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.

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

2. Welcome, Your Patients
Thank you
2

3. Origins of my commitment
3

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

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

7. We Really Need Adequate LA

8. We Really Need Adequate LA
8

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

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

12. • 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

13. 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.

14. 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

15. 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

16. 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

17. Half-Life of Dental LA’s

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

19. 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

20. 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

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

22. 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

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

24. How Much Epi Can We Give?
24

25. 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

26. 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)

27. 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

28. Pregnancy Risk Classification
of Local Anesthestics

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

30. 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

31. Workhorses For Infiltration
31

33. Basic Injection Technique

34. Basic Injection Technique

35. Placement of the Topical

36. Basic Injection Technique

37. "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.

38. 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

39. Tissue taut vsualize the needle
tip at membrane

40. Continuously inject
while advancing

41. Tissue taut - pull tissue
over needle tip for initial puncture

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

43. 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

44. 44

45. The Most Pain Free Area to
Inject in the Max Arch

46. Anatomical Considerations
For Maxillary Arch Infiltration

47. 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.

48. 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

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

50. What If The Palate Needs
More Pain Control?

51. I Got Tired Of Peeling People
Off The Ceiling

52. 52

53. Multiple Intraseptals
• Will give
overlapping
areas of
anesthetize
palatal
gingiva

54. Interseptal Injection

55. Bend the needle to
facilitate access

56. Example of Intraseptal for Palatal anesthesia

57. 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

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

59. 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

60. Basic Mental Foramen
Injection and Anatomy
60

61. 61

62. How Do We Obtain Lingual
Anesthesia?

63. 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

64. 64

65. 65

66. 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

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

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

69. 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.

70. 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

71. Inferior Nerve Block

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

73. 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

74. Needle Tract
Anesthesia Examples

75. Needle Tract
Anesthesia Examples

76. 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

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

78. Mylohyoid Nerve

79. 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

80. 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

81. 81

82. 82

83. Supplemental Injection
• Mylohyoid nerve

84. Height of Injection

85. 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

86. 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

87. Any Questions??????????

89. How Do We Obtain Lingual
Anesthesia?

90. Needle Tract

91. Infiltration on the
Mandibular Arch

92. Example of Anesthetizing Cross-over

93. How Do We Obtain Lingual
Anesthesia?

94. 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