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 ...
We Really Need Adequate LA
We Really Need Adequate LA




                        8
Factors Effecting Duration
             In Perio Cases
• Variation in
  individual response
  – Different pts will
    res...
Short Acting
• Short acting
  – pulpal anesthesia = approx 30 min.
  – Soft tissue anesthesia = approx 1.5 hrs
     • Mepi...
• Intermediate Acting
Typical LA’s      – pulpal anesthesia =
                    approx 60 min.
                  – Soft ...
Pharmacology of LA’s
• With infilration anesthesia the amounts
  used can get high in perio cases.
  – Half mouth root pla...
Systemic Effects of Dental LA’s
                     –       Distribution
                         •     once absorbed int...
Pharmacology of LA’s
• How they are metabolized:
  – Liver
  – Enzymes in the bloodstream
• Toxicity depends on [LA] in th...
Maximum Recommended
            Doses for Typical LA’s
• Short acting
  – Mepivicaine 3% (54mg per carpule)
        – Carb...
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
  – Apprehensio...
Toxicity depends on how
      much LA is in the
         bloodstream
• At higher toxic OD levels, the primary
  clinical m...
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 ...
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
 ...
Beta Blockers
• Cardioselective(β-1)
   – acebutol(Sectral), atenolol(Tenormin), betaxolol
     (Kerlone), bisoprolol(Zebe...
Why Can’t We Use Epi in
Pregnant Patients?
  • Crosses the Placeneta
  • Pregnancy Category C
    – Evidence of teratogeni...
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




       ...
Basic Injection
 Technique
• Armamentarium
  – Needle Sizes
    • 30 Gauge
       – smallest used
       – Dark blue
     ...
Workhorses For Infiltration




                          31
Basic Injection Technique
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
  ...
Common Causes of
             Discomfort
• (1) Initial puncture.
   – This can be reduced by use of topical anesthetic and...
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
    bol...
44
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 ...
Walking the LA fluid mesial
• Third carpule –
   – Use Lidocaine and
     inject into original
     site (premolar/canine
...
What If The Palate Needs
       More Pain Control?
• Multiple infiltrations   • Aim for the nasopalatine
                 ...
What If The Palate Needs
More Pain Control?
I Got Tired Of Peeling People
       Off The Ceiling
52
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
...
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...
Basic Mental Foramen
Injection and Anatomy




                        60
61
How Do We Obtain Lingual
Anesthesia?
How Do We Obtain Lingual
Anesthesia?
• The same way we
  obtained palatal
  anesthesia….
  – Multiple Interseptal
    inje...
64
65
Do Not Forget The Crossover
 On The Buccal And The

• Still add LA in the
  floor of the mouth
  just lingual to the
  lat...
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 in...
Timeline for Accomplishing Half-mouth Sc and RP
1. Start with about 3 carpules
   – 2 carpules in the max.
           • Ci...
Practically Speaking
 • How do you know when to block the
   lower arch?
   – Self report tooth sensitivity
   – Operator ...
Inferior Nerve Block
Needle insertion point for
block              • Topical
                    • Use 30 g first
                    • Open wi...
Numb the needle tract first




• Use long 30 g needle and inject as you advance
• Not looking for successful block on fir...
Needle Tract
Anesthesia Examples
Needle Tract
Anesthesia Examples
Complications
• Bleeding
• Buccal fat pad
• Epi rxn
• Sensation of throat enlarging
• Sensation of not being able to breat...
For Profound Anesthesia
                 • Tingling and
                   numbness
                   does not mean
     ...
Mylohyoid Nerve
Penetration Depth For Block
                     • Use 27 g
                     • “Need to
                       contact...
Concluding Remarks
• Causes of Discomfort during Injection
  – Choice of needle and anesthetic
  – Initial puncture
    • ...
81
82
Supplemental Injection
• Mylohyoid nerve
Height of Injection
Block Anesthesia Example
               • Use 27 g
               • “Need to contact
                 bone”
              ...
Causes of Discomfort during
    Injection
•   This can be reduced by use of topical anaesthetic and by
    keeping the sur...
Any Questions??????????
How Do We Obtain Lingual
Anesthesia?
Needle Tract
Infiltration on the
 Mandibular Arch
Example of Anesthetizing Cross-over
How Do We Obtain Lingual
Anesthesia?
Mental and buccal nerve




               Nerves Of Interest For Infiltration
                   Mental Nerve
           ...
Long Island Periodontist presents "The Art and Science of the Painless Dental Injection"
Long Island Periodontist presents "The Art and Science of the Painless Dental Injection"
Long Island Periodontist presents "The Art and Science of the Painless Dental Injection"
Long Island Periodontist presents "The Art and Science of the Painless Dental Injection"
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Long Island Periodontist presents "The Art and Science of the Painless Dental Injection"

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Periodontist who does his best when he provides Long Island with treatment for tooth and gum disease. Dentist, dental implants, laser gum treatment for periodontal disease, bone graft, gum surgery.

Explanation of how to give dental injections without causing the patient pain.

Published in: Health & Medicine

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

  1. 1. The Art and Science of the Painless Injection Edward Brant DDS, MS St. James, NY
  2. 2. Welcome, Your Patients Thank you 2
  3. 3. Origins of my commitment 3
  4. 4. With all the benefits of LA-Pts hate getting the needle 4
  5. 5. 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
  6. 6. We Really Need Adequate LA
  7. 7. We Really Need Adequate LA 8
  8. 8. Factors Effecting Duration In Perio Cases • Variation in individual response – Different pts will respond differently to any drug. – Hyporesponders and Hyperresponders
  9. 9. Short Acting • Short acting – pulpal anesthesia = approx 30 min. – Soft tissue anesthesia = approx 1.5 hrs • Mepivicaine 3% (54mg per carpule) – (Polocaine, Carbocaine, Scandonest)
  10. 10. • 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
  11. 11. 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.
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. Half-Life of Dental LA’s
  16. 16. General Rule for Avoiding Toxic Doses • One Carpule for every 20 pounds 18
  17. 17. 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
  18. 18. 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
  19. 19. General Considerations • LA overdose can occur more easily in: – Children – The ederly – Medically complex pts
  20. 20. 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
  21. 21. Why Do We Use Epinephrine • Retard Systemic Absorption • Prolonged Effect 23
  22. 22. How Much Epi Can We Give? 24
  23. 23. 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
  24. 24. 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)
  25. 25. 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
  26. 26. Pregnancy Risk Classification of Local Anesthestics
  27. 27. Recap • Why • What Do We Use • How Do LA’s Work • How Much To Use • What Happens If We Give Too Much 29
  28. 28. 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
  29. 29. Workhorses For Infiltration 31
  30. 30. Basic Injection Technique
  31. 31. Basic Injection Technique
  32. 32. Placement of the Topical
  33. 33. Basic Injection Technique
  34. 34. "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.
  35. 35. 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
  36. 36. Tissue taut vsualize the needle tip at membrane
  37. 37. Continuously inject while advancing
  38. 38. Tissue taut - pull tissue over needle tip for initial puncture
  39. 39. Finger Rests, Tissue taut, mucosa is pulled over needle tip 42
  40. 40. 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
  41. 41. 44
  42. 42. The Most Pain Free Area to Inject in the Max Arch
  43. 43. Anatomical Considerations For Maxillary Arch Infiltration
  44. 44. 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.
  45. 45. 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
  46. 46. What If The Palate Needs More Pain Control? • Multiple infiltrations • Aim for the nasopalatine and greater palantine foramens
  47. 47. What If The Palate Needs More Pain Control?
  48. 48. I Got Tired Of Peeling People Off The Ceiling
  49. 49. 52
  50. 50. Multiple Intraseptals • Will give overlapping areas of anesthetize palatal gingiva
  51. 51. Interseptal Injection
  52. 52. Bend the needle to facilitate access
  53. 53. Example of Intraseptal for Palatal anesthesia
  54. 54. 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
  55. 55. Conclusion of Maxillary Injection Technique • Questions • Basic Armamentarium • Basic Technique
  56. 56. 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
  57. 57. Basic Mental Foramen Injection and Anatomy 60
  58. 58. 61
  59. 59. How Do We Obtain Lingual Anesthesia?
  60. 60. 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
  61. 61. 64
  62. 62. 65
  63. 63. 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
  64. 64. Buccal and Lingual Crossover Analgesia and PDL of Contralateral Centaral Incisor 67
  65. 65. Supplemental Injection • PDL Injection – Used most commonly to anesthetize the contra-lateral central incisor – Any tooth in the quad that requires pulpal anesthesia
  66. 66. 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.
  67. 67. 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
  68. 68. Inferior Nerve Block
  69. 69. Needle insertion point for block • Topical • Use 30 g first • Open wide
  70. 70. 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
  71. 71. Needle Tract Anesthesia Examples
  72. 72. Needle Tract Anesthesia Examples
  73. 73. 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
  74. 74. For Profound Anesthesia • Tingling and numbness does not mean you have profound anesthesia
  75. 75. Mylohyoid Nerve
  76. 76. 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
  77. 77. 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
  78. 78. 81
  79. 79. 82
  80. 80. Supplemental Injection • Mylohyoid nerve
  81. 81. Height of Injection
  82. 82. 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
  83. 83. 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
  84. 84. Any Questions??????????
  85. 85. How Do We Obtain Lingual Anesthesia?
  86. 86. Needle Tract
  87. 87. Infiltration on the Mandibular Arch
  88. 88. Example of Anesthetizing Cross-over
  89. 89. How Do We Obtain Lingual Anesthesia?
  90. 90. 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

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