PDL injections and crown removals

[mrlantern]

1) At one clinic I'm working for, there's so much low-class managed care patients who scream when they feel the slightest pain from any handpiece. This commonly occurs with lower molars. I don't think my block injections are a problem, as I'm usually able to achieve soft tissue anesthesia towards the lip midline with just one carpule alone.

I know that PDL injections are known to be very effective for the patients I described above. The problem is I don't think I'm doing them right. I'm not quite sure how to angle the needle and how far down to inject. Even worse, I often get lidocaine squirting out the needle whenever I do a PDL injection.

Some advice on how to give good PDL injections would be appreciated.

2) I'm also having problems using the crown removal tapper. ( the instrument that you assemble into a crowbar form ) I have never in my life successfully removed a crown or bridge using this. I'm seeing that it's very time consuming and counterproductive to drill out a crown/bridge.

Much help would also be appreciated if someone can provide me with good instructions on how to use a crown tapper.

3) I don't think I'm a good dentist in spite of having finished a dental school and a residency. What should I do? Should I quit dentistry ( something I was planning on doing anyway because I'm finding it very hard to make a living based on insurance reimbursements. But the other problem is that I don't have any other life skills or connections to land me into a different career ) ? Or should I specialize in something like prostho or perio and try to become good in at least one facet of dentistry?


Thank you.

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[Visceral]

For mandibular anesthesia in the molar region consider accessory innervation from the nerve to mylohyoid.

http://www3.interscience.wiley.com/journal/114180620/abstract

Can't help you about PDL injections, only learned about them in theory so far.

 

[Daurang]

Your posts are always depressing. Why don't you just move out of NYC so you won't be overwhelmed with high living expense and debt.

 

[tinman831]

There's really no trick to PDL injections. Just aim straight down towards the apex, insert in, and squeeezeeeee. You're going to require quite a bit of force to inject anything substantial in there, but be patient and it'll be worth it.

 

[aphistis]

If you're giving blocks but your patients are still inadequately anesthetized, then your block technique IS the problem. That said, PDL's are nice supplemental injections. Take a 30g short, bevel facing toward the tooth, and insert it into the PDL space at the distal interproximal space (start there until you gain familiarity with the technique). You should feel a stick similar to an explorer tip on decayed tooth. Inject, but it doesn't take much (1/4-1/2 carpule). If you're doing it right, the anesthetic will be very difficult to inject. Maintain firm pressure, and you'll see the gingiva blanch as the anesthetic diffuses into the tissue. Withdraw, and safe your needle. That's it.

A properly administered PDL achieves pulpal anesthesia in less than a minute, with a somewhat variable duration typically in the 15-30 minute range.

 

[DrJeff]

One of my endodontist friends swears by the following with respect to lower 1st molars and anesthesia issues.

If you truly have positive anesthesia signs (i.e. lip to the midline, 1/2 the tongue, no pain sensation to when the tissue is poked with the explorer, etc) and the patient has pain in the 1st molar (especially in the MB area), then you've got a tooth with an irreversible pulpitis.

The more and more of these I see (and often wait after seeing), the more and more this irreversible pulpitis theory holds true

 

[Streetwolf]

If you truly have positive anesthesia signs (i.e. lip to the midline, 1/2 the tongue, no pain sensation to when the tissue is poked with the explorer, etc) and the patient has pain in the 1st molar (especially in the MB area), then you've got a tooth with an irreversible pulpitis.

Yeah that sounds like my #19 exactly (my own tooth....). Except when I get PDL injections it is finally anesthetized. Every other tooth in the arch is fine except that one. Weird.

 

[mike3kgt]

There's really no trick to PDL injections. Just aim straight down towards the apex, insert in, and squeeezeeeee. You're going to require quite a bit of force to inject anything substantial in there, but be patient and it'll be worth it.

I have performed a lot of these types of injections and find that there are a few things to consider.

1. You are best helped by getting a "ligajet" style syringe by Miltex or any other specific PDL syringe. See this link page 7. I These types of syringes allow for a significant, constant pressure directed along the axis of the root/pdl. You need to be patient and and take your time.

2. You also need an ultra-short needle, 30 gauge, possibly 2-3 needles to perform acceptable PDL anesthesia. The longer needles will work but you are making your life MUCH more difficult.

2. Bevel is always facing the root surface. This injection does not work properly without bevel facing root.

3. Try articaine. Sometimes made it easier, sometimes lido is better. Some people prefer 3% plain mepivicaine. They all work. Try articaine on buccal / lingual vestibule of man 1st molars. It works sometimes also.

4. http://www.youtube.com/watch?v=mVnlRFx_vvA. There are videos for everything these days.

Open your mind to several different ways of doing things.

When are you getting out of NYC? Dude, seriously, I feel bad for you but only up to a point. Dentistry, at times, is extremely challenging and sucks! There are plenty of smaller communities that you can make an excellent salary, have a great lifestyle, and STILL only be 1-2 hour drive from NYC so you can get your fix.

 

[mrlantern]

If you're giving blocks but your patients are still inadequately anesthetized, then your block technique IS the problem.

Not true. You can give one block injection and achieve soft tissue anesthesia to the midline, which is an indication of whether the block injection was successful.

But after getting the numbness towards the midline, if the patient still reports pain on a lower molar during the drilling, it won't help at all to give another block injection no matter how differently you do it this time.

In principle you're then supposed to give either an intraosseous, intrapulpal, or a PDL injection. I was asking for latter techniques because the PDL is most accessible. The problem is that most schools don't ever teach about this injection chairside.

 

[mrlantern]

I appreciate all the clinical feedback so far.

But I also asked about using crown tappers for removal of crowns and bridges. Can anyone also provide me with good instructions and tips on how this is effectively done? And what should I do if I don't think I'm a good dentist? Should I do something like a prostho residency so that I can become good in a more specific area of dentistry?