give a painless injectionI 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 occlusal 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?

Topical anesthetics

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.

buffering anesthetics

Buffering anesthetics

It’s important to note that most of the pain from an injection does not come from the needle stick; it comes from the injection of the anesthetic into the underlying tissue.

The pH of anesthetic is very acidic. So realistically we are putting something akin to lemon juice under our patients' skin and wondering why they jump when we do it. The real question is, what can we do to change it? The answer is to buffer your anesthetic with sodium bicarbonate.

By buffering anesthetics you can raise the pH to a more neutral level matching the natural pH of the human body. This takes some of the burning out of injecting the liquid subcutaneously. Now you can do this with a pre-packaged product like Onset from Onpharma, or you can do it yourself.

Onset has a dosage pen that allows you to dial in the amount of bicarbonate you will exchange for anesthetic from a standard anesthetic carpule. They currently only have recommendations for lidocaine, which is .18cc for a standard carpule. The downside to using Onset is the cost - it runs about five dollars per injection.

If you decide to do the buffering yourself, you’ll need Luer Lock draw syringes, needles and a sodium bicarbonate solution. The process is to simply draw out anesthetic and replace it with the same amount of sodium bicarbonate. It’s kind of a hassle, but it will save you a few dollars per injection; and when you do as many as we do, that can add up fast.

However, just buffering the solution will not completely take the burn out of an injection. The other cause of the burning sensation is the buildup of fluid under the surface of the tissue.

If you inject too quickly the tissue cannot adapt to the amount of fluid and it causes the tissue to lyse. This causes damage to the tissue and pain to the patient. It’s also why patients will have more post-op discomfort in the injection site.

The easiest way to prevent this from happening is to inject slowly. There are a number of computerized devices that aid in slowing the injection process. They force us to slow down and gently administer the anesthetic. It can be done without the aid of a device, but it takes patience.

palatal injections

Palatal injections

The palatal injection is one of the more difficult processes. No one likes giving them, and patients sure don’t like getting them; it's a necessary evil. So how do we make them as comfortable as possible?

Topical anesthetics don’t work very well due to the thicker keratinized tissue on the palate. So to get the tissue to not respond to the initial stick of the needle there are a couple of tricks.

A quick application of ice will numb the surface allowing the needle to enter with little to no pain. You can use endo ice for this, but make sure to be careful not to get it so cold that it causes tissue damage.

Once the tissue is numb from the ice and you have the needle in place, gently squeeze out one to two drops of anesthetic. You should give the anesthetic enough time to soak in. This will anesthetize the area and allow you to administer more local without pain. If you rush this step, your patient's tissue won’t be numb and when you inject it will be painful because of the amount of pressure you’ll need to apply.

The palatal tissue is tight to the underlying bone and has very little room for anesthetic. You’ll have to place some mild anesthetic in the area before trying to pump in more.

The other technique that can be used takes a little more time but is very effective - especially with the very anxious patient or children. First you start with an infiltration. Allow the anesthetic to take effect for a minute or so; this will give enough time for the soft tissue on the buccal to become numb. Once this has occurred, administer a small amount of local anesthetic to the facial papillae.

Make certain to apply enough pressure that you start to see the tissue change on the palatal papillae. This will cause the palatal papillae to become anesthetized. Once this has occurred you can slowly creep your way from the papillae to the palatal tissue administering more local along the way.

I have used both techniques and prefer the ice technique most of the time. It has good results without taking a long time to administer and limits the number of needle insertions necessary. The papillae technique is great when you need a lot of anesthetic or hemostasis, since you will have epinephrine placed directly in the soft tissue in numerous areas.

Difficult patients

We all have “difficult” patients in our schedule. They’re not bad patients; they’re just hard to get numb and we feel bad that we can’t figure out a way to get them comfortable.

You know the kind of patient I'm talking about. You can give them enough anesthetic that their toes are numb but as soon as you touch the tooth, you have to peel them off the ceiling. So what can we do to make these hard to numb patients comfortable?

First, let’s look at smokers. This one is easy; ask them not to smoke for two to three hours before their appointment. Nothing guarantees a bad appointment more than a smoker having a cigarette right before. I have listed in my pretreatment brochure not to smoke since it can interfere with the efficacy of the anesthetic. 

I’ve had a number of patients that couldn’t get anesthetized due to smoking. After I reappointed them and explained for them not to smoke, they were able to get comfortable after one shot. Smoking changes the liver enzymes and increases blood flow which causes faster metabolism of the anesthetic.

Now what about the ones who don’t have a discernible cause of anesthetic resistance? I mentioned buffering earlier with regards to taking the burn out of the injection. One other benefit of buffering is faster and stronger onset of anesthetic. This property helps with hyperemic teeth and infected sites. The buffering helps disassociate the anesthetic ions faster allowing for faster onset and more profound anesthesia.

Have you ever heard of the x-tip? This little beauty is awesome for getting fast profound anesthesia. It is an intra-osseous injection system. It contains two components: a drill for the slow speed hand piece used to create a hole in the cortical plate, and a very short needle to fit into the hole.

The process starts with numbing the soft tissue with a small amount of local anesthetic then taking the drill in the slow speed and making a pathway approximately 2-3 mm below the papillae in the attached gingiva next to the tooth you want to anesthetize. The drill is specially designed to leave a guide device in the bone to aid in getting the needle oriented correctly for administration of the anesthetic. The needle is then slid through the guide path and anesthetic is administered; onset is rapid and profound.

Maxillary teeth usually will respond to one of the techniques above, but mandibular teeth are a different story. So what happens when none of this works on a mandibular tooth? Now you have to bring out the big guns. This is where the Gaw-Gates injection comes into play. This is a standby for me when doing long or very involved surgical procedures.

I’ll use two different anesthetics when trying to get the difficult patient numb. I start with 3% mepivicaine without epi followed by 2% lidocaine with 1:200000 or 1:100000 epi. The mepivicaine is faster acting and has a larger distribution area from the lack of epinephrine. This gets the patient anesthetized quickly allowing me to start, but lasts long enough to overlap with the onset of the lidocaine.

Darin O'Bryan, D.D.S. www.onemorereasontosmile.com


Comments

Commenter's Profile Image Paul Ganucheau
August 22nd, 2012
How do you keep the posterior mandible area dry for that long before giving a IA block?
Commenter's Profile Image Darin O'Bryan
August 22nd, 2012
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.
Commenter's Profile Image Alan Mead DDS
August 22nd, 2012
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
Commenter's Profile Image Darin O'Bryan
August 22nd, 2012
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.
Commenter's Profile Image Dave G
August 24th, 2012
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.
Commenter's Profile Image Darin O'Bryan
August 25th, 2012
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.
Commenter's Profile Image Bart Schultz
August 27th, 2012
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
Commenter's Profile Image Fred Lewcock
September 19th, 2012
What is the name of the second topical?
Commenter's Profile Image Darin O'Bryan
September 19th, 2012
It is called the best topical ever. Here is the link http://www.thebesttopicalever.com/
Commenter's Profile Image Thomas A. Phillips
September 27th, 2012
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.
Commenter's Profile Image Thomas A. Phillips
September 27th, 2012
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.
Commenter's Profile Image Darin O'Bryan
October 8th, 2012
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.
Commenter's Profile Image Jarett Hulse
November 21st, 2012
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?
Commenter's Profile Image Darin O'Bryan
November 25th, 2012
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.
Commenter's Profile Image Antonio Pedro Silva
December 15th, 2012
COuld you inform about commercial names of lpt anesthesics? Thanks. Great article
Commenter's Profile Image Leanne
December 16th, 2012
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?
Commenter's Profile Image Darin O'Bryan
December 17th, 2012
@ 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.
Commenter's Profile Image Lou Cohen
December 8th, 2014
THIS REALLY WORKS. USE STEVEN'S TOPICAL AND THEN INJECT 1/8 of a carpule at injection site about 2 mm under tissue. wait 1-2 minutes and finish block. virtually no pain!
Commenter's Profile Image Kambiz F.
June 3rd, 2019
Please be aware that on November 2008, FDA sent a warning letter to Steven's pharmacy ( which does not Compound this gel anymore) that they were in violation. I suggest you exercise due diligence.