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CHAPTER 15 INJECTIONS FOR SUPPLEMENTAL PAIN CONTROL 307
FIGURE 15-2 Penetration Site for PDL Injections. The
penetration site for a PDLinjection is indicated by the needle.
• FIGURE 15-3 Deposition Site for PDL Injections. The
deposition site for a PDLinjection is indicated by the needle
in the spotlighted area.
standard syringes and are available only in 27 and
30 gauge diarneters.
Successful PDL injections have been performed
using 25, 27, and 30 gauge standard and specialized
needles. Since there is a negligible rate of positive aspi-
ration and the penetration depth is rninimal, safety is not
comprarnised with 30 gauge needles. While these nee-
dles may be more convenient from the standpoint of ac-
cess, some clinicians find their excessive flexibility to
be awkward. Long needles can prove awkward as well,
due to the difficulties encountered when positioning
them for sulcular access in posterior areas of the mouth.
• FIGURE 15-4 Bending Needles for Access in PDL
Injections. Enhanced visibility and access using a bent
needle for a PDLinjection. Factors related to bending needles
for PDL injections are discussed in Box 15-3.
Box 15-2 81anching & Deposition
in PDL Injections
It is important to observe light blanching in the
attached gingiva of the tooth being anesthetized
because it confirms that solution is being retained
in the tissues (not exiting via the sulcus) and that
the resisting tissues are nearing their lirnit for
accommodating solution. The deposition time
period (the 20 second count) begins only after there
is no observed backflow and blanching is observed
(the accommodation limit is reached). Deposited
solution thereafter will be diffusing through bone.
Light blanching may be described as pale
pink in color with visibly less color compared with
adjacent tissues. Stark, white blanching should be
avoided and, if it occurs, the depth of penetration
should be increased slightly.
Accessing posterior sites, in general, can be chal-
lenging with standard needle angulations. Although not
an ideal practice, this restriction can be elirninated by
bending the needle to a 45degree angle (see Figure 15-4.).
Before attempting to bend a needle, see Box 15-3 for
detailed information on bending needles and safety
recommendations.
308 SECTION IV CLINICAL ADMINISTRATION OF LOCAL ANESTHESIA
Box 15-3 Factors for Bending Needles
Needles are bent for ease of access every day. Many
experts recommend bending needles in very specific
circumstances (Jastak, Yagiela, & Donaldson, 1995;
Malamed, 2004). If a decision is made to bend a nee-
dle and there is minimal risk that the needle will be
lost within tissue, the following should be observed:
a sterile technique; the least amount of torque placed
on the hub/shaft interface; the ready availability of a
hemostat or locking pliers; and a bend in the needle
of no greater than 45 degrees (see Figure 15-4).
The bend should be made near the center of
the needle shaft, not at the hub/shaft interface, in
order to create a 45 degree angle and to avoid undue
stress on the shaft (see Figure 15-5 a). The needle
must first be bent to no more than a 90 degree angle
and then released, allowing it to "spring back" to a
45 degree angle ar less, depending on the degree of
the initial bend.
For optimal safety, commercially designed
syringe adaptors with 45 degree angles are available
and recommended (see Figure 9-33). These attach-
ments eliminate the need for bending needles and
their use does not compromise safety. OSHA regu-
lations relating to work place safety do not prohibit
bending sterile needles. Bending of contaminated
needles, however, is prohibited except under certain
"cornpelling circumstances." These devices are dis-
cussed in Chapter 9, "Local Anesthetic Delivery
Devices."
Injection Procedure
Once pre-anesthesia has been established, PDL injec-
tions may be administered in comfort and with confi-
dence. The selection of penetration sites around a tooth
is based upon ease of access, penetrating within areas of
existing anesthesia, and confirmation of diffusion
through bone (no backflow and light blanching). If any
of the three conditions is absent, a different site should
be chosen (see Box 15-4).
Bevel orientation is irrelevant to the success of
PDL injections. Ifbevels are oriented to face the roots of
teeth, two useful purposes can be served. Easier pene-
tration to depth is possible when the sharp tips of nee-
dles are kept away from root surfaces, and gouging can
be minimized while needles are advancing.
a FIGURE 15-5 Technique for Bending Needles. A
handed technique for bending a needle with a steri
mostat is illustrated, using a 90 degree bend and ali
the needle to spring back to a 45 degree final positi
ative to the shank.
Box 15-4 Site Selection and Sequen'
of PDL Injections
Ease of access is key to maintaining stability in
PDL injections. Blanching and the absence of
backflow confirm that the selected site readily
accommodates solution and willlikely result in
success. Pre-anesthesia eliminates concems that
injection is causing discomfort, A primary bene
of eliminating concems of causing discomfort is
clinician confidence when solutions are forced .
ligamental areas under pressure. If patients rea
clinicians typically "ease up" on the pressure.
The following guidelines recognize the
importance of ease of access as well as ergono
when administering PDL injections:
1. For maxillary teeth, select sites on the buc
2. For mandibular teeth, select sites on the ling
3. Observe blanching in subsequent sites before
penetrating additional sites
4. When blanching is observed circumferenti
no more penetrations are necessary
Begin by slipping beneath the su1cular epi
through the periodontal ligament attachment,
tance is met. At the point of resistance, start depo .
lution. Aspiration is unnecessary because there
CHAPTER 15 INJECTIONS FOR SUPPLEMENTAL PAIN CONTROL 311
Infraosseous
Teeth anesthetized:
indiVIdualtoo1h at
sts of InjecIion
PeriodontiumISo tissuea:
supportIng slruclures
immediately adjacent to
site of deposition
• FIGURE 15-6 Field of Anesthesia for an Inlraosseous Injection.
The field of anesthesia for an intraosseous injection is indicated by the
shaded area.
• FIGURE 15-7 Stabident Intraosseous Anesthesia
Delivery System.
the Intral-Iow" device (Pro-Dex Micro Motors). These
devices are shown in Figure 15-7 ., Figure 15-8 .,
Figure 15-9., and Figure 15-10 •.
Penetration Site
The optimal penetration site for an intraosseous injec-
tion is the most apical extent of the attached gingiva
between adjacent teeth (see Figure 15-11A .). While
• FIGURE15-8 X-Tip Intraosseous Anesthesia Delivery
System.
penetration should occur within attached tis sue,
it should be located only barely within it, in an apical
direction. Chapter 20, "Insights from Specialties: Oral
Surgery, Periodontics, and Endodontics," provides alter-
nate descriptions of this site.
In the molar region of the mandible, where corti-
cal pIate thickness is greatest, the crestal third of the
alveoIar process lies beneath the most apical extent of
the attached gingiva and is the area where the cortical
pIate of bone is thinnest.
312 SECTION IV CLINICAL ADMINISTRATION OF LOCAL ANESTHESIA
• FIGURE 15-9 IntraFlow Intraosseous Anesthesia
Delivery System. Components of the IntraFlow device.
• FIGURE 15-10 Assembled IntraFlow Device.
The site chosen should be distal to the tooth to be
anesthetized at an equal distance from the adjacent
tooth. It should approximate the apical extent of the
attached gingiva, which is approximately 2 mm below a
line connecting the gingival margins of the teeth
(Shimada & Gasser, 1989). Mesial penetration is ac-
ceptable but distal penetration is recommended.
After withdrawal of the perforator portion of the
Stabidentor X-Tip device, the needle is introduced
into the perforation to deliver a local anesthetic drug
into the periradicular medullary bone as demonstrated
in Figure 15-12 •. If an IntraFlow device is used, it is
• FIGURE 15-11 A - Penetration Site for an Intrao
Injection. The penetration site for an intraosseous inj
indicated by the perforator (Stabident). B-Removi
Perforator after Initial Penetration. The perforator is r,
prior to needle insertion with a Stabident.
Source: Courtesy of Alberl "Ace" Goerig DDS, MS.
not necessary to withdraw the perforator and ins
needle since the device contains both perforator
needle (see Figure 15-13 • and Box 15-6).
Needle Pathway
The needle follows the perforation through the c
plate of bone into interproximal bone.
Deposition Site
The deposition site is the interproximal bone und
the cortical plate. Once penetration through the c
plate is "felt" by the c1inician (for an alternate des
CHAPTER lS INJECTIONS FOR SUPPLEMENTAL PAIN CONTROL 313
(A) (B)
FIGURE 15-12 Needle Insertion for Drug Delivery with a Stabident. After remova I of the perforator portion the needle
is introduced to deliver a local anesthetic drug. A - Needle inserted through perforation. B-Needle penetration demonstrated
into spongy bone.
Source: Courtesy of Albert "Ace" Goerig DDS, MS.
of this sensation, see Chapter 20) the deposition site has
been reached (see Figure 15-13A and Figure 15-13B).
Technique Steps
Apply the basic injection steps outlined in Chapter 11
and summarized in Appendix lI-I. Additionally, apply
the guidelines listed in Box 15-6.
Periosteum overlying the mandible and maxilla is
very sensitive and pre-anesthesia is recommended for
cornfort before perforrning any intraosseous technique.
(A)
Needle Selection
For intraosseous injections, needles and other armamen-
tarium must be purchased for the specific system selected.
AlI manufacturer instructions should be followed.
Injection Procedure
With pre-anesthesia in place, begin perforation (see
Figure 15-11A, Figure 15-13A, and Figure 15-14 .),
avoiding the buildup of heat due to friction. Once the
cortical plate has been perforated, insert the needle as
(B)
• FIGURE 15-13 Initial Penetration and Delivery with the IntraFlow. The initial penetration (A) is performed in the same
manner as for Stabident and X-Tip devices. However there is no need to remove the perforator. The drug is delivered directly
through the device into spongy bone (B).
Source: Courtesy of Albert "Ace" Goerig DDS, MS.
314 SECTION IV CLlNICAL ADMINISTRATION OF LOCAL ANESTHESIA
Box 15-6 Guidelines for Administering
an Intraosseous Injection
• Step I-If there is no previous existing anesthe-
sia of soft tissue, anesthetize the attached gingiva
first
• Step 2-Mark the penetration site by blanching
with a blunt-tipped instrument
• Step 3-Perforate the cortical plate and deposit
solution into cancellous bone (this is painless
when Step 1 has been performed)
Note: Avoid vasoconstrictors (these drugs enter lhe CVS rapidly)
and observe all maximum dose recommendations.
• FIGURE 15-14 Initial Perforation Using the X-Tip
System.
• FIGURE 15-15 Needle Guide or "Guide Sleeve"
Placed for X-Tip System.
• FIGURE 15-16 Needle Insertion Following Pe
tion using X-Tip System.
recommended for the specific device being used (-
Figure 15-12, Figure 15-13B, Figure 15-15 •
Figure 15-16.). As with the PDL injection, aspiration
not necessary. Box 15-7 provides suggested volumes
solutions when using the Stabident system, as an ex
ple. It is important to refer to manufacturers' instructi
at all times for proper use of these devices. For an alte
description of this injection procedure see Chapter 20.
Confirming Anesthesia
Subjective signs of anesthesia for intraosseous injecti
are few. Patients may report a sense of numbness wh
biting down on the tooth or teeth anesthetized, or the s
tissues surrounding the tooth or teeth may feel somew
numb. The absence of a response to electronic pulp teste
(EPTs) or to the application of icy cold temperatures
confirm anesthesia. In Chapter 12, "Injections for Ma
lary Pain Control" see Figure 12-7, Figure 12-8,
Figure 12-9.
Objective signs inc1ude a lack of response to gen-
tle stimulation with an instrument and no pain during the
procedure for soft tis sues or teeth. The absence of pain
is confirming.
Common Causes of Iniection Failure
Inadequate cancellous bone in the central incisor region
may not allow this technique to be performed. Solution
is not able to diffuse easily through what is essentially a
cortical "sandwich" of bone with no intermediate
spongy layer.
Failures occur most frequently while c1inician
are learning this technique. Studies have shown it to
31 8 SECTION IV CLlNICAL ADMINISTRATION OF LOCAL ANESTHESIA
Intrapulpal
Teeth anesthetized:
individual tooth pulp
at site of injection
PeriodontiumlSoft tissues:
none
,---,-iD~íI1_,-
• FIGURE 15-18 Field of Anesthesia for an Intrapulpal Injection.
The field of anesthesia for an intrapulpal injection is indicated by the
shaded area.
Anatomical Factors
Intrapulpal anesthesia relies on direct access ta the caro-
nal ar radicular pulp. In arder for the injection to be pos-
sible, it is assumed that endodontic access has already
been accomplished.
Technique Factors
Key factors for successful intrapulpal injections are dis-
cussed as follows.
Penetration Site
The penetration site is located in the pulpal tissue of the
pulp chamber or within the root canal of the tooth (see
Figure 15-19.).
Needle Pathway
The needle is directed into the pulpal tissue of the
coronal chamber ar root canal(s), as necessary (see
Figure 15-20.). Anesthetic solutions are directed at
the remaining areas of vital nerve.
Deposition Site
The ideal site has been described as being wedged into the
chamber or the root of the tooth (Malamed, 2004). This
technique provides anesthesia in two ways, primarily as a
result of pressure (pressure anesthesia), and secondarily
as a direct action of the drug (see Figure 15-20).
• FIGURE 15-19 Penetration Site for an Intrapul
Injection. A bur must be used to access the pulp prior
needle insertion.
Technique Steps
Pre-anesthetize the area if anesthesia is not already in e
fect at the penetration site.
Needle Selection
A 25, 27, or 30 gauge short needle may be used.
travascular injection is not possible in the pulp
the needle is confined within the tooth, therefore needl
gauge selection is directly related to providing a needl
that is small enough to fit into the chamber and can
CHAPTER 15 INJECTIONS FOR SUPPLEMENTAL PAIN CONTROL 319
E 15-20 Modification for Intrapulpal Injec-
srerile stopper can be positioned on the needle shaft
in pressure while solution is deposited.
binding. Different gauges may be required on
e tooth in various roots.
'"I Procedure
endodontic access or partial access has been ac-
. hed, an intrapulpal injection can be performed.
patient should be warned that there may be a brief
tense pain experienced; however, this technique is
ive at alleviating subsequent pain.
It may be useful to bend the needle to improve ac-
Before bending a needle, see Box 15-3. Solution is
- .stered at a slow rate, 0.2 ml over 20 seconds.
firming Anesthesia
jective signs of anesthesia for intrapulpal injec-
are few. Primarily, the patient reports that the
thache is gone. A sense of numbness when biting
"11 on the tooth helps to confirm profound anesthe-
Typically, patients will report few signs or symp-
of anesthesia.
Objective signs include no response to gentle
ulation with an instrument and no pain during the
dodontic procedure.
ommon Causes of Iniection Failure
Common causes of failure include: toa shallow a pene-
tion into the pulpal tis sues resulting in backflow of
solution into the mouth versuswithin pulpal tissues;
inadequate pressure generated by the solution; the de-
gree of inflammation ar infection present; and clinician
discomfort with the procedure.
Troubleshooting
Problems encountered include: root canals that are nar-
rower than the circumference of the needle, which pre-
vents adequate access to the nerve; a very surprising
and intense initial pain that quickly subsides; and clini-
cian discomfort with the brief but intense pain that is in-
flicted.
Technique Modifications
and Alternatives
A useful modification when performing an intrapulpal in-
jection is to insert the needle through a previously steril-
ized stopper from an unused cartridge. This can be done
without touching any part of the needle and therefore
without risking needlestick injury by using two sterile he-
mostats, one to hold the stopper and the other to hold the
needle as it is being inserted into the stopper. Once in-
serted onto the needle shaft, penetration is made while the
stopper is held tightly over the endodontic access opening
of the tooth. The pressures generated by the solution will
be greater compared with wedging the needle alone (see
Figure 15-20).
Alternatives include intraosseous injections, PDL
injections, Gow-Gates nerve blocks, and pharmacother-
apies that will allow the inflammation to subside some-
what before reattempting the procedure.
Complications
The experience of brief but intense pain associated with
this technique can be stressful. The use of appropriate
sedatives ar nitrous oxide can diminish this effect for
patients and indirectly relieve clinician concerns of
causing pain.