the bloodstream • Low/Moderate Overdose Levels – Confusion – Apprehension – Restlessness – Slurred Speech – Muscular Twitching / tremor of the face – Elevated HR, BP, RR

Toxicity depends on how much LA is in the bloodstream • At higher toxic OD levels, the primary clinical manifestation is a generalized tonic-clonic convulsion. • At even higher levels generalized CNS depression

General Considerations • LA overdose can occur more easily in: – Children – The ederly – Medically complex pts

Overdose of LA - Treatment • Stop dental treatment • Oxygen • Monitor vital signs • Reassure patient, allow time for drug to distribute and be metabolized • If pt becomes unstable, Activate EMS

Why Do We Use Epinephrine • Retard Systemic Absorption • Prolonged Effect 23

How Much Epi Can We Give? 24

Use of Epinephrine in Local Anesthetics in Patients With Significant Cardiovascular Disease • Numerous studies have demonstrated that 1-2 carpules of 1:100,000 epi does cause a rise in plasma levels of epi but without significant CV effects • Use in Modest amounts 25

Beta Blockers • Cardioselective(β-1) – acebutol(Sectral), atenolol(Tenormin), betaxolol (Kerlone), bisoprolol(Zebeta), metoprolol (Lopressor) metoprololextended release (Toprol XL) • Non-Selective (β-1&2) • cartelol (Cartrol), labetalol(Trandate), nadolol (Corgard), penbutolol(Levatol), pindolol(Visken), propanolol(Inderal), propanolol long-acting (Inderal LA), sotalol(Betapace), timolol (Blocadren)

Why Can’t We Use Epi in Pregnant Patients? • Crosses the Placeneta • Pregnancy Category C – Evidence of teratogenicity • Decreased placental blood flow – Risk of fetal hypoxia • Elevated blood glucose 27

Pregnancy Risk Classification of Local Anesthestics

Recap • Why • What Do We Use • How Do LA’s Work • How Much To Use • What Happens If We Give Too Much 29

Basic Injection Technique • Armamentarium – Needle Sizes • 30 Gauge – smallest used – Dark blue – Used for all hygiene (infiltration) procedures • 27 Gauge – Largest used for block Anesthesia • 25 Gauge – Not used by Dr. Brant

Workhorses For Infiltration 31

Basic Injection Technique

Placement of the Topical

Basic Injection Technique

"Gate Control Theory" • "Everyone has two different types of nerves. One type transmits pain and the other transmits movement and pressure." • "It is an interesting fact that the nerves which transmit movement and pressure actually block some of the transmission of pain from the other nerves. Everyone has heard of rubbing something if it hurts." • The pressure and movement should continue during the initial puncture and administration of local anesthetic.

Common Causes of Discomfort • (1) Initial puncture. – This can be reduced by use of topical anesthetic and by keeping the surrounding tissues taut. Applying pressure or movement at the proposed injection site, immediately prior to the initial puncture, often reduces the experience of pain. • (2) Rapid administration. – The anesthetic should be administered very slowly to avoid tissue trauma. • (3) Misinterpretation of cold anesthetic. – If the local anesthetic is warmed to blood temperature before use the risk of any sensation is greatly reduced, especially if it is a cold day. The cartridge may be warmed under hot running water from a tap immediately prior to use. • (4) Choice of anesthetic – Ctianest vs Marcaine – pH and preservatives

Tissue taut vsualize the needle tip at membrane

Continuously inject while advancing

Tissue taut - pull tissue over needle tip for initial puncture

Finger Rests, Tissue taut, mucosa is pulled over needle tip 42

Basic Injection Technique • Continuous Slow Injection while advancing – Need to deposit at apices and move the bolus laterally. • Once at the target - slow administration • Aspiration not needed for infiltration

The Most Pain Free Area to Inject in the Max Arch

Anatomical Considerations For Maxillary Arch Infiltration

Walking the LA fluid mesial and distal • First carpule – aim to numb the mesial of the first molar to the distal of the canine – Use Citanest plain if possible • Burns the least, no epi needed at this early stage • Second Carpule – use the areas that are already numb and walk the anesthetic to the distal (2nd molar) and mesial (no more anterior than the distal of the lateral). – Use Lidocaine with 1:100k epi – Central and Lateral incisor prone to discomfort- allow for LA to diffuse into these areas.

Walking the LA fluid mesial • Third carpule – – Use Lidocaine and inject into original site (premolar/canine area) to help ensure profound buccal anesthesia and probable palatal anesthesia. – Walk anesthesia towards the labial frenum stopping at the distal of the central incisor

What If The Palate Needs More Pain Control? • Multiple infiltrations • Aim for the nasopalatine and greater palantine foramens

What If The Palate Needs More Pain Control?

I Got Tired Of Peeling People Off The Ceiling

Multiple Intraseptals • Will give overlapping areas of anesthetize palatal gingiva

Interseptal Injection

Bend the needle to facilitate access

Example of Intraseptal for Palatal anesthesia

Factors Effecting The Success of Infiltration in • Lack of pulpal Anesthesia – Canine – Molar • Very Often Palatal Infiltration Not Needed But Pt Anxiety and Anatomic Variation • Buccal alveolar bone can be more dense in some individuals

Conclusion of Maxillary Injection Technique • Questions • Basic Armamentarium • Basic Technique

Anatomical Considerations For Mandibular Arch • Nerves Of Interest For Infiltration – Mental Nerve – Long Buccal Nerve – Lingual Nerve – Mylohyoid Nerve • Other Mandibular Nerves Which Exist Within The Bone: – Inferior Alveolar Nerve

Basic Mental Foramen Injection and Anatomy 60

How Do We Obtain Lingual Anesthesia?

How Do We Obtain Lingual Anesthesia? • The same way we obtained palatal anesthesia…. – Multiple Interseptal injections – Interseptal injection in the second premolar/molar area and walk it lingually, then distally. – Give LA at midline

Do Not Forget The Crossover On The Buccal And The • Still add LA in the floor of the mouth just lingual to the lateral/canine area • Walk the bolus to the central incisor area of the quad you are working on

Buccal and Lingual Crossover Analgesia and PDL of Contralateral Centaral Incisor 67

Supplemental Injection • PDL Injection – Used most commonly to anesthetize the contra-lateral central incisor – Any tooth in the quad that requires pulpal anesthesia

Timeline for Accomplishing Half-mouth Sc and RP 1. Start with about 3 carpules – 2 carpules in the max. • Citanest then Lidocaine 1:100k epi • 1 carpules in the mand. • Citanest 1:200k epi 2. Perform OHI 3. Give another carpule in the Maxillary arch. – Lidocaine 1:100k epi 4. Begin the Sc and RP in the Max arch. 5. Before finishing the maxillary arch infiltrate the lower arch with 2 carpules. – Septocaine 1:200k epi 6. Complete the maxillary arch. 7. Perform supplemental injections as needed. – Lidocaine or septocaine 8. Begin and complete the Sc and RP in the mandibular arch.

Practically Speaking • How do you know when to block the lower arch? – Self report tooth sensitivity – Operator is familiar with pt – Air blast the teeth – Overly anxious pt

Inferior Nerve Block

Needle insertion point for block • Topical • Use 30 g first • Open wide

Numb the needle tract first • Use long 30 g needle and inject as you advance • Not looking for successful block on first injection • Use about 1/2th the carp on the way and the other 1/2th at depth

Needle Tract Anesthesia Examples

Complications • Bleeding • Buccal fat pad • Epi rxn • Sensation of throat enlarging • Sensation of not being able to breath – Can’t breath after greater palatine block or topical in throat • Hematoma • Needle Breakage

For Profound Anesthesia • Tingling and numbness does not mean you have profound anesthesia

Mylohyoid Nerve

Penetration Depth For Block • Use 27 g • “Need to contact bone” • Needle tract anesthesia gives confidence to operator to move needle around • 2/3rds to 3/4th the length of a long needle

Concluding Remarks • Causes of Discomfort during Injection – Choice of needle and anesthetic – Initial puncture • Correct use of topical, tissue taut, shallow penetration – Slow and constant administration • Go out there and do it!! • Write down if you would desire a practical portion of these techniques

Supplemental Injection • Mylohyoid nerve

Height of Injection

Block Anesthesia Example • Use 27 g • “Need to contact bone” • Needle tract anesthesia gives confidence to operator to move needle around • 2/3rds to 3/4th the length of a long needle

Causes of Discomfort during Injection • This can be reduced by use of topical anaesthetic and by keeping the surrounding tissues taut. Applying pressure or movement at the proposed injection site, immediately prior to the initial puncture, often reduces the experience of pain. (2) The anaesthetic should be administered very slowly to avoid tissue trauma. (3) Misinterpretation of cold anaesthetic. If the local anaesthetic is warmed to blood temperature before use the risk of any sensation is greatly reduced, especially if it is a cold day. The cartridge may be warmed under hot running water from a tap immediately prior to use. • (4) – Ctianest vs Marcaine – pH and preservatives

Any Questions??????????

Needle Tract

Infiltration on the Mandibular Arch

Example of Anesthetizing Cross-over

Mental and buccal nerve Nerves Of Interest For Infiltration Mental Nerve Long Buccal Nerve Lingual Nerve Other Mandibular Nerves Which Exist Within The Bone: Inferior Alveolar Nerve Incisive Nerve

Long Island Periodontist presents "The Art and Science of the Painless Dental Injection"

by Edward Brant DDS, MS

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