This document discusses the armamentarium for local anesthesia injections in dentistry. It describes the key components which include the syringe, needle, and local anesthetic cartridge. It provides details on the types of syringes available, including non-disposable and disposable options. It also discusses needles in terms of gauge, length, and proper handling. The local anesthetic cartridge is described in terms of its components and potential problems. Recommendations are provided for proper storage and use of cartridges.
The document discusses the components of the local anesthetic armamentarium including syringes, needles, and cartridges. It describes different types of syringes such as non-disposable, disposable, safety, and computer-controlled syringes. It also discusses needles in terms of bevel, gauge, and length. For cartridges it describes the components, color coding, and composition of the local anesthetic solution. It provides recommendations for proper care and handling of the components to avoid problems such as leakage, breakage, deposits and corrosion.
This document discusses local anesthesia equipment and techniques. It describes different types of syringes used to administer local anesthetics including non-disposable, disposable, safety, and computer-controlled syringes. It also discusses dental needles in terms of gauge, length, and potential clinical problems. The dental cartridge components and potential issues are explained. Topical anesthetics are recommended to be applied before needle penetration to minimize pain.
This document discusses various aspects of parental administration of medication including definitions, methods of administration, standards, equipment, and specific injection techniques. It provides details on:
- The different routes of administration including oral, topical, inhalation, irrigation, and parental routes.
- The "5 rights" that must be followed for proper administration.
- Equipment used for injections including syringes, needles, and their classification and parts.
- Specific injection techniques including intradermal, subcutaneous, intramuscular, and recommended sites, angles, and volumes for each.
The document discusses the equipment used for local anesthesia administration in dentistry. It includes the syringe, needle, and local anesthetic cartridge. The syringe consists of a metal barrel, plunger, and screw hub. There are aspirating and non-aspirating dental syringes as well as pressure syringes. Needle selection considers gauge size and length. Cartridges contain a glass tube, stopper, aluminum cap, and diaphragm. Clinical problems include leakage during injection, bubbles in the cartridge, broken cartridges, burning sensation, and pain during needle insertion or withdrawal. Safety measures like sharp disposable needles and proper needle positioning are discussed.
This document provides information on suture materials and techniques. It discusses the anatomy of skin, definitions of suturing terms, goals of suturing, ideal suture requirements, suturing armamentarium including needles and needle holders. It also covers various suture materials like catgut, silk, nylon, linen; their properties, manufacturing process, sterilization methods and uses. Principles of suture selection and different suturing techniques are also explained.
The document discusses the components of the local anesthetic armamentarium including syringes, needles, and cartridges. It describes different types of syringes such as non-disposable, disposable, safety, and computer-controlled syringes. It also discusses needles in terms of bevel, gauge, and length. For cartridges it describes the components, color coding, and composition of the local anesthetic solution. It provides recommendations for proper care and handling of the components to avoid problems such as leakage, breakage, deposits and corrosion.
This document discusses local anesthesia equipment and techniques. It describes different types of syringes used to administer local anesthetics including non-disposable, disposable, safety, and computer-controlled syringes. It also discusses dental needles in terms of gauge, length, and potential clinical problems. The dental cartridge components and potential issues are explained. Topical anesthetics are recommended to be applied before needle penetration to minimize pain.
This document discusses various aspects of parental administration of medication including definitions, methods of administration, standards, equipment, and specific injection techniques. It provides details on:
- The different routes of administration including oral, topical, inhalation, irrigation, and parental routes.
- The "5 rights" that must be followed for proper administration.
- Equipment used for injections including syringes, needles, and their classification and parts.
- Specific injection techniques including intradermal, subcutaneous, intramuscular, and recommended sites, angles, and volumes for each.
The document discusses the equipment used for local anesthesia administration in dentistry. It includes the syringe, needle, and local anesthetic cartridge. The syringe consists of a metal barrel, plunger, and screw hub. There are aspirating and non-aspirating dental syringes as well as pressure syringes. Needle selection considers gauge size and length. Cartridges contain a glass tube, stopper, aluminum cap, and diaphragm. Clinical problems include leakage during injection, bubbles in the cartridge, broken cartridges, burning sensation, and pain during needle insertion or withdrawal. Safety measures like sharp disposable needles and proper needle positioning are discussed.
This document provides information on suture materials and techniques. It discusses the anatomy of skin, definitions of suturing terms, goals of suturing, ideal suture requirements, suturing armamentarium including needles and needle holders. It also covers various suture materials like catgut, silk, nylon, linen; their properties, manufacturing process, sterilization methods and uses. Principles of suture selection and different suturing techniques are also explained.
This document provides information on microsurgery and microsurgical instruments. It discusses the history of magnification in surgery and introduces microsurgery. Key aspects of microsurgery include enhanced visualization through a microscope and less traumatic tissue handling. The document then describes different types of magnification systems used, including loupes and surgical microscopes. It outlines the benefits of microscopes and characteristics of ideal surgical loupes. Microsurgical instruments are also introduced, including scalpels, needles, sutures, needle holders, and forceps. Proper storage of microinstruments is also mentioned.
Ensuring patient safety and comfort is crucial for any medical procedure, and choosing the right anesthesia needles plays a vital role in achieving this. Anesthesia needles are used to administer anesthesia, which numbs the patient’s sensation during a medical procedure. There are various types of anesthesia needles available in the market, and selecting the appropriate one for your patients is crucial. In this blog post, we will discuss how to choose the right anesthesia needle for your patients to ensure their safety and comfort.
Dental syringes come in plastic disposable or metal reusable varieties. Metal syringes can load cartridges from the side or end. Aspirating syringes have a harpoon on the piston to engage cartridges, while non-aspirating syringes do not. Dental syringe needles come in short or long lengths for different procedures, and different gauges with smaller numbers indicating larger diameters. Proper needle technique is important to minimize pain and risk of breakage.
● As young children, most of us have feared visiting the doctor and getting a shot, considering that it involved the use of syringes, which usually implies the administration of medicines or vaccines.
Intramuscular injections deliver medication into muscles through the skin and subcutaneous tissue. They allow for faster drug absorption than subcutaneous injections due to muscles having more blood vessels. The correct technique involves using a 23G needle at a 72-90 degree angle and rotating injection sites. Potential complications include abscesses, cellulitis, and nerve damage.
The document discusses the armamentarium used for dental injections, including the components of syringes, local anesthetic cartridges, needles, and best practices for their use. It describes the parts of aspirating syringes, local anesthetic cartridges, characteristics of different gauge needles, and proper techniques for administering injections to reduce patient discomfort and risk of complications.
If you’re looking to enhance your beauty routine or explore new ways to achieve your desired aesthetic results, then you’ve come to the right place. We’ll cover everything you need to know about aesthetic cannulas, from what they are to how to choose the right one for your procedure.
This document discusses various techniques for mandibular anesthesia. It describes 8 types of syringes used in dentistry and criteria they should meet. It also discusses different types of injections including inferior alveolar nerve blocks, which have a high success rate but also risks like trismus. Proper technique is important for IANBs and involves identifying landmarks and inserting the needle at the right height, depth and orientation. The document provides guidance on caring for and handling equipment like syringes, needles and cartridges to minimize risks to patients and staff.
This document introduces common surgical instruments used in oral and maxillofacial surgery. It describes scalpel blades, periosteal elevators, retractors, forceps for grasping tissue and controlling hemorrhage, bone cutting instruments like rongeurs and chisels, instruments for removing soft tissue from bone, suturing tools like needle holders and suture materials, dental extraction instruments like elevators and forceps, and various trays used in oral surgery procedures. The purpose is to familiarize residents with the basic instrumentation required to perform routine dental extractions and other oral surgical operations.
Surgical instruments are specially designed tools used to modify tissue or provide access during surgery. Common instruments include scalpels, forceps, scissors, needles, and retractors. Proper handling is important for safety, efficiency of movement, and to prevent damage to tissues and instruments. Scalpels should be held like a pen for precise cuts. Needles should be held two-thirds from the tip. Scissors and forceps are held with fingers in the rings. Hemostats are used gently to clamp vessels. Electrocautery uses a pen grip with the index finger as a trigger. Proper handling allows surgery to be facilitated with minimal tissue damage.
This document discusses personal protective equipment (PPE) used in healthcare settings. It covers various types of PPE like gloves, masks, gowns and drapes. It describes when each type should be used and how to correctly put on and remove PPE like gloves and masks. The key learning objectives are to list different PPE, describe their uses and limitations, and demonstrate proper donning and doffing of equipment.
This document discusses appropriate use of personal protective equipment (PPE) by healthcare workers. It describes different types of PPE including gloves, gowns, masks, goggles, and shoe/head covers. The key points are: PPE should be chosen based on the risk of exposure to infectious materials; sterile PPE is needed for surgical procedures while other PPE provides barrier or fluid protection; PPE must be properly donned and removed to be effective, with hand hygiene performed before and after; when used correctly, PPE prevents exposure of healthcare workers to infectious pathogens.
This document provides guidance on the appropriate use of personal protective equipment (PPE) by healthcare workers. It defines what PPE is and discusses various types of PPE like gloves, gowns, masks, goggles, and shoe/head covers. For each type of PPE, it describes available options and provides recommendations on when they should be worn to protect against infectious pathogens. The goal is to educate healthcare workers on selecting and using proper PPE depending on the level of anticipated contact with patients' body fluids.
Minimal invasive plate osteosynthesis (MIPO) is a surgical technique that uses small incisions and limited soft tissue dissection to place a plate on a bone. This helps preserve the bone's blood supply and leads to better healing outcomes. Key aspects of MIPO include indirect reduction of fractures, minimal soft tissue stripping, and use of plates that provide stability without requiring direct bone contact.
This document discusses suturing techniques and wound closure. It covers the stages of wound healing, indications and contraindications for suturing, types of suture materials, local anesthetic administration, and techniques for simple interrupted sutures and vertical mattress sutures. Alternative closure methods like steri strips and surgical glue are also reviewed. The goal of wound closure is healing without infection, scarring or deformity.
This document discusses suturing techniques and wound closure. It covers the stages of wound healing, indications and contraindications for suturing, types of suture materials, local anesthetic administration, and techniques for simple interrupted sutures and vertical mattress sutures. The document also reviews alternative closure methods, post-closure care, and intended learning outcomes for understanding suturing procedures.
Computer in pharmaceutical research and development-Mpharm(Pharmaceutics)MuskanShingari
Statistics- Statistics is the science of collecting, organizing, presenting, analyzing and interpreting numerical data to assist in making more effective decisions.
A statistics is a measure which is used to estimate the population parameter
Parameters-It is used to describe the properties of an entire population.
Examples-Measures of central tendency Dispersion, Variance, Standard Deviation (SD), Absolute Error, Mean Absolute Error (MAE), Eigen Value
This document provides information on microsurgery and microsurgical instruments. It discusses the history of magnification in surgery and introduces microsurgery. Key aspects of microsurgery include enhanced visualization through a microscope and less traumatic tissue handling. The document then describes different types of magnification systems used, including loupes and surgical microscopes. It outlines the benefits of microscopes and characteristics of ideal surgical loupes. Microsurgical instruments are also introduced, including scalpels, needles, sutures, needle holders, and forceps. Proper storage of microinstruments is also mentioned.
Ensuring patient safety and comfort is crucial for any medical procedure, and choosing the right anesthesia needles plays a vital role in achieving this. Anesthesia needles are used to administer anesthesia, which numbs the patient’s sensation during a medical procedure. There are various types of anesthesia needles available in the market, and selecting the appropriate one for your patients is crucial. In this blog post, we will discuss how to choose the right anesthesia needle for your patients to ensure their safety and comfort.
Dental syringes come in plastic disposable or metal reusable varieties. Metal syringes can load cartridges from the side or end. Aspirating syringes have a harpoon on the piston to engage cartridges, while non-aspirating syringes do not. Dental syringe needles come in short or long lengths for different procedures, and different gauges with smaller numbers indicating larger diameters. Proper needle technique is important to minimize pain and risk of breakage.
● As young children, most of us have feared visiting the doctor and getting a shot, considering that it involved the use of syringes, which usually implies the administration of medicines or vaccines.
Intramuscular injections deliver medication into muscles through the skin and subcutaneous tissue. They allow for faster drug absorption than subcutaneous injections due to muscles having more blood vessels. The correct technique involves using a 23G needle at a 72-90 degree angle and rotating injection sites. Potential complications include abscesses, cellulitis, and nerve damage.
The document discusses the armamentarium used for dental injections, including the components of syringes, local anesthetic cartridges, needles, and best practices for their use. It describes the parts of aspirating syringes, local anesthetic cartridges, characteristics of different gauge needles, and proper techniques for administering injections to reduce patient discomfort and risk of complications.
If you’re looking to enhance your beauty routine or explore new ways to achieve your desired aesthetic results, then you’ve come to the right place. We’ll cover everything you need to know about aesthetic cannulas, from what they are to how to choose the right one for your procedure.
This document discusses various techniques for mandibular anesthesia. It describes 8 types of syringes used in dentistry and criteria they should meet. It also discusses different types of injections including inferior alveolar nerve blocks, which have a high success rate but also risks like trismus. Proper technique is important for IANBs and involves identifying landmarks and inserting the needle at the right height, depth and orientation. The document provides guidance on caring for and handling equipment like syringes, needles and cartridges to minimize risks to patients and staff.
This document introduces common surgical instruments used in oral and maxillofacial surgery. It describes scalpel blades, periosteal elevators, retractors, forceps for grasping tissue and controlling hemorrhage, bone cutting instruments like rongeurs and chisels, instruments for removing soft tissue from bone, suturing tools like needle holders and suture materials, dental extraction instruments like elevators and forceps, and various trays used in oral surgery procedures. The purpose is to familiarize residents with the basic instrumentation required to perform routine dental extractions and other oral surgical operations.
Surgical instruments are specially designed tools used to modify tissue or provide access during surgery. Common instruments include scalpels, forceps, scissors, needles, and retractors. Proper handling is important for safety, efficiency of movement, and to prevent damage to tissues and instruments. Scalpels should be held like a pen for precise cuts. Needles should be held two-thirds from the tip. Scissors and forceps are held with fingers in the rings. Hemostats are used gently to clamp vessels. Electrocautery uses a pen grip with the index finger as a trigger. Proper handling allows surgery to be facilitated with minimal tissue damage.
This document discusses personal protective equipment (PPE) used in healthcare settings. It covers various types of PPE like gloves, masks, gowns and drapes. It describes when each type should be used and how to correctly put on and remove PPE like gloves and masks. The key learning objectives are to list different PPE, describe their uses and limitations, and demonstrate proper donning and doffing of equipment.
This document discusses appropriate use of personal protective equipment (PPE) by healthcare workers. It describes different types of PPE including gloves, gowns, masks, goggles, and shoe/head covers. The key points are: PPE should be chosen based on the risk of exposure to infectious materials; sterile PPE is needed for surgical procedures while other PPE provides barrier or fluid protection; PPE must be properly donned and removed to be effective, with hand hygiene performed before and after; when used correctly, PPE prevents exposure of healthcare workers to infectious pathogens.
This document provides guidance on the appropriate use of personal protective equipment (PPE) by healthcare workers. It defines what PPE is and discusses various types of PPE like gloves, gowns, masks, goggles, and shoe/head covers. For each type of PPE, it describes available options and provides recommendations on when they should be worn to protect against infectious pathogens. The goal is to educate healthcare workers on selecting and using proper PPE depending on the level of anticipated contact with patients' body fluids.
Minimal invasive plate osteosynthesis (MIPO) is a surgical technique that uses small incisions and limited soft tissue dissection to place a plate on a bone. This helps preserve the bone's blood supply and leads to better healing outcomes. Key aspects of MIPO include indirect reduction of fractures, minimal soft tissue stripping, and use of plates that provide stability without requiring direct bone contact.
This document discusses suturing techniques and wound closure. It covers the stages of wound healing, indications and contraindications for suturing, types of suture materials, local anesthetic administration, and techniques for simple interrupted sutures and vertical mattress sutures. Alternative closure methods like steri strips and surgical glue are also reviewed. The goal of wound closure is healing without infection, scarring or deformity.
This document discusses suturing techniques and wound closure. It covers the stages of wound healing, indications and contraindications for suturing, types of suture materials, local anesthetic administration, and techniques for simple interrupted sutures and vertical mattress sutures. The document also reviews alternative closure methods, post-closure care, and intended learning outcomes for understanding suturing procedures.
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2. • Malamed Local Anesthesia
• Part II Armamentarium
• Chapters: 5 - 9
3. • The equipment necessary for the administration of local anesthetics
includes:
• Syringe
• Needle
• local anesthetic cartridge
4. The Syringe
• American Dental Association criteria for acceptance of local
anesthetic syringes include:
• They must be durable and able to withstand repeated sterilization without
damage. (If the unit is disposable, it should be packaged in a sterile container.)
• They should be capable of accepting a wide variety of cartridges and needles
of different manufacture, and permit repeated use
5. The Syringe
• American Dental Association criteria for acceptance of local
anesthetic syringes include:
• They should be inexpensive, lightweight, and simple to use with one hand
• They should provide for effective aspiration and be constructed so that blood
may be easily observed in the cartridge.
6. The syringe
• Syringe Types Available in Dentistry:
• Non-disposable syringes:
• Breech-Loading type, metallic, cartridge-type , aspirating
• Breech-loading ,plastic, , cartridge-type, aspirating
• Breech-loading. metallic, cartridge-type, self-aspirating
• Pressure syringe for periodontal ligament injection
• Jet injector ("needleless" syringe)
• Disposable syringes
• "Safety" syringes
• Computer-control local anesthetic delivery systems
7. Nondisposable Syringes
• Breech-loading, Metallic, Cartridge-type, Aspirating:
• The breech-loading, metallic, cartridge-type syringe is the most commonly
used in dentistry.
• The term breech-loading implies that the cartridge is inserted into the syringe
from the side
8. Nondisposable Syringes
• Breech-loading, Metallic, Cartridge-type, Aspirating:
• ADVANTAGES:
• Visible cartridge
• Aspiration with one hand
• Autoclavable
• Rust resistant
• Long lasting with proper maintenance
9. Nondisposable Syringes
• Breech-loading, Metallic, Cartridge-type, Aspirating:
• Disadvantages:
• Weight (heavier than plastic syringe)
• Syringe may be too big for small operators
• Possibility of infection with improper care
10. Nondisposable Syringes
• Breech-loading, Plastic, Cartridge-type, Aspirating:
• Advantages:
• plastic eliminate metallic, clinical look
• Light weight: provides better feel during injection
• Cartridge is visible
• Aspiration with one hand
• Rust resistance
• Long lasting with proper maintenance
• Lower cost
11. Nondisposable Syringes
• Breech-loading, Plastic, Cartridge-type, Aspirating:
• Disadvantages:
• Size (may be too big for small operation)
• Possibility of infection with improper care
• Deterioration of plastic with repeated autoclaving
12. Nondisposable Syringes
• Breech-loading, Metallic, Cartridge-type, Self-aspirating:
• To increase the ease of aspiration, several self-aspirating syringes have been
developed
• The major factor influencing ability to aspirate is the gauge of the needle
being use
13. Nondisposable Syringes
• Breech-loading, Metallic, Cartridge-type, Self-aspirating:
• Advantages:
• cartridge visible
• Easier to aspirate with small hands
• Autoclavable
• Rust resistance
• Long lasting with proper maintenance
• Piston is scored
14. Nondisposable Syringes
• Breech-loading, Metallic, Cartridge-type, Self-aspirating:
• Disadvantages:
• Weight
• Feeling of insecurity for doctors accustomed to harpoon-type syringe
• Possibility of infection with improper care
16. Nondisposable Syringes
• Pressure Syringes:
• Pressure syringes offer advantages over the conventional syringe when used
for PDL injections:
• the trigger permits measured dose administration
• enables a relatively weak (muscularly) administrator to overcome the significant tissue
resistance that is encountered when the technique is administered properly.
• All of the pressure syringes completely encase the glass dental cartridge with plastic or
metal
• Nonthreatening (new devices)
17. Nondisposable Syringes
• Pressure Syringes:
• Disadvantages:
• Probably the greatest disadvantage to the use of the pressure syringe is the cost
• The mechanical advantage also may prove to be detrimental if the administrator
deposits the anesthetic solution too quickly (<20 sed0.2 ml dose
• The original pressure syringes looked somewhat threatening, having the appearance of a
gun
18. Nondisposable Syringes
• Jet injector:
• The jet or needle-less injection was introduced In 1947 by Figge and Scherer
• Jet injection is based on the principle that liquids forced through very small
openings, called jets, at very high pressure can penetrate intact skin or
mucous membrane
19. Nondisposable Syringes
• Jet injector:
• The primary use of the jet injector is to obtain topical anesthesia before the
insertion of a needle
• It may be used to obtain mucosal anesthesia of the palate
• The jet injector is not an adequate substitute for the more traditional needle
and syringe in obtaining pulpal or regional block anesthesia
• Many patients dislike the feeling accompanying use of the jet injector
20. Disposable Syring
• Use of the plastic, disposable, non-cartridge-containing syringe is not
recommended for routine use.
• Its use should be considered only when a traditional syringe is not
available or cannot be used, such as in situations of severe latex
allergy where glass ampules of local anesthetics must be used in
medical syringes.
• This system is also practical when diphenhydramine is used as a local
anesthetic in cases of presumed local anesthetic allergy
21. Safety Syringe
• Use of a safety syringe minimizes the risk of accidental needle-stick
injury occurring to a dental health provider with a contaminated
needle after the administration of a local anesthetic
25. The needle
• Gauge:
• Gauge refers to the diameter of the lumen of the needle
• the smaller the number, the greater the diameter of the lumen. A 30-gauge
needle has a smaller internal diameter than a 25-gauge needle
• There is a growing trend toward the use of smaller- diameter (higher number
gauge) needles.
26. The needle
• Gauge:
• Larger-gauge needles (e.g., 25-gauge) have distinct advantages over smaller
ones:
• Less deflection occurs as the needle passes through tissues
• This leads to greater accuracy in needle insertion
• To increased success rates, especially for techniques in which the depth of soft tissue
being penetrated is significant.
• Needle breakage, although not common with disposable needles, is much less likely to
occur with a larger needle.
• Numerous authors have stated that aspiration of blood is easier and more reliable
through a larger lumen
27. The needle
• Gauge:
• Despite this ambiguity concerning ability to aspirate blood through various-
gauge needles, the use of larger needles (e.g., 25-gauge) is recommended for
any injection technique used in a highly vascular area or when needle
deflection through soft tissue would be a factor.
• The technique of rotational insertion (described as bi-rotational insertion
technique [BRIV), a technique in which the operator rotates the handpiece or
needle in a back-and-forth rotational movement while advancing the needle
through tissues
28. The needle
• Length:
• Dental needles are available in two lengths: long and short
• The average length of a short needle is 20 mm (measured hub to tip) and 32
mm for the long dental needle .
• Needles should not be inserted into tissues to their hubs unless it is
absolutely necessary for the success of the injection.
29.
30. The needle
• Length:
• A long needle is referred for an injection techniques where the penetration
of significant thicknesses of soft tissue (e.g., the inferior alveolar, Gow-Gates
mandibular, Akinosi mandibular, infraorbital, and maxillary nerve blocks) is
required.
• Short needles may be used for any injection in any patient who does not
require the penetration of significant depths of soft tissue
31. The Needle
• Care and Handling:
• Needles must never be used on more than one patient.
• Needles should be changed after several (three or four) tissue penetrations in
the same patient.
• After three or four insertions, stainless steel disposable needles become dulled. Tissue
penetration becomes more traumatic with each insertion, producing pain on insertion
and soreness when sensation returns after the procedure.
• Needles should be covered with a protective sheath when not being used to
prevent accidental needle stick with a contaminated need
32. The Needle
• Care and Handling:
• Needles must be properly disposed of after use to prevent possible injury or
reuse by unauthorized individuals. Needles can be destroyed in any of the
following ways:
• Contaminated needles (as well as all other items contaminated with blood or saliva, such
as cartridges) should be disposed of in special "contaminated" or "sharps" containers.
• Proper use of a self-sheathing (“safe" needle) needle or syringe unit minimizes risk of
accidental needle stick.
• When needles are to be reused for subsequent recapping is accomplished wing the
"scoop" technique or a needle holder
• Contaminated needles should never be discarded into open trash container
33. The Needle
• Problems:
• Pain on insertion:
• The use of a dull needle
• Breakage:
• Bending weakens needle.
• Needles should not be bent if they are to be inserted into soft tissue to a depth of more
than 5 mm
• Do not attempt to change the direction of a needle when it is embedded in tissue.
• Never attempt to force a needle against resistance
34.
35. The Needle
• Problems:
• Pain on withdrawal:
• Produced by “fishhook” barbs on the tip
• injury to the patient or administrator
36. The cartridge
The dental cartridge is a glass cylinder containing the local anesthetic
drug, among other ingredients
37. The cartridge
• Components:
• The prefilled 1.8-ml dental cartridge consists of four parts:
• Cylindrical glass tube
• Stopper (plunger, bung)
• Aluminum cap
• Diaphragm
38. The Cartridge
• CARTRIDGE CONTENTS:
• the local anesthetic drug:
• The local anesthetic drug is stabIe and is capable of being autoclaved, heated, or boiled
without breaking down. However, other components of the cartridge are more labile
(e.g., vasopressor drug and cartridge seals) and are easily destroy.
• A vasopressor drug:
• to increase safety and the duration and depth of action of the local anesthetic.
• The pH of dental cartridges containing vasopressors is lower (more acidic) than that of
cartridges not containing vasopressor
39. The Cartridge
• CARTRIDGE CONTENTS:
• an antioxidant:
• most often sodium (meta) bisulfite. It prevents the oxidation of the vasopressor by
oxygen
• Sodium chloride:
• is added to the cartridge to make the solution isotonic with the tissues of the body
• Distilled water:
• is used as the diluent to provide the volume of solution in the cartridge
40. The Cartridge
• CARTRIDGE CONTENTS:
• A significant change in cartridge composition was the removal of
methylparaben, a bacteriostatic agent.
41. The Cartridge
• Problems:
• Bubble in the cartridge
• Extruded stopper
• Burning on injection
• Corroded cap
• "Rust" on the cap
• Leakage during injection
• Broken cartridge
42. The Cartridge
• Problems:
• Bubble in the cartridge:
• It is composed of nitrogen gas, which was bubbled into the local anesthetic solution
during its manufacture to prevent oxygen from being trapped in the cartridge and
potentially destroying the vasopressor. The nitrogen bubble may not always be visible in
a normal cartridge.
• A larger bubble, which may be present with a plunger that is extruded beyond the rim of
the midge, is the result of the freezing of the anesthetic solution
43. The Cartridge
• Problems:
• Extruded stopper:
• The stopper can become extruded when a cartridge is frozen and the liquid inside
expands
• An extruded stopper with no bubble is indicative of prolonged storage in a chemical
disinfecting solution and diffusion of the solution into the cartridge
44. The Cartridge
• Problems:
• Burning on injection:
• Normal response to the pH of the drug
• Cartridge containing sterilizing solution
• Overheated cartridge
• Cartridge containing a vasopressor
45. The Cartridge
• Problems:
• Corroded Cap:
• The aluminum cap on a local anesthetic cartridge can be corroded if immersed in
disinfecting solutions that contain quaternary ammonium salts, such as benzalkonium
chloride (e.g., "cold" sterilizing solution).
• Rust on the Cap
• Rust found on a cartridge indicates that at least one cartridge in the tin container has
broken or leaked
46. The Cartridge
• Problems:
• Leakage during injection:
• Leakage of local anesthetic solution into the patient's mouth during injection occurs if
the cartridge and needle are prepared improperly and the needle puncture of the
diaphragm is ovoid and eccentric.
47. The Cartridge
• Problems:
• Broken Cartridge:
• The most common cause of cartridge breakage is the use of a cartridge that has been
cracked or chipped during shipping
• Breakage also can occur as a result of attempting to use a cartridge with an extruded
plunger
• Syringes with bent harpoons may cause cartridges to break
48. The Cartridge
• Recommendations:
• Dental cartridges must never be used on more than one patient.
• Cartridges should be stored at room temperature.
• It is not necessary to warm cartridges before
• Cartridges should not be used beyond their expiration date.
• Cartridges should be checked carefully for cracks, chips, and the integrity of
the stopper and cap before use.
Editor's Notes
he syringe is one of three essential components of the local anesthetic armamentarium (others are the needle and the cartridge). It is the vehlcle whereby the contents of the anesthetic cartridge are delivered through the needle to the patient
Eight types of syringes for local anesthetic administration are in use in dentistry today. They represent a consider- able improvement over the local anesthetic synnges for- merly used. The various types of syringes are listed in Box 5-1. Synnges that do not permit easy aspiration (e.g., nonaspi- rating syringes) are not discussed because their use unac- ceptably increases the risk of inadvertent intravascular drug administration. Use of aspirating dental syringes (capable of the aspiration of blood) represents the standard of care
he syringe is one of three essential components of the local anesthetic armamentarium (others are the needle and the cartridge). It is the vehlcle whereby the contents of the anesthetic cartridge are delivered through the needle to the patient
Eight types of syringes for local anesthetic administration are in use in dentistry today. They represent a consider- able improvement over the local anesthetic synnges for- merly used. The various types of syringes are listed in Box 5-1. Synnges that do not permit easy aspiration (e.g., nonaspi- rating syringes) are not discussed because their use unac- ceptably increases the risk of inadvertent intravascular drug administration. Use of aspirating dental syringes (capable of the aspiration of blood) represents the standard of care
The breech-loading, metallic, cartridge-type syringe (Fig. 5-1) is the most commonly used in dentistry. The term breech-loading implies that the cartridge is inserted into the syringe from the side. A needle is attached to the barrel of the syringe at the needle adaptor. The needle passes into the barrel and penetrates the diaphragm of the local anesthetic cartridge. The needle adaptor (screw hub or convertible tip) is removable and sometimes is discarded inadvertently along with the disposable needle
The aspirating syringe has a device, such as a sharp tip (called the harpoon) that is attached to the piston and is used to penetrate the thick silicone rubber stopper (bung) at the opposite end of the cartridge (from the needle). Provided the needle is of adequate gauge, when a negatizle plFessure is exerted on the thumb ring by the administrator, blood enters into the needle and is visible in the cartridge if the needle tip rests within the lumen of a blood vessel. Positive pressure applied to the thumb ring forces local anes- thetic into the needle lumen and the patient's tissues wher- ever the needle tip lies. The thumb ring and finger grips give the administrator added control over the syringe. Most metallic, breech-loading, aspirating syringes are constructed of chrome-plated brass and stainless steel
A plustic, reusable, denpal aspirating syringe is a~~ilahle. Because of recent advances in plastia. this syringe is both autoclavahie and chemically sterilizahle. Iirlth proper care and handling, multiple uses may be obtained from this syringe before ~t is discarde
The potential hazards of intravascular administration of local anesthetics are great and are discussed more fully in Chapter 18. The incidence of positive aspiration may be as high as 10% to 15% in some injection technique^.^ It is accepted by the dental profession that an aspiration test before administration of a local anesthetic drug is of great importance. Unfortunately, it is abundantly clear that in actual clinical practice too little attention is paid to this procedure
With the commonly used breech-loading, metallic, cartridge-type syringes, an aspiration test must be carried out purposefully by the administrator either before or during drug deposition. The key word here is purposfully. However, as demonstrated in Table 5-1, many dentists knowingly do not perform an aspiration test before injection of the anesthetic drug
To increase the ease of aspiration, several self-aspirating syringes have been developed (Fig. 5-3). These syringes use the elasticity of the rubber diaphragm in the anesthetic cartridge to obtain the necessary negative pressure for aspiration. The diaphragm rests on a metal projection inside the syringe that directs the needle into the cartridge
Pressure acting directly on the cartridge through the thumb disk (Fig. 5-5) or indirectly &rough rhe plunger shaft, distorts (stretches) the rubber diaphragm, producing a positive pressure within the anesthetic cartridge. When that pressure is released, suf- ficient negative pressure develops within the cartridge to permit aspiration. The thumb ring produces twice as much negative pressure as the plunger shaft. The use of a self-aspirating dental syringe permits multipje aspirations to be performed easily throughout the period of local anesthetic deposition.
Pressure Syringes. Introduced in the late 1970s, pressure syringes brougl~c about a renewed interest in the peri- odontal ligament (PDL) injection (also how as the intraligamenmry injection ma). Discussed in Chapter 16, the PDL injection, though usable for any rooth, helped make it possible to achieve consistently reliable pulpal anesthesia of one isolated tooth in the rnandihulsr arch where, in the past, nerve block anesthesia (e.g., inferior alveoIar nen7e block m], Gow-Gates mandibular nerve block), with its attendant prolonged soft-tissue (e.g., lingual) anesthesia, was necessary
The original pressure devices, Peripress (Universal Dental Implements, Edison, NJ.) and Ligmaject (IMA Associates) (Fig. 5-6), were modeled after a device that was available in dentistry in 1905-the Wilcox-Jewett Obtunder (Fig. 5-7). These first-generation devices, using a pistol-grip, are somewhat larger than the newer, pen-grip devices (Fig. 5-8). Although "special" syringes such as these are not necessary for a successful PDL injection, there are several advantages attendant to their use, not the least of which is the mechanical advan- tage they give the administrator, malang the local anes- thetic somewhat easier to administer. This same mechanical advantage, however, makes the injection somewhat "too easy7' to administer, leading to a "too- rapid" injection of the anesthetic solution and patient discomfort both during the injection and when the anes- thesia has worn off. However, when used slowly, as recommended by the tnanufacturers, pressure syringes are of some benefit in the administration of this valuable technique of anesthesia.
The original pressure devices, Peripress (Universal Dental Implements, Edison, NJ.) and Ligmaject (IMA Associates) (Fig. 5-6), were modeled after a device that was available in dentistry in 1905-the Wilcox-Jewett Obtunder (Fig. 5-7). These first-generation devices, using a pistol-grip, are somewhat larger than the newer, pen-grip devices (Fig. 5-8). Although "special" syringes such as these are not necessary for a successful PDL injection, there are several advantages attendant to their use, not the least of which is the mechanical advan- tage they give the administrator, malang the local anes- thetic somewhat easier to administer. This same mechanical advantage, however, makes the injection somewhat "too easy7' to administer, leading to a "too- rapid" injection of the anesthetic solution and patient discomfort both during the injection and when the anes- thesia has worn off. However, when used slowly, as recommended by the tnanufacturers, pressure syringes are of some benefit in the administration of this valuable technique of anesthesia.
Advantages
Pressure syringes offer advantages over the conven- tional syringe when used for PDL injections because the trigger permits measured dose administration and enables a relatively weak (muscularly) administrator to overcome the significant tissue resistance that is encoun- tered when the technique is administered properly. This mechanical advantage also may prove to be detrimental if the administrator deposits the anesthetic solution too quickly (<20 sed0.2 ml dose). All of the pressure syringes completely encase the glass dental cartridge with plastic or metal, thereby protecting the patient in the unlikely event that the cartridge cracks or shatters during injec- tion. The original pressure syringes looked somewhat threatening, having the appearance of a gun. Newer devices are smaller and considerably less intimidating
Jet Injector. In 1947 Figge and Scherer introduced a new approach to parenteral injection, the jet or needle-less injectiom8 This represented the first fundamental change in the basic principles of injection since 1853, when Alexander Wood inttoduced the hypodermic syringe. The first report of the use of jet injections in dentistry was in 1958 by Margetis and associates? Jet injection is based on the principle that liquids forced through very small open- ings, called jets, at very high pressure can penetrate intact skin or mucous membrane (visualize water flowing through a garden hose that is being crimped). The most used jet injectors in dentistry are the SyriJet Mark I1 (M~zzy, Inc.; www..yijet.com) (Fig. 5-9) and the MadaJet (Mada Medical Products, Inc.; zuu~w.rnadaintmtional.com). The SyriJet holds any 1.8 ml dental camidge of local anesthetic. It is calibrated to deliver 0.05 to 0.2 ml of solution at 2000 psi. The primary use of the jet injector is to obtain topical anesthesia before the insertion of a needle. In addition, it may be used to obtain nlucosal anesthesia of the palate. Regional nerve blocks or supraperiosteal injections still are necessary for complete anesthesia. The jet injector is not an adequate substitute for the more traditional needle and syringe in obtaining pulpal or regional block anesthesia. Additionally, many patients dislike the feeling accompanying use of the jet injector, as weli as the possi- ble postinjection soreness of soft tissue that may develop even with proper use of the device. Topical anesthetics, applied properly, sene the same purpose as jet injectors at a fraction of the cost (Sj~iJet Mark 11, US $1 595
Plastic disposable syringes are available in a variety of sizes with an assortment of needle gauges. Most often they are used for intramuscular or intravenous drug administration but also may be used for intraoral injections. These syringes contain a Luer-Lok screw-ori needle attachment but no aspirating tip. Aspiration an be amom- plished by pulling back on the plunger of the syringe hefore or during injection. Bemuse there is no thumb ring, aspiration with the plastic disposable syringe requires the use of hoth hands, In addition, these syringes do nor accept denml cartridges, Tile needle, attached to the syringe, must be inserted into a vial or cartridge of lorn1 anesthetic drug- and an appropriate volume of solution withdrawn. Care must he taken to avoid contaminating the vial during chis procedure. Two- and three-millil i ter syringes wirh 2 3 - or 25-puge needles arc recommended when the system is used for intraoml tom1 anesthetic administration
In recent years there has been a move toward the devel- opment and introduction of "safety" syringes in both med- icine and dentistry." Use of a safety syringe minimizes the risk of accidental needle-stick injury occurring to a dental health provider with a contaminated needle after the administration of a local anesthetic. These syringes pos- sess a sheath that "locks" over the needle when it is removed from the patient's tissues, preventing accidental needle stick
The UltraSafety Plus XL aspirating syringe system contains a syringe body assembly and plunger assembly (Fig. 5-10). Once the syringe is properly assembled and the injection administered, the syringe may be made "safe" with one hand by gently moving the index and middle fingers against the front collar of the guard (Fig. 5-1 I). Once "guarded," the now-contaminated needle is "safe," so that it is virtually impossible to be injured with the needle. The entire syringe is discarded into the proper receptacle (e.g., sharps container). Safety Plus is similar although somewhat different in design. It consists of an autoclavable syringe handle and a disposable self-contained injection unit. The dental anesthetic cartridge is clearly visible because the clear plastic design of the injection unit makes the result of aspiration easy to discern. The cartridge also incorpo- rates a self-aspiration system similar to those described previously. After the injection is completed the autopro- tective system is used, markedly diminishing the risk of accidental needle-stick injury. The system provides two options after the injection. The protective sheath can be slid forward to an intermediate locking position, if mul- tiple injections are necessary, or to the final locking posi- tion for safe disposal. All dental safety syringes are designed to be single-use items (changed after each injection), although they both permit reinjection. Reloading the syringe with a second anesthetic cartridge and reinjecting with the same syringe is discouraged because this obviates the important safety aspect of the device. Almost a year's clinical experience with safety syringe systems has demonstrated the ease with which these sys- tems may be learned, their simplicity, and the importance of the safety syringe. Use of a safety syringe system is strongly recommende
The needle permits the lml anesthetic solution to mvel fmm the dental artridge into the tissues surrounding the needle tip. Most needles used in dentistry are stainless steel and ate disposable. Other needles are constructed of platinum or an iridium-platinum or ruthenium-platinum alloy. The stainless steel needle is highly recommended. Needles currently available for dental practices are prester- ilized and disposable. Reusable needles should not be used for injections. Because the needle represents the most dangerous component of the armamentarium, the one most likely to produce injury to patient or doctor, "safety needles" are being developed.' Although these needles are not yet widely used in dentisay, it is probable that within che next decade their use will become commonpIace
PARTS
The needle is composed of a single piece of tubular metal around which is placed plastic or a metal syringe adaptor and the needle hub (Fig. 6-1). All needles have the following components in common: the bevel, the shaft, the hub, and the cartridge- penetrating end (Fig. 6-2). The bevel defines the point or tip of the needle. Bevels are described bv manufacturers as long, medium, and short. Several authors have confirmed that the greater the angle of the llevel with the long axis of the needle, the greater will be the degree of deflection as the needle psses through hvdrocolloid (or the soft tissues of the mouth) @is. 6-3).'4 A needle whose point is centered on the long axis (e.g., the Hnher point and the Trujecc needle; Fig. 6-41 will deflect less tharl a beveled-point needle rvhase point i.; eccentric (Fig. 6-5; Table 6-1). Several nxi~lufachlrers of dental needles have placed indicators on the plastic or metal hub to help orient the doctor to the position of the bevel. The shaji of the needle is one long piece of tubular metal running from the tip of the needle, through the hub, and continuing to the piece that penetrates the car- tridge (see Fig. 6-1). Two factors to be considered about this component of the needle are the diameter of its lumen (e.g., the needle gauge) and the length of the shaft from point to hub.
he hub is a plastic or metal piece through which the needle attaches to the syringe. The interior surface of the phtic yrirrpe aduptor of the needle is not prethreaded; therefore to arrach a plastic-hubbed ncedle to a sysinge, the needle must be pushed toward the syringe while it is being attached. Metallic-hubbed needles are prethreaded. The cartridridge-penehffting md of the denml needle extends through the needle adaptor and perforates the diaphragm of the local anesthetic cartridge. Its tip rests within the cartridge.
When needles are selected for use in various injection techniques, the two factors that must be considered are the gauge and the length
Despite this ambiguity concerning ability to aspirate blood through various-gauge needles, the use of larger needles (e.g., 25-gauge) is recommended for any injection technique used in a highly vascular area or when needle deflection through soft tissue would be a factor. Although blood may be aspirated through all 2 3- through 30-gauge needles, more pressure is necessary to aspirate when smaller-gauge needles are used, increasing the likelihood &at the harpoon will become dislodged from the nvbher plunger during aspirationThe most commonly used (e.g., most purchased) needles in dentistry are the 27-gauge long, and the 30-gauge short.'j The 25-gauge, however, is the preferred needle for all injections presenting a high risk of positive aspira- tion. The 27-gauge can be used for all other infection techniques, provided tl~e aspiration percenmge is low and tissue penemtian deprh is nor great {increased deflection). The 30-gauge needle is not specifically recommended for any injection, although it may be used in instances af local infilwation. as lvhen obtaining hernnstmis during peri- odontal therapy
One of reasons for chis precaution is needle breakage, which, although rare, does occur. The weakest (most rigid part, receiving he greatest stress) portion of the needle is at the huh, which is where needle breakage happens.
the glass cylinder itself can hold 2 ml of solution; however, as prepared today in the United Stares the dental cartridge mnmins 1.8 ml of local anesthetic solution. Lacal anesthetic products manufactured by Septodont list their &urn volume as 1.7 rnl (although in acrualiy they con- tain 1.8 ml of local anesthetic solution). In other countries, notably the United Kmgdom and Australia, the prefilled dentai cartridge contains 2.2 ml of local anesthetic solution
The dental cartridge is, by common usage, referred to as a "carpule" by dental professionals. The term carpule is actually a registered trade name for the dental cartridge prepared by Cook-Iaite Laboratories, who introduced it into dentistry in 1920
In recent years local anesthetic manufacturers in some countries (but not as of yet in the United States) have introduced a local anesthetic cartridge composed of plastic.i Plastic camidges have several negative fcan~res, primarily leakage of solution in injection techniques, requiring considerable force ro he applied to the plunger of the syringe (e.g., PDL, nasnpalatine),' and the plunger not "gliding" down rhe plastic carmidge smoothly as it does down che glass cartridge, leading to sudden spurts of focal anesthetic be in^ administered, which can produce pain in the patient
The stopper (plunger) is located at the end of rhe cat- mdge that receives the harpoon of the aspirating syringe. The harpoon is embedded into d~e silicone (non-latex- containing) rubber plunger with gentle finger pressure applied to rhe thumb ring of the syringe. The plunger occupies a little less than 0.2 ml of the volume of the entire cartridge. Until recently, the stopper was sealed wirh paraffin (wax) to produce an airtight seal apna the glass walls of the cartridge. GIy.cerin was added In channels around the stopper as a lubricant, permitting it to traverse the glass cylinder more easily. Today most local anesthetic manufacturers meat the stopper u~th silicone, eliminating both the parafin and glycerin. "Sticky stoppers" (stoppers that do not move smoothly down tile glass cartridge) are infrequent today. In recent years there has been a move toward use of a uniform black rubber stopper in all local anesthetic drug combinarions. Virtually gone are the color- coded red, pen, and blue stoppers that aided in identi- fication of the drug. Where black stoppers are used, a color-coding hand, required by the hnerian Dental Association (ADA) as of June 2003 for products to receive the ADA Seal of Approval, is found around the glass cartridge (Table 7-1). In an intact dental cartridge (Fig. 7-2), the stopper is slightly indented from the lip of the glass cylinder. Cartridges whose plungers are flush with or extruded beyond the glass of the cylinder should not be used. This problem is discused later in this chapter. (See ccProblems.") hn nlzintinuw cnp is located at the opposite end of the cartridge from the rubher plunger. It fits snugly around the neck of the glass cartridge, holding the thin diaphragm in position. It is silver colored on all cartridges. The diaphagm is a semipermeable membrane, usually latex ruhber, through which the needle peneaates into the cartridge. When properlv prepared, the perforation of the needIe is centrically located and round, forming a tight seal around the needle. Improper preparation of the needle and cartridge can produce an eccentric punc- ture with ovoid holes leading to leakage of the anes- thetic solution during injection. The permeability of the dhphragm allows any solution in wl~ich the dental cartridge may be stored to diffuse into the cartridge, con- taminating the local anesthetic solution
The local anesthetic drug is the raison d'Ctre for the entire dental cartridge. It interrupts the propagated nerve impulse, preventing it from reachng the brain
The local anesthetic drug is the raison d'Ctre for the entire dental cartridge. It interrupts the propagated nerve impulse, preventing it from reachng the brain
g. Sodium llisulfite reacts with oxvgen before the oxygen is able to desaoy the vasopressor. Sodium bisul- fite is oxidized to sodium bisulfate, which has an wen lower pH. The clinical relevance of this lies in the fact that increased burning (discomfort) is experienced by the patient on injection of an "alder" cart7irlge of anesthetic with vasopressor than with a fresher cartridge. Allergy to bisulfites also must be considered in the medical eval- uation of all patients before local anestheric adrninistra- tion
s. It and related compounds (ethyl - paraben, propylparaben, and butylpamben) are wrnmonly used as presenzitives in ointments, creams, lotions, and dentifrices. In addition, paraben preservatives are found in all multiple-dose vials of drugs. Methylparaben is commonly used in a 0.1% concentration (1 mg/ml). Its removal From local anesthetic carmidges was predicated on two facts. First, dental local anesthetic cartridges are sin9le-use itenis meant to be discarded and not reused. Therefore inclusion of a bacteriostatic agenr is unwar- ranted. Second, repeated exposure to parallen has led to reports of increased allergic reactions in some persons
During the few seconds immediately after deposition of a local anesthetic solution the patient may complain of a slight sensation of burning. This normal reaction is caused by the pH of the local anesthetic solution; it lasts a second or two, until the anesthetic takes effect, and is noted mainly by sensitive patients. A more intense burning on injection is usually the result of the diffusion of disinfecting solution into the dental cartridge and its subsequent injection into the oral mucous membranes. Although burning is most often a mere annoyance, the inclusion of disinfecting agents such as alcohol in dental cartridges can lead to more serious sequelae, such as postinjection paresthesia and tissue edema
may produce burning on injection. The (Chrisrrnas tree) bulb-type cartridge warmer is most often at fault in this regard. Unless local anesthetic carrridges are unusually cold, there is little justification for use of a camidge warmer. Local anesthetic solutions injecred at room temperature are well tolerated by tissues and patients
Use of a vasopressor-containing local anesthetic solution also may be responsible for the sensation of burn- ing on injection. The addition of a vasopressor and an antioxidant (sodium bisulfite) lowers the pH of the solu- tion to between 3.3 and 4, significantly more acidic than solutions not containing a vasopressor (pH about 5.5).4JJ6 Patients are more likely to feel the burning sensation with these solutions. A further decrease in the pH of the local anesthetic solution results when the sodium bisul- fite is oxidized to sodium bisulfate. This response can be minimized by carefully checlung the expiration date of all cartridges before use. Conversely, increasing the pH of the anesthetic solution has the effect of making local anesthetic administration more comfortable for the patient
Corroded Cap
The aluminum cap on a local anesthetic cartridge can be corroded if immersed in disinfect in^ solutions that con- - tain quaternary ammonium salts, such as benzalkonium chloride (e.g., "cold" sterilizing solution). These salts are electrolytically incompatible with aluminum. Aluminum- sealed cartridges should be disinfected in either 9 1 % isopropyl alcohol or 70% ethyl alcohol. Cartridges with corroded caps must not be used. Corrosion (Fig. 7-9) may be easily distinguished horn rust, which appears as a red deposit on an intact aluminum cap.
Rust on the Cap
Rust found on a cartridge indicates that at least one cartridge in the tin container has broken or leaked. The "tin" container (actually steel dipped in molten tin) rusts, and the deposit comes off on the caddges. Cartridges containing rust should not be used. If any cartridge contains rust or a crack (Fig. 7-10), all car- tridges in the container must- he carefully checked hefore use. With the introduction of nonmetal packaging, rust is rarely seen.
Leakage of local anesthetic solution into rhe patient's mouth during injection occurs if the cartridge and needle are prepared improperly and the needle puncture of the diaphrap is ovoid and eccentric. Properly placed on the syringe afrer the cartridge is inserted, the needle pro- duces a cenmc perforation of the diaphragm that tightly seals itself around the needle. \When pressure is applied to the plunger during injection, all of the solution is directed into the lumen of the needle. If the cartridge is placed in a breech-loading syringe afieer the needle, an eccentric ovoid perforation may occur and, with pressure on the plunger, some solution is directed into the lumen of the needle while some may leak out of the cartridge between the needle and the diaphragm and run into the patient's mouth