How to Give a Painless Injection [Part I]
I once heard someone say at a continuing education seminar that, “Patients only know three things: Did it hurt? Does it look good? Did they treat me nice?” There is certainly some truth to this. Patients don’t understand if your margins are impeccable or if you have put them in the most stable occlussal scheme possible. But if you make them jump when you give them an injection, they sure as heck remember that.
So what can we do to help ease one of the most unpleasant parts of our practice?
It’s important to address the topical. There are two topical anesthetics I would use. The first is Profound from Steven’s Pharmaceutical. It’s a mixture of 10% prilocaine, 10% lidocaine and 4% tetracaine. It comes in both a regular and a light. The regular is very viscous and the light is runnier.
The second is The Best Topical Ever. It’s a mix of 10% lidocaine, 10% tetracaine, 2.5% prilocaine and 2% phenylephrine. Both of these topical anesthetics seem to work magic; however, making their magic work takes more than just swabbing some on.
One of the keys to make the topical work is to dry the gingiva before applying the topical. This removes the saliva and salivary proteins that can act as a barrier to the medications within the topical. Thoroughly dry the area with gauze and apply topical. Let the topical sit for 30-60 seconds or until the tissue gets a corrugated look to it.
This lets you know that the topical has penetrated the outer mucosa and affected the subepithelial nerve fibers. At this time you can penetrate the tissue with the needle with little to no sensation. If you give the tissue a little jiggle when inserting the needle, it also distracts the patient and helps stimulate the nerves so they don’t register the needle poke.
There are devices, like the Vibrajet that aid you in shaking or jiggling the tissue, but personally I can do it myself. After giving the injection be sure to thoroughly rinse the tissue as the topical can cause some sloughing of the mucosa if left on too long.
Find part II here, and you can also read part III here.
Darin O’Bryan, DDS [ www.onemorereasontosmile.com ]
How do you keep the posterior mandible area dry for that long before giving a IA block?
I will place a gauze around the cotton applicator or if they really drool I will dry the area while the assistant maintains suction. As soon as it gets stippled I inject.
Great tips, Darin! I agree on all counts and I’m going to try those topicals. I’ve had a local compounding pharmacy make TAC gel, but the last batch didn’t seem to have the same efficacy as previous batches and it tastes REALLY bad.
I like using a 30 gauge needle whenever possible, too. There’s no tissue pull when it goes in, so that makes a big difference as well. I’ve also found that injecting very slowly helps with the pain of an injection. The 30 gauge needle helps with that, too.
Al
Very good point Al. I use a 30 gauge for most injections as well. And your slow injection technique is a good point, as a matter of fact it is in part 2.
I haven’t done any studies on this but I use plain old topical ( 10% Benzocaine) and apply it on a Q-tip for 1 minute as described above. It does the trick. Have to dry the tissue…key. It really doesn’t matter what topical you use, it numbs only the surface. Where you’re going with the tip of the needle won’t be numb; I don’t care what you’re using, especially with a block. Slow injections typically don’t hurt. The strech and pressure receptors within the tissue become anethesized and don’t register the pain of the solution distending the tissue. Also, you may think using a 30 gauge is less traumatic but there have been numerous studies showing that the patient cannot perceive the difference between a 30 and 27 gauge. The 30 though does not always allow for a positive aspiration if in a plexus or vessel. The 27 is recommended.
I tried out all the topical solutions on myself first, my assistants love to walk in and see my trying to give myself an inferior block, and I can tell you there is a difference. I try out any new technique on myself first before I do it on a patient. The level and depth of anesthesia is more with the profound topical. The only injection it does not help with as much is the palatal due to the thickness of the keratinized tissue.
Just another quick note. I use Topical Anesthetic Gel from John Hollis Pharmacy (615)-327-3234. About 30 per 30 gram tube. Call me crazy but when I got the stuff. I placed in near # 8 and 9 for about a minute. And gave myself an infection of Septocaine with not one sensation. I even tell my sedation and fearful patients this story. I think it makes them feel more at ease or maybe they think I am crazy.
bart
What is the name of the second topical?
It is called the best topical ever. Here is the link
http://www.thebesttopicalever.com/
Good points all Darin- I hope you mention the virtues of using Citanest plain 4% first, and NEVER Marcaine first as it burns big time….I’ve actually seen inexperienced ( or obtuse) dentists use Marcaine first and it made me cringe! I haven’t tried the new pH raising agents yet, but they make sense.
Good points all Darin- I hope you mention the virtues of using Citanest plain 4% first, and NEVER Marcaine first as it burns big time….I’ve actually seen inexperienced ( or obtuse) dentists use Marcaine first and it made me cringe! I too use the “jiggling” technique with great success- I believe that vibratory stimuli reach the brain faster than the slower pain neurons can convey pain stimuli, and as such get “priority” in perception. I haven’t tried the new pH raising agents yet, but they make sense. I’m looking forward to trying your “topicals”! Thanks for a great thread.
Thomas
In regard to using Prilocaine first. That is what I did before using the buffering solutions. The solution takes the burn out and also increase the dissolution allowing for faster anesthetic. Try out the topicals, I think you will like them.
I know this is an old topic, but perhaps someone will reply.
I’ve used John Hollis’s pharmacy topical in the past with great results.
But with all this praise for besttopicalever, I’ve given it a try.
My first few times, I’ve had unacceptable tissue sloughing. I contacted the company and they said with their topical they recommend NOT drying the tissue. The opposite of what I’ve heard about every other topical.
As for how I was using it.
Drying tissue, small amount at injection site. Started with 2 minutes, then rinse thoroughly. I have since reduced to one minute, and still seeing sloughing.
I’m going to try on wet tissue now, as suggested.
Anyone else have a similar experience?
Jarett
I have not had any tissue sloughing with the besttopicalever. I did have some with the profound thick solution. I had two separate cases were I had sloughing. The big thing to prevent this is to make sure to rinse after about a minute with the thick solution and about 2-3 minutes with the light solution.
COuld you inform about commercial names of lpt anesthesics?
Thanks. Great article
Hi! I am interested in purchasing the best ever topical and I was wondering if there was a flavor that’s more preferred? Also, isn’t it quite easy to overdose a patient on topical anesthetic?
@ Antonio The commercial names for the LPT anesthetics are Profound from stevens pharmaceutical and the best topical ever.
@ Leanne, the flavors for the best topical ever are like any topical they taste bad. I tried a few and there was not one that stood out as better tasting. I looked into the overdose on local anesthetics. The concern is prevalent when sprays are being used for endoscopies and other GI surgeries. I could not find a instance of topical overdose in dentistry.