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Topical Anesthesia
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BasicInjectionTechnique
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In this chapter, we review the basic technique for injecting
local anesthetic intraorally. We present the various phases
in order and with all the relevant steps (even though these
often overlap in clinical practice), placing emphasis on
those aspects that make dental injections safer and more
comfortable, given that injections are the main reason
people fear dental treatment (Kleinknecht et al. 1973;
Messer 1977; Berggren and Meynert 1984; Milgrom
et al. 1997). Furthermore, following the approach we
present here helps to reduce the stress experienced by
almost 20% of dentists themselves with respect to adminis‑
tration of local anesthetic (Simon etal.1994).
In the second part of the chapter, we address the compo‑
nents of the injection technique that lead to pain by separat‑
ing them into those that directly produce pain and those that
are much less significant but are popularly considered to be
closely associated with pain. The final part of the chapter
will address the terminology of the different anesthetic tech‑
niques. We have divided the basic technique into 10 phases
(sections “Initial Preparation” to “Post‑treatment Phase”).
CommentonRetraction
With the aim of preventing accidental needle‑ stick injury
and the resulting risk of transmission of HIV, hepatitis B, or
hepatitis C infection to the health professional (Cleveland
etal.2007; David etal.2007), dentists now tend to avoid plac‑
ing their fingers into the patient’s mouth during administra‑
tion of local anesthetic to retract the soft tissues and palpate
dental structures (Cleveland etal.2007; David etal.2007; Fa
et al. 2016). Alternatives include a dental mirror (David
etal. 2007; Fa et al. 2016), a Minnesota retractor, a tongue
depressor (David etal. 2007), or even devices such as the
vibrating device DentalVibe
Nevertheless, a study based on information collected
from 1995 to 2004 in the United States that provides
®
(Fa etal.2016) (Chapter11).
‑ ranging review of previous studies found that, since
awide
1987, the frequency of accidental needle
‑ stick injury in
dentistry had decreased, and that of the 59 recorded cases
of transmission of HIV infection to healthcare personnel,
none involved dental professionals (Cleveland etal.2007).
Furthermore, of the 360 accidental needle
‑ stick cases
recorded in dental health personnel, 88 were caused by
dental needles (25%), with 70% affecting dentists and oral
surgeons and 25% affecting dental assistants and hygienists
(Cleveland etal.2007).
In this book, dental local anesthetic techniques are
addressed by inserting the fingers of the supporting hand
into the patient’s mouth (left hand in right
‑ handed dentists)
to separate the soft tissues and thus stabilize the area to
facilitate injection. This is the approach recommended in
all of the texts in this specialty, although emphasis is placed
on methods to prevent accidental needle‑ stick injuries.
PhasesoftheInjection
InitialPreparation
Before the patient enters the dental office, we should evalu‑
ate and anticipate a series of concerns.
1) Assess how well the patient will cooperate.
The previous visit (generally the first visit), especially in
children, gives an idea of how the patient will behave. It
is important to remember that children are brought to
the dentist by their parents. Thus, aside from age,
demeanor, and physical appearance, two specific situa‑
tions enable us to predict disruptive behavior in future
visits to the dentist:
○ Examination of the mouth.
○ Intraoral radiographs.
Any difficulty observed while these maneuvers are
being performed points to a high risk of disruptive
Local Anesthesia in Dentistry: A Locoregional Approach, First Edition. Jesús Calatayud and Mana Saraghi.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
Companion website: www.wiley.com/go/Calatayud/local
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Basic Injection Technique
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220
behavior during administration of oral anesthesia at the
following visits.
In contrast, if the examination reveals the patient to
have undergone considerable restorative work and
complicated dental procedures and the parents report
that no specific measures were taken (sedation, medica‑
tion), then the patient’s behavior should be acceptable
for the administration of local anesthesia.
2) Review the health questionnaire and dental history.
We can review the following questions:
1) What level of anxiety and fear does dental treatment
cause you?
None □
lot □
A little □ Moderate □ Quite a
A lot □
2) Have you ever experienced abnormal reactions,
fainting, dizziness when receiving local anesthetic or
vaccinations or when giving blood?
Yes □
No □
These two questions enable us to better evaluate dis‑
ruptive behavior. Other questions on health status,
medical problems, and medications taken will enable
us to determine whether there are absolute or relative
contraindications for administration of dental local
anesthetic or whether there are limitations for the use
of anesthetics or vasoconstrictors (see Chapters 8, 9,
and10 on contraindications for the techniques, anes‑
thetics, and vasoconstrictors).
3) Review body weight in small patients and children.
The basic purpose of reviewing body weight is to avoid
overdose, which can have serious consequences
(Goodson and Moore 1983; Hersh et al. 1991;
Moore 1992; Virts 1999; Council on Clinical
Affairs2015). Surveys among dentists show that around
half believe (erroneously) that the maximum dose
should not be based on the patient’s weight but that the
same dose should be administered to all patients, there‑
fore in patients weighing less than 40
kg there may be a
risk of overdose (Linscott et al. 1978; Cheatham
etal.1992; Daubländer etal.1997). Annex 10 shows the
maximum absolute doses by body weight in dentistry.
4) Organize all local anesthetic equipment.
Before the patient comes into the dental office, the den‑
tal equipment should be prepared and covered so as not
to increase the anxiety generally felt by the patient
(Mink and Spedding1966). Some authors recommend
having tweezers or mosquito clamp to prepare for the
unfortunate case where a needle breaks in the patient’s
mouth, so that the end protruding from the soft tissue
can be removed before it disappears completely into the
tissue (Armbrecht and Schwetz 1962; Orr 1983;
McDonogh1996).
PreparationPhase
Once the patient is in the office, we can proceed as follows:
1) Position of the dentist and patient.
● The dentist should be seated at between 8 and
10 o’clock (maximum 7–11 o’clock) with respect to
the patient’s mouth, depending on the technique and
approach used, and on the patient’s right (for right
handed dentists). Being seated ensures better accu‑
racy and control.
● The patient should be in a semi‑ recumbent position
so that the dentist can work from a seated position,
thus improving accuracy and reducing risk for the
patient: having the patient in a semi
‑ recumbent posi‑
tion reduces the risk of a vasovagal reaction caused by
the lack of blood flow to the brain resulting from anx‑
iety. Consequently, the risk of serious complications
is reduced (Bourne1957,1970).
2) Assistant beside the dentist.
Having the assistant seated at 2–4 o’clock can make it eas‑
ier to pass the syringe and hold the patient to prevent sud‑
den movements (especially in children) and help where
necessary, such as in cases of needle breakage, when he/
she can pass the dentist tweezers or a mosquito clamp to
remove the protruding end of the needle (Orr1983).
3) Where possible, remove prosthesis and braces from the
patient’s mouth. Where possible orthodontic braces in
children and dentures in adults should be removed,
since these hamper administration of anesthetic and
increase the risk of lesions in uncooperative patients.
4) Preparation of the syringe by the assistant.
● Insert the cartridge into the syringe. Some dentists
prefer to disinfect the mouth of the cartridge by wip‑
ing it with gauze soaked in alcohol immediately
before loading the syringe. This maneuver is not nec‑
essary with modern packaging (blister packs).
Cartridges should never be placed in disinfectant
since this can reach the interior of the cartridge and
contaminate the solution (Shannon and Feller1972;
Shannon and Wescott1974).
● Place the needle over the mouth of the syringe loaded
with the cartridge by removing the posterior cap of
the needle and screwing the posterior part of the nee‑
dle into the mouth of the syringe. Note that the ante‑
rior cap covering the front part of the needle, the
active part, is not removed. The needle should not be
bent for intraoral injections (Dentists’ Desk1983). In
cases where it is necessary to bend the needle to reach
a difficult area, then it should be bent half‑ way down
the shaft of the needle and not at the hub‑ adapter,
since this is the weakest area and thus increases the
risk of breakage (Burgess1988).
‑
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● Finally, place a protective disk on the front cap of the
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needle to prevent needle
‑ stick injury when the
syringe containing the cartridge and needle is passed
to the dentist (needle
‑ stick protector) (Figure11.10,
Chapter11).
5) Do not use words with a high emotional content.
Try to avoid these terms and use more pleasant
euphemisms:
● Do not use the terms “syringe,” “injection,” or “prick”;
instead use “anesthesia,” which is more general and
less aggressive.
● Do not use the words “pain” or “harm”; instead use
“notice” or “discomfort.”
● Do not use the term “soft tissue anesthesia,” as it is
too technical; instead use “numbness,” “dullness,”
“tingling,” “tickling,” or “swelling” (Table13.1).
Using words with a high emotional content in expla‑
nations increases anxiety and makes more predisposed
patients consider low levels of stimulus as pain
(Jackson1974; Firestein1976; Wepman1978).
6) With children, use the tell‑ show‑ do technique
(Addelston 1959), which is actually the tell
‑ do tech‑
nique (McClure 1968), since in this case neither the
needle nor the syringe should be shown: seeing these
objects increases anxiety in children (Spedding and
Mink 1964; Majstorovic and Veerkamp 2004)
(Figure 13.1). The approach should be as follows
(Spedding and Mink1964: Mink and Spedding1966):
● Provide brief explanations with positive sentences and
continuous specific references in a level of language that
is suited to the patient’s age. Prolonged explanations
lead the child to stop listening and begin to feel anxious.
● The dentist can tell the child that only his/her “teeth
are going to sleep” and that these are small (show
using the fingers), unlike him/her, who is big (show
using the arms). This strategy is aimed at reassuring
the child by showing him/her that he/she is big in
comparison with the teeth, which are small and that,
therefore, the maneuver will be “a little one.”
Table13.1 The most common terms used withpatients
indentistry toexplain thefeeling ofsoft tissue anesthetized
(lips, tongue, andmouth).
Children Adults
221
Figure13.1 Do not show children the syringe with the needle
in place. Source: Drawn with modifications according to
Snawder (1987).
● The dentist explains that he/she is going to use
“anesthetic” on the gum near the teeth and touches
the area to be injected with a finger (this should be
clearly visible). Thus, the patient becomes familiar
with the touch and pressure on this area of the mouth.
The dentist can tell the child that when the anesthetic
goes in, “it will feel just as it does now.”
● The dentist then explains how the anesthetized lips and
mouth will feel “fat” or that they will feel “ticklish” or
that the “lip will feel swollen.” These terms are nicer
than those used with adults, such as “tickling sensa‑
tion,” “tingling,” “numbness,” or “dullness” (Table13.1).
● The dentist should ensure that the patient does not
confuse the sensation of “pressure” at the injection
site with “discomfort,” therefore the dentist carefully
takes the child’s wrist (without hurting) and presses it
so that the patient notices the sensation of pressure
without pain and moves the patient’s arm.
● It is important to use a calm, soft, gentle, and mono‑
tone voice to ensure an atmosphere of normality
where everything is known, understood, and accepted
(Addelston1959).
● Finally, tell the patient that he/she will feel like they
have a “fat lip” or “swollen lip” and that this will last
for some time and then go away. You can even give
the patient a mirror so that he/she can see that the lip
is not swollen even if it feels like it is.
● Fat → feeling a “fat lip”
sensation
● Tickling
● Swollen
● Tingling
● Numbness
● Dullness
● Itching
● Pins and needles
● Frozen → getting frozen
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Questions commonly asked by children:
● Will it be painful? Will it hurt? Simply tell the patient
that he/she will feel the same “discomfort” as when
you put your finger in his/her mouth.
● Are you going to stick a needle in me? Are you going
to give me an injection? Tell the patient that “you give
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