200604PPAD_EdCom_Kravitz.qxd 6/8/06 11:36 AM Page 242 • 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.

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