Topical anesthetics

Reduce discomfort during insertion of needle Many forms : liquid, gel, oinment Steps :
Dry the mucosa Apply the anesthetic agent with cotton swab Effective approximately 30seconds

tell the child : tooth is going to be put to sleep

Management techniques
Disposable syringe preferable to stainless steel syringe ( appeared threatening)

Infiltration of mandibular teeth

Infiltration of mandibular primary incisors

There maybe conjoined innervation of mandibular incisors
Infiltration placed close to midline and also at opposite side

Useful in :
Superficial caries excavation Removal of partially exfoliate incisor Adjunct to ID block

Infiltration of mandibular primary molars

Injection at mucobuccal fold between roots of primary molars Useful in : most restorative procedure Less effective in extraction and pulpotomy

Gow-gates mandibular block technique

Anesthetize all distribution of 5th mandibular nerve in mandibular region Inferior dental , lingual, buccal, mental, incisive, auriculotemporal and mylohyoid nerve

Gow-gates mandibular block technique

Landmarks : tragus of ear and corner of mouth Insert needle medial to temporal muscle Needle inclined upward and parallel to a line from corner of mouth to lower border of tragus (intertragic notch) Needle directed from opposite side

Infiltration of maxillary teeth

Infiltration of primary incisor and canines

Conjoined innervation from opposite side Technique : Place injection close to gingival margin, close to bone, near to apex of tooth Some prefer pull lip downwards to penetrate tissue rather than advancing the needle upwards Remember anesthetize palatal tissue!

Infiltration of maxillary primary central incisor

Anesthetization of palatal tissues

Painful After buccal infiltration, interdental (interpapillary ) infiltration maybe usedminimize pain

Nasopalatine nerve block

Palatal tissue of 6 anterior teeth

Infiltration of maxillary primary molars and premolars

Middle superior alveolar nerve & posterior superior alveolar nerve form plexus at primary molar area Both nerve must be anesthetized Thin bone over first primary molar, but thick over second primary molar and first permanent molar (zygomatic process) Supplemented injection over second primary molar and 1st permanent molar placed at area superior to maxillary tuberosity

Advances in LA techniques
Computer-controlled delivery system Intraosseous method Intraligamentary method Topical anaesthetic patches

Computer-controlled delivery system

Advantages:
Excellent tactile sensation Allows coring penetration that minimizes needle deflection Slow rate of flow reduces pt discomfort Ease of administration

Computer-controlled delivery system

In a study that compared computer-controlled delivery of LA with syringe delivery,
subjects reported less pain with injections delivered using the computer-controlled device total injection time was similar to that required for syringe injections. Both techniques provided adequate anesthesia.

Computer-controlled delivery system

Computerized delivery of intrasulcular anaesthesia (CDS-IS)
In a study that involved 193 children aged 2-13 years old, it was found that CDS-IS was effective for anesthetizing primary molars, mainly for amalgam, resin-based composite and stainless steel crown restorations.
ASHKENAZI et al. 136 (10) 1418. Journal of the American Dental Association 2005

Intraosseous method
Placement of anesthetic solution directly into the cancellous bone or marrow space adjacent to the tooth or teeth to be anesthetized, and allows for rapid onset of profound pulpal anesthesia.
as a primary or supplemental technique pt do not experience numb lips or tongues post-op immediate onset of anaesthesia and reduced dosage levels of anaesthetics results in low perceived pain ratings, mild or no pain during and after procedure

Intraligamentary delivery method

By inserting needle through gingival sulcus and into the PDL between tooth and alveolar bone. The modern PDL technique involves slow injection of a relatively small volume (approximately 0.2 ml) of anesthetic. Slow injection due to back-pressure resistance in PDL. Small volume because of confined tissue space and design of special PDL injection devices. However, researchers have recommended that PDL injection should not be used when infection or significant inflammation exists at the injection site, as well as with primary teeth.

Topical anaesthetic patches

Bioadhesive patch impregnated with 10 or 20% lidocaine Based on a recent study, it reduced pain significantly better than did benzocaine gel and placebo for all painful stimuli tested

References
ASHKENAZI and BLUMER. Effectiveness of computerized delivery of intrasulcular anesthetic in primary molars. J Am Dent Assoc 2005;136;1418-1425 PERRY PETER M. LOOMER and DOROTHY A. Computercontrolled delivery versus syringe delivery of local anesthetic injections for therapeutic scaling and root planing. J Am Dent Assoc 2004;135;358-365 CHRISTOPHER H. KLEBER. Intraosseous anesthesia: Implications, instrumentation and techniques. J Am Dent Assoc 2003;134;487-491 PATRICIA L. BLANTON and ARTHUR H. JESKE. Dental local anesthetics: Alternative delivery methods. J Am Dent Assoc 2003;134;228-234