Supplemental Injection Techniques PDF

# Supplemental Injection Techniques ## Introduction * In this chapter a number of injections are described that are used in specialized clinical situations. * Some may be used as the only technique for pain control for certain types of dental treatment. * For example: * The periodontal ligame...

# Supplemental Injection Techniques ## Introduction * In this chapter a number of injections are described that are used in specialized clinical situations. * Some may be used as the only technique for pain control for certain types of dental treatment. * For example: * The periodontal ligament (PDL) * Intraosseous * Intraseptal injection techniques * Those injection is almost always reserved for situations in which other injection techniques have failed or are contraindicated for use. * The effectiveness of mandibular infiltration in adults with the local anesthetic articaine hydrochloride has helped make the achievement of clinically profound mandibular anesthesia more consistently reliable. * The ability to provide pulpal anesthesia in circumscribed areas of the mandible without the need for nerve blocks (e.g. [IANB] is valuable when these nerve blocks fail to provide the depth of anesthesia required for painless dentistry. ## Intraosseous Anaesthesia * Intraosseous anesthesia involves the deposition of local anesthetic solution into the cancellous bone ## Periodontal Ligament Injection * Because of the thickness of the cortical plate of bone in most patients and in most areas of the mandible, it is not possible to achieve profound pulpal anesthesia for a solitary tooth in the adult. * An exception to this is the mandibular incisor region, where Certosimo and Archer demonstrated a 97% success rate for pulpal anesthesia following infiltration of 0.9 mL of articaine hydrochloride (with epinephrine 1:100,000) on both the buccal and the lingual aspects of the teeth. * Buccal infiltration of articaine hydrochloride also provides considerable success in mandibular molars. * The PDL injection may also be used successfully in the maxillary arch. ## Benefits of PDL Injection * The greatest potential benefit of the PDL injection lies in the fact that it provides pulpal and soft tissue anesthesia in a localized area (one tooth) of the mandible without producing extensive soft tissue (e.g., tongue and lower lip). * Almost all dental patients prefer this technique to any of the "mandibular nerve blocks." In a clinical trial, Malamed reported that 74% of patients preferred the PDL injection primarily because of its lack of lingual and labial soft tissue anesthesia. ## Primary Indications for the PDL Injection * Need for anesthesia of one or two in mandibular teeth * Treatment of isolated teeth in both mandibular quadrants (to avoid bilateral IANB) * Treatment of children (because residual soft tissue anaesthesia increases the risk of self-inflicted soft tissue injury). * Nerve block is contraindicated. * Its use as a potential assist in diagnosis (e.g., localization) of mandibular pain. ## Contraindications to the PDL injection * Infection or severe inflammation at the injection site. * In 1984 Brannstrom et al. reported the development of enamel hypoplasia or hypomineralization or both in 15 permanent teeth after administration of the PDL injection on primary molars. * Subsequent research and clinical experience has shown that use of a PDL injection on a primary tooth with a permanent tooth developing below it is not a contraindication to its administration.  * Ashkenazi et al. demonstrated that with use of a C-CLAD device with a controlled low-pressure administration, the risks of enamel hypoplasia and/or hypomineralization are not as high as previously reported. * In those instances when a PDL injection is recommended for the primary dentition, a C-CLAD instrument is recommended. * Apical areas appeared normal; the epithelial and connective tissue attachment to enamel and cementum was not disturbed by the needle puncture; slight resorption of nonvital bone occurred in the crestal regions, forming a wedge-shaped defect; soft tissue damage was minimal. * The disruption of tissue that did occur showed repair in 25 days, with absence of inflammation and with the formation of new bone in the regions of resorption; and injection of the solution was not in itself damaging. * Walton and Garnick concluded that the PDL injection is safe for the periodontium. In addition, no evidence to date suggests that inclusion of a vasoconstrictor in the local anaesthetic solution has any detrimental effect on pulpal microcirculation after the PDL injection. ## Postinjection Complications * Postinjection complications are also of concern with the PDL injection. Reported complications have included mild to severe postoperative discomfort, swelling and discoloration of soft tissues at the injection site, and prolonged ischemia of the interdental papilla, followed by sloughing and exposure of crestal bone. * Some of these complications result directly from poor operator technique, lack of familiarity with the pressure syringe, and injection of excessive volumes of local anaesthetic into the PDL. * The most frequently voiced postinjection complications are mild discomfort and sensitivity to biting and percussion for 2 or 3 days. * The most common causes of postinjection discomfort are: * Too rapid injection * Injection of excessive volumes of local anaesthetic into the site. ## Conventional vs. "Special" PDL Syringes * Before the PDL technique is described, it must be mentioned that although "special" PDL syringes can be used effectively and safely, usually there is no need for them. * A conventional local anaesthetic syringe is equally effective in providing PDL anaesthesia. * Use of a conventional syringe requires that the administrator apply significant force to deposit the local anaesthetic into the periodontal tissues. ## Arguments Against Use of a Conventional Syringe for PDL Injections * It is too difficult to administer the solution. * Comment: Slow administration of the local anesthetic makes the PDL injection atraumatic. Improper use of the PDL syringe (fast injection) produces both immediate and postinjection pain. * The extreme pressure applied to the glass may shatter the cartridge. * Comment: The risk can be minimized in several ways: Because only small volumes of solution are injected (0.2 mL per root), a full, 1.8-mL cartridge is not necessary. Eliminate all but about 0.6 mL of solution before starting the PDL injection. This minimizes the area of glass being subjected to increased pressures, decreasing the risk of breakage. * Many manufacturers of PDL syringes recommend use of 30-gauge short or ultrashort needles in this technique. * Comment: the 30-gauge needle bent easily. It was too fragile to hold the force applied to it without bending. * PDL injection failure rates were excessive, using the more readily available 27-gauge short needle. * The PDL injection administered with a conventional or PDL syringe is painful. * Comment: Use of a C-CLAD device for administration of painless PDL injections has been strongly recommend. ## Common Names, Nerves and Areas Anesthetized * **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:** Bone, soft tissue, and apical and pulpal tissues in the area of 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. ## PDL Indications and Contraindications * **Indications:** * Pulpal anaesthesia of one or two teeth in a quadrant. * Treatment of isolated teeth in two mandibular quadrants (to avoid bilateral IANB) * Patients for whom residual soft tissue anaesthesia is undesirable. * Nerve block anaesthesia is contraindicated. * Helping to diagnosis of pulpal discomfort. * As an adjunctive technique after nerve block anaesthesia. * **Contraindications:** * Infection or inflammation at the site of injection * Patients who requires "numb" sensation for their psychological comfort. ## PDL Advantages and Disadvantages * **Advantages:** * There is no anaesthesia of the lip, tongue, and other soft tissues. * Minimum dose of local anaesthetic is necessary. * An alternative to nerve block anaesthesia. * Rapid onset of profound pulpal and soft tissue anaesthesia (30 seconds). * Less traumatic. * Perfect for pediatric procedures, extractions, periodontal procedures and endodontic treatment of single teeth and multiple quadrants.. * **Disadvantages:** * Proper needle placement is difficult in some areas (e.g., distal to the second or third molar). * Leakage of local anesthetic solution. * Excessive pressure injection may break the glass cartridge. * A special syringe may be necessary. * Excessive pressure can produce focal tissue damage. * Postinjection discomfort may persist for several days. * The potential for extrusion of a tooth exists if excessive pressure or volumes are used. ## PDL Technique * **Technique:** * A 27-gauge short needle is recommended. * 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) interproximal. * Target area: depth of the gingival sulcus. The needle is wedged between the root of the tooth and the interproximal bone. * Landmarks: * Root(s) of the tooth. * Periodontal tissues. * 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. * Procedure: * Assume the correct position. Sit comfortably, have adequate visibility of the injection site, and maintain control over the needle. * Position the patient supine or semisupine. * Stabilize the syringe and direct it along the long axis of the root to be anesthetized. The bevel faces the root of the tooth. * With the bevel of the needle on the root, advance the needle apically until resistance is met. * Deposit 0.2 mL of local anesthetic solution in a minimum of 20 seconds. When using a conventional syringe, note that the thickness of the rubber stopper in the local anaesthetic cartridge is equal to 0.2 mL of solution. With a PDL syringe, each squeeze of the "trigger" provides a volume of 0.2 mL. * There are two important indicators of success of the injection: * Significant resistance to the deposition of local anaesthetic solution. This is especially noticeable when the conventional syringe is used. The local anaesthetic should not flow back into the patient's mouth. If this happens, repeat the injection at the same site but from a different angle. * Ischemia of the soft tissues adjacent to the injection site. * If the tooth has only one root, remove the syringe from the tissue and cap the needle. Dental treatment may usually start within 30 seconds * If the tooth is multirooted, remove the needle and repeat the procedure on the other root(s). ## PDL Signs and Symptoms * **Signs and Symptoms:** * Subjective: There are no signs that absolutely assure adequate anesthesia. When the following two signs are present, there is an excellent chance that profound anesthesia is present: * Ischemia of soft tissues at the injection site. * Significant resistance to injection of solution (with a traditional syringe). * 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:** * Keep the needle against the tooth to prevent over insertion into soft tissues on the lingual aspect. * Do not inject anaesthetic solution too rapidly (minimum 20 seconds for 0.2 mL). * Do not inject too much solution (0.2 mL per root retained within tissues). * Do not inject anaesthetic solution directly into infected or highly inflamed tissues. ## PDL Failures of Anaesthesia * **Failures of Anaesthesia:** * Periapical infection. The pH and vascularity changes at the apex and periodontal tissues minimize the effectiveness of the local anaesthetic. * Solution not retained. * Each root must be anesthetized with approximately 0.2 mL of solution. ## PDL Complications * **Complications:** * Pain during insertion of the needle: * Cause 1: the needle tip is in soft tissues. * Cause 2: the tissues are inflamed. * Pain during injection of solution: * Cause: too rapid injection of local anaesthetic solution. * Postinjection pain:. Cause: too rapid injection. * **Duration of Expected Anaesthesia:** The duration of pulpal anaesthesia obtained with a successful PDL injection is quite variable and is not related to the drug administered. For example, provides pulpal anaesthesia ranging in duration from 5 to 55 minutes. ## Intraseptal Injection * The intraseptal injection is similar in technique and design to the PDL injection. * **Other Common Names:** Crestal anaesthesia. * **Nerves Anesthetized:** Terminal nerve endings at the site of injection and in adjacent soft and hard tissues * **Areas Anesthetized:** Bone, soft tissue, root structure around injection. * **Indication:** When both pain control and haemostasis are desired for soft tissue and osseous periodontal treatment or for minor restorative procedures on mandibular posterior teeth. * **Contraindication:** Infection or severe inflammation at the injection site. ## Intraseptal Advantages and Disadvantages * **Advantages:** * Lack of lip and tongue anaesthesia. * Minimum volumes of local anaesthetic necessary. * Minimized bleeding during the surgical procedure. * Atraumatic. * Immediate onset of action (<30 seconds). * Few postoperative complications. * Useful on periodontally involved teeth (avoids infected pockets). * **Disadvantages:** * Multiple tissue punctures may be necessary. * Bitter taste of the anaesthetic drug (if leakage occurs). * Relatively short duration of pulpal anaesthesia. * Clinical experience necessary for success. * **Positive Aspiration:** Zero percent. * **Alternatives:** * PDL injection in the absence of infection or severe periodontal involvement. * Intraosseous anaesthesia. * Regional nerve block with local infiltration for hemostasis. ## Intraseptal Technique * **Technique:** * A 27-gauge short needle is recommended. * Area of insertion: canter of the interdental papilla adjacent to the tooth to be treated. * Target area: canter of the interdental papilla adjacent to the tooth to be treated. * Landmarks: papillary triangle, about 2 mm below the tip, equidistant from adjacent teeth. * Orientation of the bevel: not significant. * Procedure: * Assume the correct position. * Position the patient supine or semisupine. * Prepare tissue at the site of penetration: * Dry it with sterile gauze. * Apply topical antiseptic (optional). * Apply topical anaesthetic for minimum of 1 minute. * Stabilize the syringe and orient the needle correctly. * Slowly inject a few drops. * While applying pressure to the syringe, push the needle slightly deeper (1 to 2 mm) into the interdental septum. * Deposit 0.4 mL of local anaesthetic in not less than 20 seconds. ## Intraseptal Signs and Symptoms * **Signs and Symptoms:** * As with the PDL injection, * Subjective: ischemia of soft tissues is noted at the injection site. ­ * Subjective: resistance to the injection of solution is felt. * **Safety Feature:** Intravascular injection is extremely unlikely to occur. * **Precautions:** * Do not inject anaesthetic solution into infected tissue. * Do not inject anaesthetic solution rapidly (not faster than 20 seconds). * Do not inject too much solution (0.4 mL per site). ## Intraseptal Failures of Anaesthesia * **Failures of Anaesthesia:** * Infected or inflamed tissues. * Solution not retained in tissue. ## Intraseptal Complications * **Complications:** * Postinjection pain is unlikely to develop because the injection site is within the area of surgical treatment. * **Duration of Expected Anaesthesia:** The duration of osseous and soft tissue anaesthesia is variable after an intraseptal injection. Using an epinephrine concentration of 1:50,000. ## Intraosseous Injection * Deposition of local anesthetic solution into the interproximal bone between two teeth, intraosseous anaesthesia required the use of a half-round burr to provide entry into interseptal bone that had been surgically exposed. * The Stabident system comprises a slow-speed hand piece driven perforator, a solid 27-gauge wire with a beveled end that when activated drills a small hole through the cortical plate. The anaesthetic solution is delivered to cancellous bone through the 27-gauge ultrashort injector needle placed into the hole made by the perforator. * Intraosseous technique has shown that perforation of the interproximal bone is almost always entirely atraumatic. * Some persons initially had difficulty placing the needle of the local anaesthetic syringe back. * The X-Tip eliminated this problem. * The X-Tip anaesthesia delivery system consists of an X-Tip that separates into two parts: the drill and the guide sleeve component. The drill (a special hollow needle) leads the guide sleeve through the cortical plate, then it is separated and withdrawn. The remaining guide lead is designed to accept a 27-gauge needle to inject the anaesthetic solution. The guide lead is removed after the intraosseous injection is complete. ## Intraosseous Advantages and Disadvantages * The intraosseous injection technique can provide anaesthesia of a single tooth or multiple teeth in a quadrant. * It is recommended that 0.45 to 0.6 mL of anaesthetic when treat not more than one or two teeth. * Greater volumes (up to 1.8 mL) may be required when treatment of multiple teeth in one quadrant is planned. * The intraosseous injection may be used when six or eight mandibular anterior teeth. * Because intraosseous injections deposit local anaesthetic into a vascular site suggested that the volume of local anaesthetic recommended minimum to avoid possible overdose. * Because of the high incidence of palpitation noted when vasopressor-containing local anaesthetics are used, a "plain" local anaesthetic is recommended. Transient tachycardia has been reported following intraosseous injections with epinephrine- or levonordefrin-containing local anaesthetic solutions between 46% and 93% of the time. * The use of a plain solution such as 3% mepivacaine does not lead to a significant increase in heart rate. ## Intraosseous Nerve and Areas Anesthetized * **Nerves Anesthetized:** Terminal nerve endings at the site of injection and in adjacent soft and hard tissues. * **Areas Anesthetized:** Bone, soft tissue, and root structure in the area of injection. * **Indication:** Pain control for dental treatment on single or multiple teeth in a quadrant. * **Contraindication:** Infection or severe inflammation at the injection site. * **Advantages:** * Lack of lip and tongue anaesthesia (appreciated by most patients). * Atraumatic. * Immediate onset of action (<30 seconds). * Few postoperative complications. * **Disadvantages:** * Usually requires a special device. * Bitter taste of the anaesthetic drug (if leakage occurs) * Occasional (rare) difficulty in placing the anaesthetic needle into a predrilled hole * High incidence of palpitation when a vasopressor containing local anaesthetic is used. * **Positive Aspiration:** Minimal. Approximately 1% to 3%. * **Alternatives:** * PDL injection, in the absence of infection or severe periodontal involvement * Intraseptal injection. * Supraperiosteal injection. * Regional nerve block. ## Intraosseous X-Tip Technique * **Technique** * Selection of site for injection: * Lateral perforation: * At a point 2 mm apical to the intersection of lines drawn horizontally along the gingival margins of the teeth and a vertical line through the interdental papilla. * The site should be located distal to the tooth to be treated, if possible, although this technique provides anaesthesia in most cases when anaesthetic is injected anterior to the tooth being treated. * Avoid injecting anaesthetic in the mental foramen area (increased risk of nerve damage). * Vertical perforation (for edentulous areas): * Perforate at a point on the alveolar crest mesial or distal to the treatment area (also called the crestal anaesthesia technique). * Remove the X-Tip from its sterile vial. * Hold the protective cover as you insert the X-Tip onto the slow-speed handpiece * Prepare soft tissues at the perforation site: * Prepare tissue with sterile gauze. * Apply topical anaesthetic * Place the bevel of the needle against gingiva injecting a small volume of local anaesthetic until blanching occurs. * Inject a few drops of local anaesthetic into the dimple. * Perforation of the cortical plate: * While holding the perforator perpendicular to the cortical plate, gently push the perforator through the attached gingiva until its tip rests against bone. * Activate the handpiece, using a gentle "pecking” motion on the perforator until a sudden loss of resistance is felt. Cortical bone will be perforated within 2 seconds (Fig. 15.13). ­ * Hold the guide sleeve in place as the drill is withdrawn (Fig. 15.14). * Injection into cancellous bone: * It is easy to insert the needle into the hole when a short needle is used (Fig. 15.15). * Press the tapered needle gently against the guide sleeve to minimize local anaesthetics leakage. * Slowly and gently inject the local anaesthetics solution * The recommended doses for the X-Tip are the same for each local anaesthetic solution as is recommended for other injections. * For Stabident doses, see Table 15.3. * **A Table of Stabident Doses** | To Anesthetize | Injection Site | Dose (1.8-mL Cartridges) | |---|---|---| | **Stabident Mandibular Doses** | | | | One tooth | Immediately distal or immediately mesial | One-quarter to one-third | | Two adjacent teeth | Between the two teeth or immediately distal to the more distal tooth | One-third to half | | Three adjacent teeth | Immediately distal to the middle tooth | Half | | Six front teeth plus the first premolars (i.e., total of eight teeth) | Give two injections, one on each side, between the canine and the first premolar | Half on each side (total of one) | | **Stabident Maxillary Doses** | | | | One tooth | Immediately distal or immediately mesial | One-quarter | | Two adjacent teeth | Between the two teeth | One-quarter | | Four adjacent teeth (e.g., 1, 2, 3, and 4) | Midway (e.g., two teeth distal and two teeth mesial to the injection site) | Half | | Up to eight teeth on one side | Midway (e.g., four teeth distal and four teeth mesial to the injection site) | One | ## Intraosseous Signs and Symptoms * **Signs and Symptoms:** * Subjective: ischemia of soft tissues at the injection site. * Objective: use of freezing spray (e.g., Endo-Ice). * **Safety Feature:** Intravascular injection is extremely unlikely, although the area into which anaesthetic is injected is quite vascular. Slow injection of the recommended volume of solution is important to keeping intraosseous anaesthesia safe. * ** Precautions:** * Do not inject anaesthetic into infected tissue. * Do not inject anaesthetic rapidly. * Do not inject too much solution. * Do not use a vasopressor-containing local anaesthetic unless necessary, and then only 1:200,000 or 1:100,000 concentration. Avoid use of epinephrine 1:50,000. * **Failures of Anaesthesia:** * Infected or inflamed tissues. Changes in tissue pH minimize the effectiveness of the anaesthetic * Inability to perforate cortical bone. ## Intraosseous Complications * **Complications:** * Palpitation: This reaction frequently occurs when a vasopressor-containing local anaesthetic is used. * Postinjection pain is unlikely (~5%) after intraosseous anaesthesia. * Fistula formation at the site of perforation has been reported on occasions. * Separation of the perforator or cannula. * Perforation of lingual plate of bone (Fig. 15.16). This is prevented by proper technique. * **Duration of Expected Anesthesia:** Pulpal anaesthesia of between 15 and 30 minutes can be expected. If a vasopressor-containing solution is used, the duration approaches 30 minutes. If a plain solution is used, a 15-minute duration is usual. The depth of anaesthesia is greater with a vasopressor-containing local anaesthetic. <start_of_image> Patient positioning/setup is a strong component of many dental procedures. The document describes various techniques for injection as well as the use of syringes and other tools to achieve successful administration and adequate anesthesia. It also includes information on risks, side effects, and potential complications to help dentists and their staff determine the best course of treatment for their patients.