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• Inform the patient that he or she wil feel
Patients generaly do not enjoy having sharp needles
injected into their oral mucosa. Since many patients
generate anxious and fearful feelings around the local
• Apply pressure to the palatal mucosa with
anesthesia process, a reduction in injection pain can
reduce anxiety and facilitate a more favorable dental
• Place the beveled side of a 30-gauge nee-
experience.1 Palatal anesthesia is necessary to reduce
dle so that it is gently touching the mucosa
discomfort during surgical, endodontic, and restorative
procedures. Pain traditional y associated with palatal
• Simultaneously press and roll the handle of
injections can be minimized with one of several meth-
the mirror toward the needle (Figure 3), with
ods: electronic,2,3 topical,4,5 cryogenic,6,7 pressure,8 or,
concomitant injection of several drops of the
as presented in the following, through the palatal press
• Remove the needle and then remove the mir-
• Inquire with the patient if he or she felt the
• Have a positive mental at itude while
visualizing a successful, pain-free dose of
• After waiting 1 minute, reinsert the beveled
palatal anesthesia. Explain to the patient the
side of a 30-gauge needle and dispense the
appropriate amount of anesthetic for pro-
• Dry the palatal mucosa with cotton gauze;
The resultant palatal anesthesia technique should yield
• Place topical anesthetic on the palatal
adequate palatal anesthesia in a comfortable manner
Figure 1. Diagram conveys how to apply pressure to
Figure 2. Placement of beveled edge of 30-gauge needle
200604PPAD_EdCom_Kravitz.qxd 6/8/06 11:36 AM Page 244
The uniqueness of the palatal press and rol
technique is the rol ing pressure applied while the anesthetic agents are injected. The science of the pressurized rol can be understood in pressure anes-thesia literature.13 The Gate Control Theory was initial ybased on the fact that smal diameter nerve fibers carrypain stimuli through a gate mechanism,14 but larger-diameter nerve fibers going through the same gate can inhibit the transmission of the smal er nerves carrying the pain signal. Pressure anesthesia was later
Figure 3. Illustration demonstrates “press and roll” of the
corroborated mathematical y.15 The pain nerve fibers in
mirror handle while the needle is simultaneously injected.
the palatal mucosa are A-delta and C fibers. The A-delta fibers are larger in diameter, myelinated, and
are more localized in sensation; the C fibers are
To successful y administer dental anesthesia, a scien-
smal er in diameter, nonmyelinated, slower, and more
tific understanding of the prevention of pain is para-
diffuse. The delivery of the pressurized rol can be
mount. There are two types of nerve fibers that are present
perfected with practice, where mechanoreceptors
in the palatal mucosa relative to the generation of pain:
(A-beta) are stimulated through pressure. The nonpainful
A-delta and C fibers. Pain impulses can be blocked with
pressure stimulus can block the noxious stimulus of
the stimulation of mechanoreceptors known as A-beta
fibers, which travel to the brain more rapidly. When the
A slower rate of injection of anesthetic has been
A-beta fibers associated with pressure are stimulated first
shown to cause less pain and therefore be more com-
(ie, with the mirror handle), the A-delta and C fibers asso-
fortable to the patient.16 The type of anesthetics, such
as prilocaine without vasoconstrictor, has also been
Dental anesthesia also involves one’s adherence to
shown to contribute to lower pain level during injec-
the aforementioned technique. Framing the patient’s
expectations about what is possible with pain-free injec-
Once topical and pressure anesthesia is present,
tions and then delivering on this goal can set the stage
placement of the needle bevel towards bone may
for future successful injections. The operator’s belief
prevent unnecessary mucosal tears. The pressure anes-
system regarding what is possible can create a more
thesia occurs by the application of a blunt instrument
favorable outcome. Contrarily, if the operator sees a
and the rol ed pressure over the injecting needle. The
painful injection as the only option, then an unsuccess-
clinician’s goal is to produce mucosal anesthesia through
ful outcome may be more likely.9-11 Therefore, it behooves
ischemia, thereby preventing pain impulses with the Gate
the clinician to maintain an optimistic demeanor before,
Control Theory of pain. Another key distinction of
during, and after the palatal injection process.
this technique is slow gradual dispensation of the
Drying the palatal mucosa al ows for faster dif usion
anesthetic agent. Several drops of anesthetic are
of the topical anesthetic agent through the epithelium and
deposited under the rol ed mirror handle. Asking patients
connective tissue. Topical anesthetics have been shown
if they felt the pressure al ows them to remember the
to be effective when used prior to injections. The effec-
pressure and leads them towards a successful, com-
tiveness of topical anesthetic agents is variable based
fortable dental experience. One minute is needed to
on single or mixed agents.12 Two minutes is the general
al ow for regional anesthesia, prior to reinsertion of
time needed for adequate topical anesthesia.
200604PPAD_EdCom_Kravitz.qxd 6/8/06 11:36 AM Page 245
ConclusionA technique for improving the delivery of anesthetic agents
to the palatal mucosa is described herein. It is simple,
safe, and predictable. Pain-free injection can lead to a
For registrations, inquiries, or questions regarding the CE
Program, cal Lisa Holman at 800-899-5350 ext. 114 or
more favorable patient experience while undertaking sur-
address correspondence to Montage Media Corporation,
gical, endodontic, and restorative treatment.
Continuing Education Department, 1000 Wyckoff Avenue,
Mahwah, NJ 07430-3164.
Montage Media is an ADA/CERP-recognized provider.
Montage Media Corporation is designated as an approved
The author mentions his gratitude to Mark Yonkovitz for
PACE Program Provider by the Academy of General Dentistry.
The formal continuing education programs are accepted by the
his support in the preparation of this presentation.
AGD for Fel owship, Mastership, and membership maintenance
credit. Approval does not imply acceptance by a state or pro-
vincial board of dentistry. The current term of approval extends
1 Rosenberg ES. A computer-control ed anesthetic delivery sys-
Al or part of the CE credit offered in Practical Procedures &
tem in a periodontal practice: Patient satisfaction and accep-
Aesthetic Dentistry is accepted in most states that require CE.
tance. J Esthet Restor Dent 2002;14(1):39-46.
CE credit requirements vary from state to state. Participants
2. Ravela ED, de Guzmann EF, Masa AV, et al. Electronic dental
are encouraged to contact their state boards for information
anesthesia versus topical anesthesia for the control of pain caused
by nasopalatine block injections. J Philipp Dent Assoc
3. Meechan JG, Winter RA. A comparison of topical anesthesia
The CE presentations within Practical Procedures & Aesthetic
and electronic nerve stimulation for reducing the pain of intra-
Dentistry for CE credit are intended for General Dentists, Dental
oral injections. Br Dent J 1996;181(9):333-335.
Specialists, and Dental Laboratory Technicians.
4. Meechan JG. Ef ective topical anesthetic agents and techniques.
Dent Clin North Am 2002;46(4):759-766.
5. Rosa AL, Sverzut CE, Xavier SP, Lavrador MA. Clinical effec-
Participants are encouraged to take advantage of our 1-year
tiveness of lidocaine and benzocaine for topical anesthesia.
(10-issue) enrollment for just $128. Anyone wishing to partici-
pate in a single course may do so by returning their completed
6. Harbert H. Topical ice: A precursor to palatal injections. J Endod
exam and payment in the amount of $20.
7. Duncan JD, Reeves GW, Fitchie JG. Technique to diminish dis-
comfort from the palatal injection. J Prosthet Dent
A 10-question, multiple-choice examination fol ows each
designated CE presentation. To earn CE credit, complete the
8. Malamed S. Handbook of Local Anesthesia. St. Louis, MO:
answer form located on the adjacent page. The answer form
9. Peterson C, et al. “Optimism and bypass surgery” in Learned
Helplessness: Theory for the Age of Personal Control. New York:
10. El iot T, Wit y TE, Herrick S, Hof man JT. Negotiating reality after
physical loss; Hope, depression, and disability. J Personality and
No tests wil be processed until al applicable fees are received.
11. Cousins N. Anatomy of an Illness as Perceived by the Patient.
12. Meechan JG. Ef ective topical anesthetic agents and techniques.
The deadline for completed exams is one (1) calendar year
Dent Clin North Am 2002;46(4):759-766.
from the date of publication. Al answer forms must be post-
13. Melzack R, Wall PD. The challenge of pain. London: Penguin
marked no later than the date indicated. Tests postmarked after
the deadline date will not be processed.
14. Melzak R, Wall PD. Pain mechanisms: A new theory. Science
Participants must correctly answer at least seven (7) of the
15. Britton NF, Skevington SM. A mathematical model of the gate
ten (10) multiple-choice questions in order to earn two (2) hours
control theory of pain. J Theor Biol 1989;137(1):91-105.
16. Primosch RE, Brooks R. Influence of anesthetic flow rate deliv-
ered by The Wand local anesthetic system on pain response
to palatal injections. Am J Dent 2002;15(1):15-20.
Verification of participation will be sent to each participant on
17. Kramp LF, Eleazer PD, Scheetz JP. Evaluation of prilocaine for
a per test basis, within three weeks of receipt of their exam,
the reduction of pain associated with transmucosal anesthetic
from the Continuing Education Department at Montage Media
administration. Anesth Pro 1999;46(2):52-55.
*Adjunct Clinical Faculty of Periodontics and Prosthodontics,
National Naval Medical Center, Bethesda, MD; private
Refunds for annual enrol ments must be requested within
practice, Bethesda, MD. He may be reached at
distribution of the first three issues. Single exam fees wil be
refunded prior to verification of participation disbursement.
Jennifer Parlee Vancouver Island Zone Personal Information: Jennifer Parlee, Grade 3 teacher and Music Specialist at Strawberry Vale Elementary in Victoria, BC, brings nearly 20 years of community service to her candidacy. Jennifer’s passionate commitment to her community began when she became a Big Sister in the 1990’s, and has continued with participation on local municipal
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