Supplemental Injection Techniques PDF

Supplemental Injection Techniques Dr. Anuroop Singhai Oral Surgery Division  PDL injection Intrapulpal Comparison  PDL Injection Other Common Names Peridental (original name) injection, intraligamentary injection. Nerves Anesthetized Terminal nerve endings at the site of injection and at...

Supplemental Injection Techniques Dr. Anuroop Singhai Oral Surgery Division  PDL injection Intrapulpal Comparison  PDL Injection Other Common Names Peridental (original name) injection, intraligamentary injection. Nerves Anesthetized Terminal nerve endings at the site of injection and at the apex of the tooth. Areas Anesthetized CHAPTER 15 Supplement Bone, soft tissue, and apical and pulpal tissues in the area of injection. Lingual Advantages soft tissue 1. There is no anesthesia of the lip and bone tissues, thus facilitating treatme during a single appointment. Tongue 2. Minimum dose of local anesth anesthesia (∼0.2 mL per root). Alveolar 3. An alternative to partially succe Mental mucous foramen membrane anesthesia. 4. Rapid onset of profound pulpal Extraoral (30 seconds). soft tissue 5. Less traumatic than convention 6. Well suited for procedures in c Fig. 15.4 Area anesthetized by a periodontal ligament injection. periodontal and endodontic sin quadrant procedures.! 4. The PDL injection administered with a conventional or Disadvantages PDL Injection Indications 1. Pulpal anesthesia of one or two teeth in a quadrant 2. Treatment of isolated teeth in two mandibular quadrants (to avoid bilateral IANB) 3. Patients for whom residual soft tissue anesthesia is undesirable 4. Situations in which regional block anesthesia is contraindicated 5. As a possible aid in the diagnosis of pulpal discomfort 6. As an adjunctive technique after nerve block anesthesia if partial anesthesia is present Contraindications 1. Infection or inflammation at the site of injection 2. Patients who requires “numb” sensation for their psychological comfort  PDL Injection Advantages 1. There is no anesthesia of the lip, tongue, and other soft tissues, thus facilitating treatment in multiple quadrants during a single appointment. 2. Minimum dose of local anesthetic necessary to achieve anesthesia (∼0.2 mL per root). 3. An alternative to partially successful regional nerve block anesthesia. 4. Rapid onset of profound pulpal and soft tissue anesthesia (30 seconds). 5. Less traumatic than conventional block injections. 6. Well suited for procedures in children, extractions, and periodontal and endodontic single-tooth and multiple-quadrant procedures. Disadvantages 1. Proper needle placement is difficult to achieve in some areas (e.g., distal to the second or third molar). 2. Leakage of local anesthetic solution into the patient’s mouth produces an unpleasant taste. Excessive pressure or overly rapid injection may break the glass cartridge. 3. A special syringe may, on occasion, be necessary. 4. Excessive pressure can produce focal tissue damage. 5. Postinjection discomfort may persist for several days. 6. The potential for extrusion of a tooth exists if excessive pressure or volumes are used.  PDL Injection Positive Aspiration Zero percent. Alternative Supraperiosteal injection for the entire maxilla and mandibular incisor region. The infiltration of articaine hydrochloride in the mandibular molar region has a significantly high success rate. Technique 1. A 27-gauge short needle is recommended. 2. Area of insertion: long axis of the tooth to be treated on its mesial or distal root (one- rooted tooth) or on the mesial and distal roots (of a multirooted tooth) interproximally. 3. Target area: depth of the gingival sulcus. The needle is wedged between the root of the tooth and the interproximal bone. 4. Landmarks: Root(s) of the tooth. Periodontal tissues.  PDL Injection 5. Orientation of the bevel: although not significant to the success of the technique, it is recommended that the bevel of the needle face toward the root to permit easy advancement of the needle in an apical direction. 6. Procedure: a. Assume the correct position (this differs significantly with PDL injections for different teeth). Sit comfortably, have adequate visibility of the injection site, and maintain control over the needle. It may be necessary to bend the needle to achieve the proper angle, especially on the distal aspects of second and third molars. b. Position the patient supine or semisupine, with the head turned to maximize access and visibility. c. Stabilize the syringe and direct it along the long axis of the root to be anesthetized. If possible, use a mouth mirror to minimize the risk of accidental needlestick injury to the administrator. i. The bevel faces the root of the tooth. ii. If interproximal contacts are tight, the syringe should be directed from the lingual or buccal surface of the tooth but maintained as close to the long axis as possible. iii. Stabilize the syringe and your hand against the patient’s teeth, lips, or face.  PDL Injection d. With the bevel of the needle on the root, advance the needle apically until resistance is met. e. Deposit 0.2 mL of local anesthetic solution in272 a minimum of 20 seconds. PART III Techniques of Regional Anesthesia in Dentistry o When using a conventional syringe, note that the thickness of the rubber stopperi. When u in the local anesthetic cartridge is equal to 0.2 mL of solution. This may be used as thickness cartridge a gauge for the volume of local anesthetic to be administered. used as a be admin o With a PDL syringe, each squeeze of the “trigger” provides a volume of 0.2 mL. ii. With a P provides f. If the tooth has only one root, remove the syringe from the tissue and cap the needle.f. There are t injection: Dental treatment may usually start within 30 seconds. i. Significan thetic sol g. If the 272 tooth is multirooted, remove the needle PA RT I I I Techniques of Regional Anesthesia in Dentistry and repeat the procedure on the other conventio felt with t root(s). A the reason The lo i. When using a conventional syringe, note that the the patien thickness of the rubber stopper in the local anesthetic tion at th cartridge is equal to 0.2 mL of solution. This may be tenths of used as a gauge for the volume of local anesthetic to and mus be administered. be effecti ii. With a PDL syringe, each squeeze of the “trigger” provides a volume of 0.2 mL. preventin f. There are two important indicators of success of the mouth o injection: be left in i. Significant resistance to the deposition of local anes- 10 secon thetic solution. This is especially noticeable when the permit th conventional syringe is used; resistance is similar to that ii. Ischemia felt with the nasopalatine injection and is thought to be site. (Thi the reason for reports of PDL injections being painful. but is mo A B The local anesthetic should not flow back into ing local Fig. the15.5 patient’s Area ofmouth. If for insertion thisa happens, repeat periodontal the injection. ligament injec- (A) g. If the tooth Buccal. tion (B) Lingual. at the same site but from a different angle. Two- the tissue a tenths of a milliliter of solution must be deposited usually start h. If the tooth  PDL Injection Signs and Symptoms 1. Subjective: There are no signs that absolutely assure adequate anesthesia; the anesthetized area is quite circumscribed. When the following two signs are present, there is an excellent chance that profound anesthesia is present: a. Ischemia of soft tissues at the injection site. b. Significant resistance to injection of solution (with a traditional syringe). 2. Objective: use of a freezing spray (e.g., Endo-Ice) or an electric pulp tester (EPT) with no response from the tooth with maximal EPT output (80/80). Safety Feature Intravascular injection is extremely unlikely to occur. Precautions 1. Keep the needle against the tooth to prevent over insertion into soft tissues on the lingual aspect. 2. Do not inject anesthetic solution too rapidly (minimum 20 seconds for 0.2 mL). 3. Do not inject too much solution (0.2 mL per root retained within tissues). 4. Do not inject anesthetic solution directly into infected or highly inflamed tissues.  PDL Injection Failures of Anesthesia 1. Periapical infection. The pH and vascularity changes at the apex and periodontal tissues minimize the effectiveness of the local anesthetic. Use of the PDL injection is not contraindicated in the presence of apical disease, but its success may be minimized. 2. Solution not retained. In this case, remove the needle and re-enter at a different site(s) until 0.2 mL of local anesthetic is deposited and retained in the tissues. 3. Each root must be anesthetized with approximately 0.2 mL of solution. Duration of Expected Anesthesia The duration of pulpal anesthesia obtained with a successful PDL injection is quite variable and is not related to the drug administered. Administration of lidocaine with epinephrine 1:100,000, for example, provides pulpal anesthesia ranging in duration from 5 to 55 minutes.  PDL Injection Complications o Pain during insertion of the needle. Cause 1: the needle tip is in soft tissues. To correct this, keep the needle against tooth structure. Cause 2: the tissues are inflamed. To correct this, avoid use of the PDL technique or apply a small amount of topical anesthetic for a minimum of 1 minute before injection. o Pain during injection of solution. Cause: too rapid injection of local anesthetic solution. To correct this, slow down the rate of injection to a minimum 20 seconds for a 0.2 mL solution, regardless of the syringe being used. o Postinjection pain. Cause: too rapid injection, excessive volume of solution, too many tissue penetrations. (The patient usually complains of soreness and premature contact when occluding.) To correct this, manage the pain symptomatically with warm saline rinses and mild analgesics, if necessary (usually resolves within 2 to 3 days).  Intrapulpal Injection Nerves Anesthetized Terminal nerve endings at the site of injection in the pulp chamber and canals of the involved tooth. Areas Anesthetized Tissues within the injected tooth. Indication When pain control is necessary for pulpal extirpation or other endodontic treatment in the absence of adequate anesthesia following repeated attempts with other techniques. Contraindication None. The intrapulpal injection may be the only local anesthetic technique available in some clinical situations.  Intrapulpal Injection Advantages 1. Lack of lip and tongue anesthesia (appreciated by most patients) 2. Minimum volumes of anesthetic solution necessary 3. Immediate onset of action 4. Very few postoperative complications Disadvantages 1. Traumatic: the intrapulpal injection is associated with a brief period of pain as anesthetic is deposited. 2. Bitter taste of the anesthetic drug (if leakage occurs). 3. Relatively short duration of action (15 to 20 minutes). 4. May be difficult to enter certain root canals (bending of the needle may be necessary). 5. A small opening into the pulp chamber is needed for optimum effectiveness. Large areas of decay make it more difficult to achieve profound anesthesia with the intrapulpal injection.  Intrapulpal Injection Positive Aspiration Zero percent. Alternatives Intraosseous injection. However, when intraosseous injection fails, intrapulpal injection may be the only viable alternative to provide clinically adequate pain control. Technique 1. Insert a 25- or 27-gauge short or long needle into the exposed pulp chamber or the root canal as needed. 2. Ideally, wedge the needle firmly into the pulp chamber or root canal. Occasionally the needle does not fit snugly into the canal. In this situation the anesthetic can be deposited in the chamber or canal. Anesthesia in this case is produced only by the pharmacologic action of the local anesthetic; there is no pressure anesthesia. 3. Deposit anesthetic solution under pressure. A small volume of anesthetic (0.2 to 0.3 mL) is necessary for successful intrapulpal anesthesia if the anesthetic remains within the tooth. In many situations, the anesthetic simply flows back out of the tooth into the aspirator (vacuum) tip.  Intrapulpal Injection 4. Resistance (back pressure) to injection of the drug should be felt and is important for the success of the injection. 5. Bend the needle, if necessary, to gain access to the pulp chamber. Although there is an increased risk of breakage with a bent needle, this is not a problem during intrapulpal anesthesia, because the needle is inserted into the tooth itself, not into soft tissues. In addition, 25- and 27-gauge needles rarely break. Retrieval is relatively simple if the needle breaks. 6. When the intrapulpal injection is performed properly, a brief period of sensitivity (ranging from mild to very painful) usually accompanies the injection. Pain relief usually occurs immediately thereafter, permitting 286 PART III Techniquesinstrumentation of Regional Anesthesiato proceed atraumatically. in Dentistry 7. Instrumentation may begin approximately 30 seconds after the injection is given. Summary A number of successful and (u mental injection techniques are of, or as a supplement to, unsuc techniques. The availability of t the chances of a patient being u lack of profound anesthesia. References 1. Masselink BH. The advent of p  Intrapulpal Injection Signs and Symptoms As with PDL, intraseptal, and intraosseous injections, no subjective symptoms ensure adequate anesthesia. The area is too circumscribed. Objective: the endodontically involved tooth may be treated painlessly. Safety Features 1. Intravascular injection is extremely unlikely to occur. 2. Small volumes of anesthetic are administered. Precautions 1. Do not inject anesthetic into infected tissue. 2. Do not inject anesthetic rapidly (not