ALTERNATIVE TECHNIQUES

INTRASEPTAL INJECTION
 Similar in technique and design to the PDL injection
 Useful in providing osseous and soft-tissue anesthesia and hemostasis for periodontal
curettage and surgical flap procedures
 It may be effective when the condition of the periodontal tissues in the gingival sulci
precludes use of the PDL injection (infection or acute inflammation

Nerves Anesthesized:
 Terminal nerve endings at the site of injection and in the adjacent sift and hard
tissues

Areas Anesthesized:
 Bone, soft tissue, root structure in the area of injection

Indication:
 When both pain control and hemostasis are desired for soft tissue and osseous
periodontal treatment

Contraindication:
 Infection or severe inflammation at the injection site

Advantages:
1. Lack of lip and tongue anesthesia (appreciated by most patients)
2. Minimum volumes of local anesthetic necessary
3. Minimized bleeding during the surgical procedure
4. Atraumatic
5. Immediate (< 30 second) onset of action
6. 6. Few post operative complications
7. 7. Useful on periodontally involved teeth (avoids infected pockets)

Disadvantages:
1. Multiple tissue punctures may be necessary
2. Bitter taste of the anesthetic drug (if leakage occurs)
3. Short duration of pulpal anesthsia; limited area of soft-tissue anesthesia (may
necessitate reinjection)
4. Clinical experience necessary for success

Alternatives
1. PDL injection in the absence of infection or severe periodontal involvement
2. Intraoral anesthesia
3. Regional nerve block with local infiltration for hemostasis

Technique
1. A 27-gaugue short needle is recommended
2. Are of insertion: center of the interdental papilla adjacent to the tooth to be treated
3. Target area: same
4. Landmarks: papillary triangle, about 2mm below the tip, equidistant from adjacent teeth
5. Orientation of the bevel: not significant, although Saadoun and Malamed recommend
toward the apex
 6. Assume the correct position, which varies significantly from tooth to tooth.
-dentist must have adequate visibility of the injection site
-dentist should maintain control over the needle
b. Position the patient supine or semisupine with the head turned to maximize access and
visibility
c. Prepare tissue at the site of penetration
- dry with sterile gauze
- apply topical antiseptic (optional)
- apply topical anesthetic for minimum of 1 minute
d. Stabilize the syringe and orient the needle correctly
- frontal plane is 45° to the long axis of the tooth
- sagittal plane: at right angles to the soft tissue
- bevel facing the apex of the tooth
e. Slowly inject a few drops of local anesthetic as the needle enters soft tissue and advance the
needle until contact with bone is made
f. Applying pressure to the syringe, push the needle slightly deeper (1-2mm0 into the interdental
septum)
g. Deposit 0.2 to 0.4 ml of local anesthetic in minimum of 20 seconds
- with a conventional syringe, the thickness of the rubber plunger is equivalent to
0.2ml
h. Two important items indicate success of the intraseptal injection
1. significant resistance to the deposition of soulution
* this is especially noticeable when a conventional syringe is used.
Resistance os similar to that felt with the nasopalatine and PDL injections
* anesthetic solution should not come back into the patient’s mouth. If this
occurs, repeat the injection with the needle slightly deeper
2. Ischemia of soft tissues adjacent to the injection site (although noted with all local anesthetic
solutions, this is more prominent with local anesthetics containing a vasoonstrictor)
i. Repeat the injection as needed during the surgical procedure

Signs And Symptoms

1. As with the PDL injection, there are no objective symptoms that ensure adequate
anesthesia. The anesthesized area is too circumscribed
2. Subjective: ischemia of soft tissues is noted at the injection site
3. Subjective: resistance to the injection of solution is felt
4. Objective: there is absence of pain during treatment

Safety Procedure
-Intravascular injection is extremely unlikely to occur

Precautions
1. Do not inject into infected tissue
2. Do not inject rapidly (minimum 20 second)
3. Do not inject too much solution (0.2 to 0.4 per site)

Failures of Anesthesia
1. Infected or inflamed tissues. Changes in tissue pH minimize the effectiveness of the
local anesthetic
2. Solution not retained in tissue
- to correct, advance the needle further into the septal one and re-administer 0.2
to 0.4 ml
Complications
- Post injection pain is unlikely to develop because the injection site is whithin the area of
surgical treatment
- Saadoun and Malamed demonstrated that postsurgical periodontal discomfort after the use of
intraseptal anesthesia is no greater than that after a regional nerve block

Duration Of Expected Anesthesia

 The duration DURATION OF EXPECTED ANESTHESIA
 of osseous and soft tissue anesthesia is variable after an intraseptal injections
 Using an epinephrine concentration of 1:50,000, Saadoun and Malamed found pain
control and haemostasis adequate for completion of the planned procedure without
reinjection
*some requires reinjection

INTRAOSSEOUS INJECTION
 Deposition of local anesthetic solution into the interproximal bone between two teeth
 Originally, IO anesthesia necessitated the use of a half round bur to provide entry into
interseptal bone that had been surgically exposed
 Once the hole had been made, a needle would be inserted into this hole and local
anesthetic deposited

Stabident system
 Consist of two parts:
a. Perforator
- a solid needle that perforates the cortical plate of bone with a
conventional; low-speed contra-angle handpiece
b. 8mm long, 27 gauge needle
- inserted into this predrilled hole for anesthetic administration

X-tip
 Composed of:
a. Drill
- which leads the guide sleeve through the cortical plate of bone after which it is
separated and withdrawn
b. Guide sleeve
- remains in the bone and easily accepts a 27- gauge ultrashort needle

Alternative Stabident System

 Introduced to eliminate the problem of elimination the problem of locating the “hole”
by inserting a conical shaped “guide sleeve” into the hold
 The 27 gauge ultrashort needle could then be easily placed into the hole

IntraFLow IO
 Combines the two steps
 Anesthetic cartridge is attached to a standard four-hole air hose on a treatment room
delivery unit and is controlled by a foot rheostat
 It is a specially modified slow-speed handpiece that consist of four main parts...

4 main parts:
1. A needle or drill that makes the perforation through the bone and delivers the local
anesthetic
2. A transfuser that acts as a conduit from the local anesthetic cartridge to the needle or
drill
3. A latch tip or clutch that drives and governs the rotation of the needle or drill
4. A motor or infusion drive that powers the rotation of the needle or drill and while holding
the local anesthetic cartridge in place, powers the infusion plunger
- 24 gauge dual bevelled needle is used
 the IO injection technique can provide anesthesia sof a single tooth or multiple teeth in a
quadrants
 To a significant degree the area of anesthesia is dependent on both the site of injection
and the volume of local anesthetic deposited
 It is recommended that 0.45 to 0.6 ml of anesthetic be administered when treatment is to
be confined to not more than one or 2 teeth
 Greater volumes may be used if multiple teeth in one quadrants is contemplated
 The IO injection may be used when managing 6 r 8 mandibular anterior teeth
 Bilateral IO injections are necessary, the perforation being mad between the canine and
first premolar on both sides
 This provides pulpal anesthesia of 8 teeth

o Nerves anesthesized:
 Terminal nerve endings at the site of injection and in the adjacent soft and hard tissues
o Areas anesthesized:
 Bone, soft tisse and root structure in the area of injection
o Indication:
 Pain control for dental treatment on single or multiple teeth in a quadrant
o Contraindication
 Infection or severe inflammation at the injection site

Advantages
1. Lack of lip and tongue anethesia
2. Atraumatic
3. Immediate (<30 seconds onset of action
4. Few postoperative complications

Disadvantages:
1. Require a special syringe (E.G Stabident system, x-tip, intraflow)
2. Bitter taste of the anesthetic drug (if leakage occurs)
3. Occasional difficulty in placing anesthetic needle into predrilled hle
4. High recurrence of palpitations when vasopressor-containing local anesthetic is used

Alternatives
1. PDL injection in the absence of infection or severe periodontal involvment
2. Intraseptal injection
3. Supraperiosteal injection
4. Regional nerve block

Technique
1. Selection of site of injection
a. Lateral perforation
 - at a point 2mm apical to the intersection of lines drawn horizontally
along the gingival margins of the teeth and a vertical line through the interdental papilla
- the site should be located distal to the tooth to be treated if possible
although the technique provides anesthesia is most cases when injected anterior to the
tooth being treated

-avoid injecting in the mental foramen area (risk of nerve damage)

b. Vertical perforation (for edentulous areas)
- perforate at a point on the alveolar crest either mesial or distal to the
treatment are (also called the crestal anesthesia technique)

2. Technique
a. Remove the X-tip from its sterile vial
- hold the protective cover as you insert the X-tip onto the slow speed
handpiece (20,000rpm)
b. Prepare soft tissues at perforation site
-prepare tissue at the injection site with 2x2 inch sterile gauze
-apply topical anesthetic to the injection site for minimum of 1
minute
-place bevel of needle against gingiva, injecting a small volume of
local anesthetic until blanching occurs
- chck soft tissue anesthesia using a cotton plier.
-inject a few drops of local anesthetic into the dimple
c. Perforation of th cortical plate
- holding the perforator perpendicular to the cortical plate, gently push the
perforator through the attached gingiva until its tip rests against bone
-activate the handpiece, using a gentle “pecking” motion on the perforator
until a sudden loss of resistance is felt. Cortical bone will be perforated within 2 seconds

-hold the guide sleeve in place as the drill is withdrawn. Withdraw the
perforator and dispose it safely
* the guide sleeve remains in place until you are certain you have
adequate anesthesia
d. Injection into cancellous one
- it is easy to insert the needle into the hole using an ultrashort needle
- press the tapered needle gently against the guide sleeve to minimize local
anesthetic leakage
* compress a coton roll against the mucosa to absorb any excess local
anesthetic

-slowly and gently inject the local anesthetic solution

e. X-tip doses: recommended dosages for the X-tip are the same for each lcal anesthetic
solution as is recommended for other injections
f. Stabident doses
g. Recommended technique for the IntraFlow IO syringe system is presented (table)
 TO ANESTHESIZED INJECTION SITE DOSE (# of 1.8ml
(maxillary) cartridges

One tooth Immediately distal or mesial 1/4

Two adjacent teeth Between the two teeth 1/4

Four adjacent teeth (ex. Midway (ex. Two teeth distal and two teeth 1/2
1,2,3 and 4) mesial to the injection site)

Up to 8 teeth on one side Midway (ex. 2 teeth distal and 2 teeth 1

mesial to the injection site

TO ANESTHESIZED INJECTION SITE DOSE (# OF

(mandibular) 1.8ml cartridge)

One tooth Immediately distal or mesial 1/4

1/3
Two adjacent teeth Between the 2 teeth or immediately 1/3
distal to the more distal tooth ½

Three adjacent teeth Immediately distal to the middle tooth 1/2

Six front teeth plus the first Give 2 injections, one on each side, 1/2 on ach side
premolars (e.g. Total of 8 teeth) between the canine and the first (total of 1)
premolar

Signs and Symptoms

 No objective signs that ensure adequate anesthesia. The anesthesized are is too
circumscribed.
 Subjective: ischemia of soft tissue at the injection site
 Objective: absence of pain during treatment

Safety feature
 Intravascular injection is extremely unlikely, although the area injected into is
vascular. Slow injection of the recommended volume of solution is important to
keeping IO anesthesia safe.

Precautions:
 Do not inject into infected tissue
 Do not inject rapidly
 Do not inject too much solution
  Do not use a vasopressor- containing local anesthetic unless necessary and then
only 1:200,000 or 1:100,000.
 do not use 1:50,000 epinephrine

Failures of anesthesia
 Infected or inflamed tissues. Changes in tissue pH minimize the effectiveness of
anesthetic.
 Inability to perforate cortical bone. If cortical bone is not perforated within 2 seconds, it is
recommended that drilling be stopped and an alternative site be used

Complications
 Palpitations: this reaction frequently occurs when a vasopressor-containing local
anesthetic is used
 Postinjection pain is unlikely after IO anesthesia
 *use of mild analgesics is recommended if there is discomfort
 Fistula formation at the site of perforation has been reported on several occasions.
 Separation of the perforator or cannula
 Perforation of lingual plate of bone.
 can be prevented by proper technique

Duration of expected anesthesia

 Pulpal anesthesia of between 15 and 30 minutes can be expected
 If a vaso pressor-containing solution is used
 The duration approaches 30 minutes
 If a plain solution is used, a 15-minute duration is usual.
 The depth of anesthesia is greater with a vasopressor – containing local anesthetic

INTRALIGAMENTARY INJECTION

Indications:
1. Pulpal anesthesia of one or two teeth in a quadrant
2. Treatment of isolated teeth in two mandibular quadrants
3. Patients whom residual soft-tissue anesthesia is undesirable
4. Situations in which regional block anesthesia is contraindicated
5. As a possible aid in diagnosis of pulpal discomfort
6. As an adjunctive technique after nerve block anesthesia is present

Contraindications:
1. Infection or Inflammation at the site of injection
2. Primary teeth, when the permanent tooth bud is present
a) Enamel hypoplasia
b) Little reason to use PDL since incisive nerve block and infiltration s
effective.
3. Patient who requires a numb sensation for psychological comfort

Advantages:
 Prevents anesthesia of lip, tongue, & other soft tissues
  Minimum dose of LA necessary (0.2 ml per root)
 An alternative to partially successful regional nerve block
 Rapid onset of profound and soft-tissue anesthesia (30 secs.)
 Less traumatic
 Well suited for procedures in children

Disadvantage:
 Proper needle placement is difficult to achieve in some areas
 Leakage of LA solution into the patient’s mouth procedures a unpleasant taste
 Excessive pressure can produce focal tissue damage.
 Post-injection discomfort may persist for several days
 Potential for extrusion of tooth exists if excessive pressure or volume are used

Technique:
 24 gauge short needle
 Area of insertion: Long axis of the tooth to be treated on its mesial or distal of the root
 Target area: depth of the gingival sulcus
 Landmarks: Root(s) of the tooth
Periodontal tissues
 Bevel towards the root

Procedure:
1. Assume patient in correct position (varies)
2. Stabilize syringe and direct along the long axis of the root to be anesthesized
3. With the bevel of the needle on the root, advance the needle apically until resistance is
met
4. Deposit 0.2 ml of LA solution in a minimum of 20 seconds
5. Two important indicators of success of injection:
a) Significant resistance to the deposition
-Resistance as similar that felt to nasopalatine injection
-LA solution should not flow back on patient’s mouth
b)Ischemia of Soft tissue adjacent to injection site
6. If the tooth is multirooted, remove needle & repeat the procedure on the other root
7. If the tooth is monorooted, remove the needle from the tissue and cap the needle.
Dental treatment usually starts within 30 seconds.

INTRAPULPAL INJECTION
• Deposition of local anesthetic directly into the pulp chamber of a pulpally involved tooth
provides effective anesthesia for pulpal extirpation and instrumentation where other
techniques have failed.

Nerves Anesthetized
• Terminal nerve endings at the site of injection in the pulp chamber and canals of the
involved tooth
Indication
 • When pain control is necessary for pulpal extirpation or other endodontic treatment in
the absence of adequate anesthesia from other techniques

Contraindication
• None. The intrapulpal injection may be the only local anesthetic technique available in
some clinical situations

Advantages
• Lack of lip and tongue anesthesia
• Minimum volumes of anesthetic solutions necessary
• Immediate onset of action
• Very few postoperative complications

Disadvantages
• Traumatic
- The intrapulpal injection is associated with a brief period of pain as anesthetic is deposited
• Bitter taste of the anesthetic drug
• May be difficult to enter certain root canals
- bending of needles may be necessary
• Need a small opening into the pulp chamber for optimum effectiveness
- Large areas of decay make it more difficult to achieve profound anesthesia with the
intrapulpal injection

Technique
1. Insert a 25- or 27-gauge short or long needle into the pulp chamber or the root canal as
needed
2. Ideally, wedge the needle firmly into the pulp chamber or root canal
a) Occasionally the needle does not fit snugly into the canal. In this situation the
anesthetic can be deposited in the chamber or canal. Anesthesia in this case is
produced only by the pharmacological action of the local; there is no pressure
anesthesia.
3. Deposit anesthetic solution under pressure
a) A small volume of anesthetic (0.2 to 0.3 ml) is necessary for successful
intrapulpal anesthesia, if the anesthetic stays within the tooth. In many situations
the anesthetic simply flows back out of the tooth into the aspirator tip.
4. Resistance to the injection of the drug should be felt
5. Bend the needle, if necessary, to gain access to the canal.
a) Retrieval is relatively simple if the needle breaks.
6. When the intrapulpal injection is performed properly, a brief period of sensitivity (ranging
from mild to very painful) usually accompanies the injection. Pain relief usually occurs
immediately thereafter, permitting instrumentation to proceed atraumatically.
7. Instrumentation may begin approximately 30 seconds after the injection

MANDIBULAR NERVE BLOCK: THE GOW-GATES TECHNIQUE

• 1973
• Dr. George Gow-Gates, a general practitioner of dentistry in Australia
• True mandibular nerve block
• Percent positive aspiration: 2%

Nerves Anesthetized
• Inferior Alveolar Nerve
 • Mental Nerve
• Incisive Nerve
• Lingual Nerve
• Mylohyoid Nerve
• Auriculotemporal Nerve
• Buccal Nerve

Areas Anesthetized
• Mandibular teeth to midline
• Buccal mucoperiosteum and mucous membranes on side of injection
• Anterior two-thirds of tongue and floor of oral cavity
• Lingual soft tissues and periosteum
• Body of mandible and inferior portion of ramus
• Skin over zygoma and posterior portion of cheek and temporal regions

Indications
• Multiple procedures on mandibular teeth
• Where buccal soft tissue anesthesia, from third molar to midline is required
• Where lingual soft tissue anesthesia is required
• When conventional inferior alveolar nerve block is unsuccessful

Contraindications
• Infection or acute inflammation in area of injection
• Patients who might bite either the lip or tongue (e.g, very young children, physically or
mentally handicapped patients)
• Patient’s who are unable to open mouth widely

Advantages
• Requires only one injection: buccal nerve block not necessary; accessory innervation
usually blocked
• High success rate (>95%)
• Minimum aspiration rate
• Few postinjection complications
• Provides successful anesthesia where bifid inferior alveolar nerve and bifid mandibular
canals are present

Disadvantages
• Lingual and lower lip anesthesia is uncomfortable for many patients and possibly
dangerous for certain individuals
• Time to onset of anesthesia is somewhat longer than with inferior alveolar nerve block,
primarily because of size of nerve trunk being anesthetized and distance of nerve trunk
from deposition site (approximately 5 to 10mm)

Technique
1. 25-gauge long needle is recommended
2. Area of insertion: mucous membrane on medial border of ramus of mandible, at point
parallel to line drawn from intertragic notch of ear to corner of patient”s mouth and just
distal to maxillary second molar
3. Target area: lateral region of condyle neck, just below insertion of lateral pterygoid
muscle
4. Landmarks
 a. Extraoral
(1) Lower border of tragus of ear (intertragic notch); correct landmark is center of
external auditory meatus, which is concealed by tragus; its lower border is therefore
adopted as visual aid
(2) Corner of patient’s mouth
b. Intraoral
(1) Height of injection is established by placement of tip of needle just below
mesiolingual (mesiopalatal) cusp of maxillary second molar
(2) Penetration of soft tissues occurs at site just distal to maxillary second molar at
height established in preceding step
5. Orientation of bevel: not critical
6. Procedure
a. Position of administrator
(1) For right Gow-Gates mandibular nerve block, administrator is seated in 8 o’clock position
facing toward patient
(2) For left Gow-Gates mandibular block, administrator is seated in 10 o’clock position facing in
same direction as patient
(3) Positions are those used for right and left inferior alveolar nerve blocks
b. Position of patient
(1) Supine position is recommended
(2) Patient is requested to extend neck and to open mouth widely for duration of technique;
condyle assumes more frontal position and is closer to mandibular nerve trunk
c. Locate extraoral landmarks
(1) Intertragic notch
(2) Corner of mouth
d. Place index finger or thumb of left hand on coronoid notch: determination of coronoid notch is
not essential to success of Gow-Gates technique
e. Visualize intraoral landmarks
(1) Mesiolingual cusp of maxillary second molar
(2) Injection site just distal to maxillary second molar
f. Prepare tissues at site of penetration
(1) Dry tissue with sterile gauze
(2) Apply topical antiseptic (optional)
(3) Apply topical anesthesia
g. Direct syringe, held in right hand, toward site of injection from corner of mouth on opposite
side
h. Insert needle gently into tissues at injection site just distal to maxillary second molar tooth at
height of mesiolingual cusp of second molar
i. Align needle to plane extending from corner of mouth to intertragic notch on side of injection
and parallel with angle of ear to face
j. Direct syringe toward target area on tragus of ear
k. Slowly advance needle until bone is contacted
l. Withdraw needle 1mm
m. If aspiration positive, wirthdraw needle slightly, angle needle superiorly, reinsert, reaspirate,
and, if negative, deposit solution.
o. Slowly deposit 1.8ml of local anesthetic solution. Gow-Gates originally recommended that 3.0
ml of anesthetic solution recommended
p. Slowly withdraw syringe and recap needle
q. Request that patient keep mouth open for 30 to 60 seconds following injection to permit
diffusion
r. Wait approximately 3 to 5 minutes before commencing dental procedure;
Gow-Gates mandibular block may require approximately 5 to 7 minutes for the ff reasons:
(1) Greater diameter of nerve trunk at site of injection
(2) Distance (approximately 5 to 10 mm) from deposition of local anesthetic solution to nerve
trunk

Complications
1. Hematoma
2. Trismus

AKINOSI CLOSED-MOUTH MANDIBULAR BLOCK

• 1977
• Dr. Joseph Akinosi

Nerves Anesthetized
• Incisive Nerve
• Mental Nerve
• Lingual nerve
• Mylohyoid Nerve

Areas Anesthetized
• Mandibular teeth to midline
• Body of mandible and inferior portion of ramus
• Buccal mucoperiosteum and mucous membrane in front of mental foramen
• Anterior two thirds of tongue and floor of oral cavity (lingual nerve)
• Lingual soft tissues and periosteum (lingual nerve)

Indications
• Limited mandibular opening
• Multiple procedures on mandibular teeth

Contraindications
• Infection or acute inflammation in area of injection
• Patients who might bite either the lip or tongue (i.e., very young children or physically or
mentally handicapped patients)

Advantages
• Relatively atraumatic
• Patient need not be able to open the mouth
• Fewer postoperative complications
• Lower aspiration rate (<10%) than in inferior alveolar nerve block
• Provides successful anesthesia where bifid ian and bifid mandibular canals are present

Disadvantages
• Difficult to visualize path of needle and depth of needle insertion
• No bony contact; depth of penetration somewhat arbitrary
• Potentially traumatic if needle is too close to periosteum

Technique
- 25-gauge long needle is recommended
- Area of insertion: soft tissue overlying medial border of ramus of mandible directly adjacent to
maxillary tuberosity at height of mucogingival junction of maxillary third molar
 • Target area: Soft tissue on medial border of ramus of mandible in region of inferior
alveolar, lingual and mylohyoid nerves as they run inferiorly from foramen ovale toward
mandibular foramen
Landmarks
• Mucogingival junction of maxillary third (or second) molar
• Maxillary tuberosity
• Coronoid notch on ramus of mandible
Procedure
a. Position of administrator: 8 o’clock position facing toward patient
b. Position of patient: supine position is recommended
c. c. Place index finger or thumb of left hand on coronoid notch, reflecting the tissues on
medial side of ramus laterally; reflecting soft tissue aids in visualization of injection site
and decreases trauma during needle insertion
d. d. Visualize landmarks
e. (1) Mucogingival junction of maxillary third or second molar
f. (2) Maxillary tuberosity
g. e. Prepare tissues at site of penetration
h. f. Ask patient to bring teeth into occlusion, with cheek and muscles of mastication
relaxed
i. g. Reflect soft tissues on medial border of ramus laterally
j. h. Barrel of syringe is held parallel to maxillary occlusal plane with needle at level o
mucogingival junction of maxillary third molar
k. Syringe is directed posteriorly and slightly laterally, so that it advances at tangent to
posterior maxillary alveolar process and parallel to occlusal plane
j. Advance needle 25 to 30mm into tissue; tip of needle is lying in midportion of
pterygomandibular space, close to branches of mandibular nerve
l. Aspirate
m. If negative, deposit 1.5 to 1.8 ml of local anesthetic solution in approximately 60 seconds
n. Withdraw needle slowly and immediately recap needle
o. Anesthesia of lip and tongue will be noted in 40 to 90 seconds; dental procedure may
start within 4 minutes
 Precaution: Do not overinsert needle (25 to 30 mm) decrease depth of
penetration in smaller patients

Complications
• Hematoma (<10%)
• Trismus
• Transient facial nerve paralysis caused by overinsertion and injection of solution into
bady of parotid gland

ELECTRONIC DENTAL ANESTHESIA (EDA)

Mechanism of Action of EDA
- Acts for prevention of acute pain during any surgical or dental procedure, is adequately
explained by the Gate-control theory
- Used at a higher frequency (≥120 Hz).
- Involves stimulation of larger diameter nerves (A fibers), which transmit the sensations of
touch, pressure, and temperature.
- If the patient can maintain a minimum “threshold” intensity of A fiber stimulation; then the
pain impulse produced by the dental or surgical instruments (high speed drill, blade, or
 curette) that is transmitted to CNS more slowly along the smaller Alpha-ᵹ fiber and C
fibers, will come on a “closed gate”. Hence, it will be unable to reach the brain, where it
is translated into physical pain. Thus, the large-fiber input is said to inhibit central
transmission of the overall effects of small-fiber input. The pain impulse failing to reach
the brain, the pain sensation does not occur.
- The blood levels of serotonin and endorphins are elevated during high frequency
stimulation. These hormones probably play a secondary, but an important role, in
providing acute pain control during most types of dental procedures.

Indications:
Main indication: Needle phobia (Fear of injection)
Other indications:
1. Ineffective local anesthesia
2. History of allergy to local anesthetic agents: in cases of true or documented allergy to local
anesthetiv agents, these agents cannot be administered.

Contraindications:
1. Cardiiac Pacemakers
2. Neurological disorders
a. Post-cerebrovascular accident (CVA) (stroke)
b. History of transient ischemic attacks
c. History of epilepsy
3. Pregnant
4. Lack of maturity: Inability to understand the concept of pain control
a. Very young patient
b. Very old patients with senile dementia
c. Language communication difficulties

Dental Procedures:
The various dental procedures where in EDA can be successful are:
1. Chronic pain in case of TMJ, or Myofascial Pain Dysfunction syndrome (MFPD)
2. Administration of local anesthesia
3. Non-surgical periodontal procedures
4. Restorative dentistry
5. Fixed Prosthodontics procedures
6. Endodontics

Uses in Dentistry
Most important use of this technique dentistry is that EDA is an effective method of minimizing
patient discomfort during the injection of local Anesthetic agents.
However proper application of topical anesthetic agent, and following the basic principles of
injection technique such as slow injection of local anesthetic solution, minimizes patient’s
perception to a great extent.

Other uses: Post surgical pain

EDA can also be used after surgical procedures. It can minimize post-surgical procedures. It
can minimize post-surgical pan after surgical procedures.

Application:
The use of EDA at a low frequency setting for 30-60 minutes at the completion of surgery
provides the comfortable post operative recovery from local anesthesia.

Advantages:
The advantages of using EDA over Local anesthesia achieved following injectable local
anesthetic agents are as follows:
1. No need for further needle pricks
2. No need for injection of drugs
3. Patient is in control of anesthesia
4. No residual anesthetic effect at the end of the procedure
5. Residual analgesic effect remains for several hours

Disadvantages:
1. Cost of equipment
2. Training of the personnel
3. Intraoral electrodes: the intraoral electrodes offer a weak link in the entire system, However, a
greater depth of anesthesia is obtained with intraoral electrodes. Also, in some units, extraoral
electrodes are available.

TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS)

Mechanism of action of TENS
 Used at low-frequency of 2 Hz (hertz or cycles per second)
 Changes in blood levels of:
 l-tryptophan - ↓ amounts
 Serotonin - ↑ amounts
 β-endorphins - ↑ amounts
Use: Chronic Pain
Residual Effect
 Serotonin & β-endorphins
- ↑ blood levels for several hours
- Residual analgesic action in the immediate post-treatment period
TENS in Dentistry:
 Chronic pain of dental origin such as:
- TMJ problems
- Myofascial Pain Dysfunction (MFPD) syndrome

VENEPUNCTURE
 • process of obtaining intravenous access for the purpose of intravenous therapyor
for blood samplingof venous blood.
• WHAT ARE THE MAIN ADVANTAGES OF IV SEDATION?
• IV sedation tends to be the method of choice if you don't want to be
aware of the procedure–you "don't want to know". The alternative is
oral sedation using Halcion, however this method is not as reliably
effective as IV sedation.
• The onset of action for IV sedation is very rapid, and drug dosage and level of
sedation can be tailored to meet the individual's needs. This is a huge advantage
compared to oral sedation, where the effects can be very unreliable.
• IV sedation, on the other hand,is both highly effective and highly reliable.
• Unlike General Anaesthesia, conscious IV sedation doesn't really introduce any
compromises per se in terms of carrying out the actual procedures,
because people are conscious and they can cooperate with instructions,
and there is no airway tube involved.
• ARE THERE ANY DISADVANTAGES?
• A needle has to be put in the arm or hand ("venipuncture"). If you
have a general phobia of needles, this isn't much fun.
• If you cannot tolerate this, having inhalation sedation ("laughing gas")
before the venipuncture helps, because it relaxes you and distracts you
from
the venipuncture.
• It is possible to experience complications at the site where the needle entered,
for example hematoma (a localized swelling filled with blood).
• Recovery form IV administered drugs is not complete at the end of
dental treatment. You need to be escorted by a responsible adult.
You should want to be sedated. If for any reason, you're unwilling to
"let go", for example because you don't like not being in control, it
will be more difficult to be successfully sedated.
Materials
• Tray
• Mediswab
• Tourniquet
• Small adhesive dressing.
• Sharps Container
• Gloves
• Isopropyl alcohol 70% solution hand rub solution
• ‘Vacutainer’ system
• needle, holder Sterile syringe, Sterile needle, Appropriate evacuated tube
Procedure
1. Assemble equipment
2. Inform patient of procedure
3. Select a suitable vein - e.g. the vein in the antecubital fossa or forearm
4. Palpate the vessel to exclude the possibility that it is an artery
5. Apply a tourniquet medial to selected site
6. Put on gloves
7. Cleanse skin with alcohol wipe
8. Fix the vein by applying pressure to skin over the vein, approximately two inches below
venepuncture site
9.Leaving the coloured shield on the needle, screw it onto the holder
10. Remove shield and approach the skin, with needle bevel uppermost at an angle of 35~45
degrees
11. When the needle has penetrated the skin, realign it with the vein and reduce the angle to
about 15 degrees
12. Introduce the tube into the holder, with middle and forefmger supporting flange of the holder,
push the tube with the thumb to the end of the holder, puncturing the diaphragm of the stopper.
13. As soon as blood starts to flow into the tube, remove the tourniquet.
14. When blood flow ceases, gently disengage tube from holder
– if more samples are required, repeat from stage 12
15. Tubes with additives should be gently inverted to mix contents - shaking may cause
haemolysis.
16. Always draw samples without additives first.
17. Place a clean swab or piece of cotton wool over the needle as it is gently withdrawn,
pressure should be applied to the site until haemostasis occurs, at which time an adhesive
dressing is applied. It is not recommended that the patient bend their arm as this increases the
intravascular pressure.
18. Ensure all samples are clearly labelled
19. Never re-sheath needles as this is the commonest source of needles tick injury.
20. Ensure all sharps are disposed of safely and examine holder for any contamination, in which
case it should be discarded - in normal practice the holder does not come into contact with
blood products and is intended for multiple use

Hypnosis
"The patient's mind goes to a pleasant place, but the body stays in the operating room."

Hypnodontics, an analgesia free method of treating dental pain, which was promoted by
Dr. Aaron Moss and accepted by the American Dental Association over fifty years ago (1957 –
Hypnodontics: Hypnosis in Dentistry).
Hypnosis plus a local anesthetic leaves patients sedated but aware, reports the
Associated Press, and doctors say their recovery time is faster and their need for painkillers
reduced. This method is feasible for only certain operations, of course - not those involving the
heart or internal organs.
In the U.S., there are no guidelines on the surgical use of hypnosis, according to
president of the American Society of Anesthesiologists, Dr. Mark Warner. Dr. Warner often uses
music therapy or asks patients to picture a soothing scene to distract them from any discomfort.
"If we could get more research on the right patient groups that would benefit from (hypnosis),
that would be wonderful," he said.
Using hypnosis means patients recover faster and hospitals save money, according to
some studies. But it may require doctors to spend more time with patients beforehand to do the
hypnosis and they may need more careful monitoring during surgery.
'Our brains control everything about our bodies and our subconscious is the most
powerful part - it controls our breathing and the blood pumping through our veins.
'Hypnosis taps into the subconscious mind. It's all about mind over matter.'

Acupuncture
Defined as the stimulation of specific acupuncture points and meridians (where Qi flows)
along the skin of the body using thin stainless steel needles (0.51 – 5.12 in.) and can be
associated with heat, pressure or laser.
 Very helpful in chronic pain management but there is little valid support in the literature
for its use to control postoperative pain, although it is used.
In dentistry, it is used in TMDs, facial pain, and Sjögren’s syndrome pain management.
This method of pain control uses the gate control theory.

Acupressure
A non-invasive form of bodywork which uses a physical pressure applied to acupressure
points and meridians by the hand or elbow, or with various devices in order to relieve pain on
the area the pressure is applied on. It uses the same principle as with acupuncture.

STA or Single Tooth Application Wand

STA or Single Tooth Application Wand uses a microprocessor to control the delivery of a
small amount of anesthesia ahead of the needle, thus ensuring a steady flow of anesthetic
through the needle into the tissue. This delivery method reduces the amount of pain that
patients experience and increases their comfort. In addition, delivering anesthesia using this
device may help patients avoid numbness of the tongue, lips, face, and other muscles because
it only numbs one tooth.

The safety system has a pen-like grasp that allows maximum tactile control and an auto-
retracting design that shields the needle when not in use. The rate of injection is at a
preprogrammed technique-specific rate selected by the dentist. A disposable cartridge sheath is
required for each patient, but a standard dental needle and anesthetic cartridge can be used
with this device.

Phentolamine Mesylate (OraVerse)

This is an anesthetic reversal agent that reduces time of numbness by half. It is injected
using the same technique that is used in local anesthesia, with about half the dosage of
anesthetic used. Although not covered yet by insurance, it is becoming a standard of care in
many practices. It is not indicated in children less than 6 years of age or persons weighing less
than 33 lbs.