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My painless injection
Apologize profusely in advance I dont know whether its help full but Il
get amaring result by these technique. Although we all learned about
painless injection technique at college, there are some special tips from
my side to make patient smile during injection at dental office.
Thanx in advance

Dr piyali patel

I noticed someone mentioning on the forum that they hate hurting people so I decided to
share how I do local anesthesia. Maybe that would help someone here. I can't promise that
patients won't feel a thing (although it does happen often). At least, it will be a pinch or
It goes without saying that pain is one of the biggest barriers to dental care. Because of
painful experiences in dental chair, everybody suffers.

- Patients postpone care and get worse outcome.

- They don't come to the office often and don't bring us the money. Instead, they go to
sedation docs
- We are portrayed as villains in movies and then get hated at the parties. "OMG, you're a
dentist? Ugh, how can you hurt people?"
- It''s stressful for us. Once I heard this from the audience at a seminar, "It creates stress for
me to inject others". That was one of the reasons that doctor hated his job.
- Screaming kids cause hearing loss and scare other patients away ;)
This method was perfected on 4 to 6-year olds. The most extreme fan (6 y.o.) said, "Next
time, will I get a shot? I want a shot!" I hate children screaming in my ear, and if a child
starts crying, it's game over, pretty much. So I had to develop this method. Some of it I
learned from a pedodontics resident at my school. The breathing trick I took from an
acupuncturist I saw once.
Sorry if this text becomes too detailed, I wanted to make sure I don't miss anything. The
intended audience is more beginning dentists, I guess.

General principles
First, you must develop a gentle touch. "Doctor should have the wisdom of a serpent and
touch of a girl". Avicenna, afaik. The mouth is the most sensitive part of our body
(remember sensory homunculus?), so it's even more important in dentistry.
This is how I practiced gentle touch. The hands should feel weightless for the patient. If
someone puts an arm on your shoulder with all its weight, it's unpleasant. It's even more
painful when that weight is placed on the needle. Exercise: touch your left hand with the
right middle finger, so that you barely feel the touch, like a feather. That's how it should feel
to the patient. Now, notice which muscles in your shoulder and arm are working. You
should feel those muscles contracted when treating a patient.
When injecting someone for the first time, I never tell the patient, esp. a child, that they
won't feel anything. It's not true and breaks the trust right out of the gate. They still feel a
pinch and they will feel pressure/cold/movement during extraction.
Instead, I say, "You will feel a pinch, like this (and pinch the skin on their hand lightly with
my fingernails). Can you cope with that?". Usually they will say yes.
Inject slowly, about 1 minute per carpule. It decreases the pain from rapidly expanding the
tissue with 1.7 ml of liquid. Usually pain is from rapid expansion of tissue, not from the
needle itself. Stick yourself in the mucobuccal fold with a needle, you'll feel it. Plus, AFAIK,
slow injections are more profound.
Rapid injection doesn't save time. We get 20-30 seconds more, but the patient is tense,
less trusting, and more likely to cancel later because of fear. So, I think, spending 40
seconds more per injection is a good time investment if patients are happier. It doesnt
hurt, Mom! is pretty good free advertising :)

Insert the needle slowly, pushing anesthetic in front of the needle, (it pushes tissue away
from the needle).
Then, always wait for at least 5 minutes. I have a timer set in my watch, so I do something
during those 5 minutes until it beeps. I run the water through the high speed (if it's the first
patient of the day), show them a video with post-extraction instructions, etc.
If the patient isn't numb after 5 minutes, I'd add intraseptal on mesial and distal with 4%
septocaine 1:100K epi. Inject right into the papilla at 45 degree angle, stick the needle in
the bone. Inject, until the tissue becomes white.
For the mandibular block, if the initial injection was with lidocaine, you can also add IAN
block with mepivacaine. Endo trick.
If I find out that the patient is very afraid/sensitive, I use septocaine instead of lidocaine for
infiltration. I warn them that they can be numb for several hours later and it's OK.

Always use a triple bevel needle at first. Stick yourself to find the least painful one. That
will also give you a right to say that it won't hurt much.
The first injection is always with a X-short 30G needle. I use Shotgum from SAFCO: triple
bevelled and cheap. And yes, I stuck myself with them to know what my patients feel.
Since it's only 10 mm long, it doesn't look as scary as a 2 inch-long 27G needle.
The second injection may be with 27G for mandibular blocks

Rapid deep inhalation

This is paramount to my technique. The mechanism (as it was explained to me) is that
such inhalation blocks transmission of pain through the nervous system for a fraction of a
second and that's all you need for a painless insertion. After you insert the needle, other
tricks will decrease the pain from injection.
To the patient:
"Usually, people don't like injections. There is a trick to decrease or remove the pain. Let
me show you. On the count of three, Inhale deeply and quickly through your nose into your
stomach ("into your belly" if I'm with a kid). Don't move your nose [people often jerk], just
breathe through it. The faster you inhale, the less you will feel. Look at me. This is how it's
I count, "One, two, three" and inhale myself.
"Now, let's practice. 1,2,3."
The patient inhales. Some do perfectly immediately, others will need feedback.
I say, "Yes, but it has to be deeper (or faster, or both, whatever the case). The faster you
inhale the less you will feel. Let's do it again. 1,2,3 "
If there's no improvement after 2 tries, I don't insist and just do the rest of the elements.
The patient will learn eventually.
The speed of inhalation should be full lung capacity in about 0.1 seconds. I attached a
sound file so that you know how this should sound. It's in ZIP archive because the system
doesn't support attaching of MP3.
Practice with the patient while the topical is in place. Topical takes 20-60 seconds to work,
this gives you enough time for practice.
Some people will be openly sceptical at first. If you do several injections on them, urge

them to try to do as you say the second time. I always tell them "It should be deeper (or
faster). The faster and deeper you inhale, the less you feel."
Ask the patient if they felt the injection. That gives you feedback in every case so you can
improve. Just pay attention to it as you do it. To the patient, it shows that you care.

Penetration of the needle.

I always start with 30G extra-short. The tissue is taut, I insert quickly and go just a couple
mm in. Inject a bit, then move deeper. Repeat until get to full length of the needle, then
inject the whole carpule in 1 minute or so.

Additional tricks for specific sites

Pull the cheek away so the tissue is taut. Tactile stimulation blocks transmission of pain.
That's why we rub the bruised spot immediately after being hurt.
Palatal block.
This is considered the most painful spot. In addition to topical for 20 secs and deep
inhalation, take a Q-tip and press hard about 5 mm to any side of the injection spot. Again,
same principle: pressure blocks transmission of pain. The only thing the patient will feel is
that pressure from the Q-tip.
Mandibular block
When I do a mandibular block, first I inject 0.2 ml with a x-short 30G needle (anesthetize
the injection site).
I wait about 30 secs, then do the rest with a long 27G one.
I inject a bit, then move deeper. Repeat until get to desired depth, then inject the whole
carpule in 1 minute or so. When we push the anesthetic in front of the needle, it pushes the
tissue away and anesthetizes our path. Appendectomy was done with such layered local
anesthesia before they invented general.
If the patient isn't numb in 5 minutes, I'd add intraseptal on mesial and distal with 4%
septocaine 1:100K epi. Inject right into the papilla at 45 degree angle, stick the needle in
the bone. Inject, until the tissue becomes white.
If the initial injection was with lidocaine, I can also add IAN block with mepivacaine. Endo
For children, I try not to use mandibular blocks. On deciduous teeth, I use mental blocks if I
work on molars. It's less intimidating for them and easier technically for me.

All of these things decrease the pain from injection. Thus, if something fails (say, the
patient doesn't inhale as well as you want), it'll still hurt less.