Painless (or less painful) injection techniques

[Squeegified]

Just wondering what the more experienced people out there do to minimize pain and discomfort experienced by patients while giving injections (IAN blocks, infiltrations, whatever...) Techniques, distractions, etc...

I thought it might be helpful to share some techniques that people use to help minimize pain, or distract the patient to make things a little more comfortable. This would be especially helpful for those of us just starting out, as well as for those just trying to improve their skills.

Share some techniques, ideas, whatever. Any input would be appreciated...

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[Daurang]

I use 30 gauge ultrasharp short needle on everybody and virtually everyone seems happy. Those that absolutely refuses needle are so far and few in between I just discontinue and refer them out.

 

[DrJeff]

I use 30 gauge ultrasharp short needle on everybody and virtually everyone seems happy. Those that absolutely refuses needle are so far and few in between I just discontinue and refer them out.

Big fan of 30 guage short's for just about every injection situation too👍

First thing I do is TELL the patient what they can expect to feel (i.e. me shaking their lip/cheek{see below}, a mild pinch {a "mosquito bite" if I'm working on a pedo patient} and how long it will take me to deposit the carpule)

Also, even though from a research standpoint, it's efficacy is called into question, I do use some topical on a cotton tipped applicator for the time it takes me to wash my hands and glove up (I think atleast psychologically it helps the patient), and then I'll shake what ever piece of lip/cheek is close to the injection site as I'm giving the injection. Lastly, I SLOWLY inject the carpule, taking 30+ seconds per carpule.

This seems to work quite well for me as very often I'll have patient's tell me that I give "the best" injections they've ever had😀

Also, when I have to give some anesthesia on the palate, I just flat out tell the patient that they're likely to feel the pinch (although I've often infiltrated enough in the papilla area from the buccal ahead of time that when I do get to the palatal side, that tissue is blanched and the injection is usually pretty comfy there too.

Best thing, is find a routine that works in your hands and then keep repeating it

 

[Theillestill]

Just wondering:

How often do you do maxillary nerve blocks and gow gates blocks in clinical practice?

 

[DrJeff]

Just wondering:

How often do you do maxillary nerve blocks and gow gates blocks in clinical practice?

Very rarely, and only when "traditional" infiltration or Inferior Alveolar Blocks won'tget profound anesthesia as both the maxillary "trunk nerve" blocks and Gow Gates are quite often uncomfortable for the patient. And hands down, one of the ways that a patient judges how "good" you are as a dentist(and as a result how likely they are to come back and see you and tell their friends to come and see you) is how comfortably you can anesthetize them. Seems dumb, but it's very true🙄

 

[PlaqueAttack]

Something to check out when you get out of D-school is "The Wand" which delivers the anesthetic at a set pressure (which is adjusted via foot pressure on a rheostat). I recently graduated from D-school and was using this at my dad's office. My wife and some other patients that I had at both D-school and at his office said it was much more pleasant and I was definitely one to take my time during an injection in d-school (especially on my wife). It takes between 30 and 60 seconds to deliver a carp and it makes these beeping noises that help with kids as well and lets you know how fast its being delivered. It also aspirates as a requirement before delivering anesthetic so you'll never forget to do that. I've experienced it and it makes it much more pleasant because it is a constant pressure. Don't listen to all the "computer controlled delivery" crap on the web though, you control the pressure via the amount of pressure you place on the rheostat.

here's a couple links if you're interested:

http://www.d-p-s.uk.com/othe-wand-anaesthesia.htm

http://jada.ada.org/cgi/content/full/133/1/106

48/50 pts rated "the wand" as less painful than the conventional syringe and there are numerous companies that make this same product

 

[aphistis]

I use Gow-Gates blocks frequently. DrJeff is correct, your ability to successfully anesthetize a patient goes a long way toward shaping their opinion of your skill as a dentist. In my experience patients tolerate it as well as a conventional IANB, and both objective data and my personal experience suggest that its success rate is considerably better. I use V2 blocks less frequently, but still not uncommonly. Anesthetic technique is one of those things that every dentist does a little bit differently, and the only thing that makes one method better than another is its success rate in your hands.

 

[Squeegified]

First, thanks for the great responses! It was exactly what I was hoping for.

Second, I always figured that a 30 gauge would make a difference compared to a 25. In our pain control class, our instructor said that patients can't tell the difference between a 25 and a 30, but I really haven't had enough experience to tell the difference yet.
Also, We infiltrate just about everything on the maxilla, but we've been taught to use an IAN Block for just about everything on the lower arch. Is that common? or do any of you have success with infiltrating the mandible as well?

One other question, might be kind of dumb, but like i said, I'm still not very experienced; are you guys using a 30 short for your IAN blocks? We always use 25 longs, because they are easier to aspirate and because we've been taught that a short won't reach the ramus. Let me know what you think.

Thanks again for all the responses!

 

[OceanDMD]

I use Gow-Gates blocks frequently. DrJeff is correct, your ability to successfully anesthetize a patient goes a long way toward shaping their opinion of your skill as a dentist. In my experience patients tolerate it as well as a conventional IANB, and both objective data and my personal experience suggest that its success rate is considerably better. I use V2 blocks less frequently, but still not uncommonly. Anesthetic technique is one of those things that every dentist does a little bit differently, and the only thing that makes one method better than another is its success rate in your hands.

Why do you use the Gow Gates injection frequently?

 

[aphistis]

Why do you use the Gow Gates injection frequently?

Short answer, because it just works more reliably for me. I don't begrudge anybody the regular IANB if it works well for them.

For myself, though, I don't like how often I have to supplement conventional IANB's for endo or oral surgery. I think the landmarks are more reliable for the Gow-Gates (no guesswork about what fraction of the needle is embedded, no imaginary lines intersecting, when the needle tip touches something hard it's either the condyle or the neck, and either one puts you right beside the nerve), and I suspect that blocking the nerve more proximally (i.e. at the condyle vs. at the mandibular foramen) eliminates any potential of aberrant nerve anatomy, recurrent branches, etc., etc, as the nerve trunk travels down the ramus.

With the way I currently distribute my two initial carps of anesthetic--Gow-Gates first, then a little lower on the ramus for the second--for my mandible blocks, I'd estimate my success rate (success = profound anesthesia obtained with initial injections only) has gone from 75-80% to around 95%, which is a figure my patients and I are all much happier with. YMMV.

 

[gryffindor]

It also aspirates as a requirement before delivering anesthetic so you'll never forget to do that.

I never forget to aspirate during an IAN, but too often I look down at the syringe and find that it hasn't engaged the rubber end of the carpule because it's blunted so there was no point to aspirating. At that point you just pray.

I use a 27 gauge for IAN, but I hate hate hate giving IAN blocks because I'm not good at giving them reliably. I need to look into the Gow Gates technique a bit more.

Topical anesthetic is supposed to work better if you adequately dry the mucosa with some gauze prior to application. I've never been in a situation where the assistant and patient were patient enough to let me really try this out but maybe one of you could try it.

How about some feedback on these scenarios:

1) There are dentists who swear by infiltration only in the mandible with septocaine and never give IANs.

2) I worked with a restorative dentist recently who anesthetized the mandible using 3 carpules of septocaine for what I was taught to do with 1 carpule of lidocaine. First she gave an IAN block with one carpule, then she injected an entire carpule in the buccal mucosa near #30, and then she injected the last carpule in the floor of the mouth near #30. Is this common? I've never seen anyone inject the floor of the mouth for restorative, only seen oral surgeons do it. Also, we were taught that 1/4 carpule near the buccal of #30 was plenty for anesthetizing the lingual nerve on that side.

 

[DrJeff]

First, thanks for the great responses! It was exactly what I was hoping for.

Second, I always figured that a 30 gauge would make a difference compared to a 25. In our pain control class, our instructor said that patients can't tell the difference between a 25 and a 30, but I really haven't had enough experience to tell the difference yet.
Also, We infiltrate just about everything on the maxilla, but we've been taught to use an IAN Block for just about everything on the lower arch. Is that common? or do any of you have success with infiltrating the mandible as well?

If I'm doing some relatively minor looking restorative and/or perio work anterior to the molars in the mandible, I'll often use a mental nerve block with a very high degree of patient comfort. I also regularly use a mental nerve block on the contra-lateral side when I'm working on 24/25 to deal with cross innervation. As for straight infiltration of the mandible, I usually just use that as supplemental soft tissue anesthesia when I'm doing an extraction in the mandible.

One other question, might be kind of dumb, but like i said, I'm still not very experienced; are you guys using a 30 short for your IAN blocks? We always use 25 longs, because they are easier to aspirate and because we've been taught that a short won't reach the ramus. Let me know what you think.

Thanks again for all the responses!

No problems reaching the medial surface of the ramus with a 30 guage short on about 99% of my patients. For the REALLY BIG folks, I'll break out a 27 guage long needle (or as I call it, "The Harpoon") to get the "juice" where I need it! 😉

 

[DrTacoElf]

If the tissue is dry the topical works better thats for sure. I tested it on myself 😛. It stays in one place better and seems to provide anesthesia a little quicker (probably because its in direct contact with the mucosa).

At school we always used 27 guage but I have used 25 before and prefer it - less deflection and less chance of breakage. Personally I don't care if the patient is in a little bit more pain if it means safety. No way i'd use a 30 gauge for an inferior alveolar block - I've seen 2 cases of broken needles and both were 30 gauge used on inferior alveolar block. Also in Malamed he says that the patient can't tell 25 gauge from 30 gauge (not sure I agree with this but its what he has stated). One very important thing to remember is to always use a sharp needle. If you have contacted bone multiple times that needle is pretty much shot - if you continue to use it, it will tear mucosa and the patient won't be happy with you once the anesthesia wears off 🙁

 

[NileBDS]

Just wondering what the more experienced people out there do to minimize pain and discomfort experienced by patients while giving injections (IAN blocks, infiltrations, whatever...) Techniques, distractions, etc...

I thought it might be helpful to share some techniques that people use to help minimize pain, or distract the patient to make things a little more comfortable. This would be especially helpful for those of us just starting out, as well as for those just trying to improve their skills.

Share some techniques, ideas, whatever. Any input would be appreciated...

Somethings that have worked for me in my limited experience:

• Dry mucosa before topical (biggie). Topical is great when it works. Only use a dab, leave it for 2 minutes.

• Warm anesthetic solution (they have some LA carpule dispensers with a lamp, which helps keep the solution warm prior to injection).

• New needle for every injection (not practical).

• 3 step infiltrations (buccal, inter dental papilla, palatal) - waiting 1-2 minutes in between, or until tissue is visibly blanched

• Always long buccal to augment IANB

• Always always ALWAYS talk during injection (just explain to patient what you're doing or what to expect) or just make small dentist talk as a distraction

• The famous "cheek jerk" while penetrating tissue

• I personally have had good success with Gow Gates, but do not use it that often due to increased incidence of post-op trismus

 

[Daurang]

One other question, might be kind of dumb, but like i said, I'm still not very experienced; are you guys using a 30 short for your IAN blocks? We always use 25 longs, because they are easier to aspirate and because we've been taught that a short won't reach the ramus. Let me know what you think.

I use 30 short on EVERYONE the past eight years, and have failed maybe twice. Now I infiltrate with articaine if necessary and can't recall the last time I've failed.

 

[Thaxil]

Dry mucosa, topical for 2 mins, 25 gage long for every injection, shake cheek, and slow injections while making small talk to assistant.

 

[jmick101]

I am not sure if this is going to make sense but... I am going to throw it out there anyways. When initially penetrating the mucosa I like to place the needle as close to, if not on the mucosa and then gently pull the mucosa over the needle tip. You have to kind of jiggle the cheek to do this, but that is a good thing to do anyways.

 

[OceanDMD]

I use 30 short on EVERYONE the past eight years, and have failed maybe twice. Now I infiltrate with articaine if necessary and can't recall the last time I've failed.

Im the same. Dry that tissue and let the topical sit for 2 minutes. The tissue will appear "wrinkly". Then you know you have good topical anesthesia. A comfortable injection goes a long way as far as internal marketing. I personally think the gow gates is uncomfortable, and a last resort. Its so easy to block conventionally, and if you still have problems articaine is a best friend.

 

[Lidopaine82]

Im the same. Dry that tissue and let the topical sit for 2 minutes. The tissue will appear "wrinkly". Then you know you have good topical anesthesia. A comfortable injection goes a long way as far as internal marketing. I personally think the gow gates is uncomfortable, and a last resort. Its so easy to block conventionally, and if you still have problems articaine is a best friend.

What is the best technique for applying topical for an IA?

 

[OceanDMD]

What is the best technique for applying topical for an IA?

I will do my best (my assistant will do her best) to suction the patient, and blow dry the injection site, wipe the injection site with gauze, and apply a good amount of topical letting the patient close with either a cotton roll or piece of gauze against the topical. Waiting the full 2 minutes really does help, I also rarely wiggle the cheek anymore when giving an injection. I just go real slow into the tissue with a bead of anesthetic dripping out. My IA injections usually take almost a full minute to dispense the carpule. Obviously sometimes the patient will feel a good pinch, or wince, and you feel like your injection sucked. But I really think its the pressure these patients are feeling, and maybe there pain threshhold is low.

Oh, and remember in dental school where they say and IA injection must be given with a long needle? Not true. I may have used a yellow twice this year, and usually on patients with a lot of body fat.