Local Anesthesia for the Dental Hygienist Dr. R. Cordell Johns Old Dominion University Day 1 Basic Injection Technique

Objectives Which steps in the injection technique will ensure the patients comfort and safety? Which medical contraindications, will influence administration of local anesthetics? List local and systemic complications, which can arise due to local anesthetic administration. What is the proper physiologic position for the patient and operator for all injection techniques? List the steps in the injection procedure using correct aseptic techniques.

Objectives What patient responses should the clinician observe before, during and after injection technique? What information is recorded in the patient’s chart relating to performance of any injection technique? List at least 3 reasons why a patient should not be given an anesthetic injection. (relevant to their medical history) What is the recommended cardiac dose of epinephrine? Explain what is meant by using a “cocktail” approach for local anesthesia? What would be the best anesthetic solution to use on a woman who is breastfeeding due to its half life? When will the drug be removed from breast milk?

Secondary Objectives Know the two most commonly occurring psychogenic reactions to local anesthetic administration. Know the frequency of reviewing and updating a medical history. Know how pain and discomfort affect pain control. How does being nervous affect pain control? Know the drug interactions of local anesthetic agents

Patients Perception of Local Anesthesia

Which Steps in the Injection Technique Will Ensure the Patients Comfort and Safety? Use a sterilized sharp needle. Check the flow of the local anesthetic solution Determine whether or not to warm the anesthetic cartridge or syringe. Sometimes a needle will come from the manufacturer that has a fish hook or barb on the end. IF inserted in a patient it will cause pain upon removal because the barb tears the tissue. Use a sterile 2x2 and run the needle backwards and see if it catches. If it does discard the needle and try again. (this step is optional if concern of needle contamination is of a concern.) Change the needle after three insertions Don’t use larger than 25gauge needles 2 dispense a few drops of anesthetic before injecting There is no reason to warm a cartridge if left at room temperature. Cartridge warmers can overheat the cartridge and weaken its effectiveness, cartridges stored in the refrigerator should be warmed up to room temperature before injecting. Some suggest the metal syringe should be warmed to room temperature since cold instruments increase patients anxiety.

Which Steps in the Injection Technique Will Ensure the Patients Comfort and Safety? Position the patient Dry the tissue Apply topical antiseptic (optional) Apply topical anesthetic and communicate with the patient. All patients should be in a supine position (head and heart parallel to the floor) with the feet slightly elevated. This can be adjusted slightly by providers preference, patients medical history and specific injection technique. If a patient is anxious blood flow is increasingly directed toward the skeletal muscles and the expense of other organ systems such as the gastrointestinal tract, (the fight or flight response). In the absence of muscular movement (I can take it like a man) the increased volume of blood in skeletal muscles remains their, decreasing venous return to the heart and decreasing the volume of blood available to be pumped by the heart uphill to the brain. Decreased cerebral blood flow is evidenced by the appearance of signs and symptoms of vasodepressor syncope (common faint) (light headedness, dizziness, tachycardia, and palpation). If this situation continues, cerebral blood flow declines still further and consciousness is lost. More than half of all dental emergencies in the dental office will be from syncope 5 use a sterile 2x2 to dry the area of injection to remove any gross debris and to make injection easier. If the lip must be retracted for better visibility it too should be dried. 6 by using a topical antiseptic after the area is dried will further reduce inflammation or infection. Antiseptics include Betadine (povidone-iodine) and merthiolate (thimerosal) Alcohol containing antiseptics can cause burning to the soft tissue and should be avoided. 7 should only be placed in areas of injection and not all over the tissues or in large amounts. Excess amounts of some topical anesthetics (such as lidocaine based) can cause a rapid absorption into the cardiovascular CVS system leading to increased risk of overdose. Topical is effective for the first two to three mm of mucus membrane and should remain in contact with the tissue for 2 minutes. When talking to the patient tell them what you are doing and that it will make the procedure much more comfortable. Words such as shot, injection, pain or hurt should be avoided since these can increase anxiety. Could say “administer the local anesthetic.” Should also avoid saying this will not hurt. Patients hear only hurt. The same is true for pain, should say discomfort

Which Steps in the Injection Technique Will Ensure the Patients Comfort and Safety? Establish a firm hand rest 8

Which Steps in the Injection Technique Will Ensure the Patients Comfort and Safety? Establish a firm hand rest

Which Steps in the Injection Technique Will Ensure the Patients Comfort and Safety? Make the tissue taut 11-9 a

Insert the needle into the mucosa Which Steps in the Injection Technique Will Ensure the Patients Comfort and Safety? Keep the syringe out of the patient’s line of site Insert the needle into the mucosa

Which Steps in the Injection Technique Will Ensure the Patients Comfort and Safety? Watch and communicate with the patient While inserting the needle you should watch the patients face for any signs of discomfort. Signs such as furrowing of the brow or forehead and blinking of the eyes may indicate discomfort. More frequently, no change will be noticed in the patient’s facial expression at this time (indicating a painless or traumatic, needle insertion. You should talk to the patient during this time and could say things like I don’t expect you to feel this, Again as before avoid saying things like this will not hurt. Inject several drops of local anesthetic solution (optional)

Which Steps in the Injection Technique Will Ensure the Patients Comfort and Safety? Slowly advance the needle toward the target. Most patients will not experience pain between the initial insertion of the needle and the end target. Apprehensive patients will interpret any sensation as pain for these patients tell them you are going to deposit a small amount of anesthetic as you advance. Do not deposit more than 1/8 of a cartridge No need to aspirate since depositing a small amount

Which Steps in the Injection Technique Will Ensure the Patients Comfort and Safety? Deposit several drops of local anesthetic before touching the periosteum. Techniques where you will hit or be close to periosteum you need to deposit a few drops just before reaching target. Periosteum is highly innervated Techniques requiring deposit include Inferior Alveolar, Gow-Gates Mandibular, Infraorbital

Which Steps in the Injection Technique Will Ensure the Patients Comfort and Safety? Aspirate Must always be done at any site where a large deposit will be performed. Create a negative pressure to see if in a blood vessel Do not pull needle out as you are aspirating Pull on thumb ring 1-2mm

Which Steps in the Injection Technique Will Ensure the Patients Comfort and Safety? ANY sign of blood means positive aspiration and LA should not be deposited at that site. Aspirate at least twice at each site Rotate barrel of syringe 45 degrees before doing second aspiration Try using 25 gauge needle if possible if in area that may result in a positive aspiration

Which Steps in the Injection Technique Will Ensure the Patients Comfort and Safety?

Which Steps in the Injection Technique Will Ensure the Patients Comfort and Safety? Slowly deposit the anesthetic solution Reasons to deposit slow Watch for emergencies Slow technique reduces tearing the tissue and postoperative pain Defined 1 ml/60 seconds A full 1.8 cc cartridge should take about 2 minutes Most clinicians deposit in 20 seconds Wait at least 60 seconds

Which Steps in the Injection Technique Will Ensure the Patients Comfort and Safety? Communicate with the patient Alleviates and distracts patients fears Explain you are depositing solution slowly so it will be more comfortable and I am giving you the regular amount. Slowly withdraw the needle Immediately after removing the needle replace the cap with the single hand scoop method or cap holder

A Good Reason to Keep Your Sharps Contained

Which Steps in the Injection Technique Will Ensure the Patients Comfort and Safety? Observe the patient NEVER leave the patient alone Most adverse reactions will occur during the injection or within 5-10 minutes after

What To Record In The Chart Record the patients injection in the patients chart. Include the local anesthetic drug used, vasoconstrictor used (if any), dose (in milligrams), solution(s) used, the needle(s) used, the injection(s) given, and the patients reaction. Example R-IANB, 25-long, 2% lido + 1:100,000 epi, 36mg, tolerated procedure well.