Basic Injection Technique (found in page 173, Handbook of Local Anes 7 th ed.

)
“Local anesthetics can and should be administered in a nonpainful, or atraumatic, manner.”
◆Step 1: Use a Sterilized Sharp Needle
 The stainless-steel disposable needles currently used in dentistry are sharp and rarely produce any pain
on insertion or withdrawal.
 Disposable needles are sharp on first insertion. However, with each succeeding penetration, their
sharpness diminishes. By the third or fourth penetration, the operator can feel an increase in tissue
resistance to needle penetration. Clinically, this is evidenced by increased pain on penetration

◆ Step 2: Check the Flow of Local Anesthetic Solution

 a few drops of local anesthetic should be expelled from the cartridge. This ensures a free flow of
solution when it is deposited at the target area.

◆ Step 3: Determine Whether to Warm the Anesthetic Cartridge or Syringe (optional)

 If the cartridge is stored at room temperature (approximately 22°C, 72°F), there is no reason for a local
anesthetic cartridge to be warmed before injection of the anesthetic into soft tissues.
 Cartridges stored in refrigerators or other cool areas should be brought to room temperature before
use.

◆ Step 4: Position the Patient

 Any patient receiving local anesthetic injections should be in a physiologically sound position before
and during the injection.
 Vasodepressor syncope (common faint), the most commonly seen medical emergency in dentistry,
most often occurs before, during, and, on occasion, immediately after local anesthetic administration.
 it is recommended that during local anesthetic administration, the patient should be placed in a supine
position (head and heart parallel to the floor) with the feet elevated slightly
o Although this position may vary according to the dentist’s and the patient’s preference, the
patient’s medical status, and the specific injection technique, all techniques of regional block
anesthesia can be performed successfully with the patient in this physiologic position.
◆ Step 5: Dry the Tissue
 A 2- × 2-inch gauze should be used to dry the tissue in and around the site of needle penetration and to
remove any gross debris. In addition, if the lip must be retracted to attain adequate visibility during the
injection, it too should be dried to ease retraction.

◆ Step 6: Apply Topical Antiseptic (Optional)

 The antiseptics used include povidone-iodine (Betadine) and thimerosal (Merthiolate).

◆ Step 7A: Apply Topical Anesthetic

 should be applied only at the site of needle penetration.
 Topical anesthetics produce anesthesia of the outermost 2 or 3 mm of mucous membrane; this tissue is
quite sensitive. Ideally the topical anesthetic should remain in contact with the tissue for 2 minutes to
ensure effectiveness. A minimum application time of 1 minute is recommended.

◆ Step 7B: Communicate With the Patient

 During the application of topical anesthetic, it is desirable for the administrator to speak to the patient
about the rea sons it is being used. Tell the patient, “I’m applying a topical anesthetic to the tissue so
that the remainder of the procedure will be much more comfortable.”
 Note that the words injection, shot, pain, and hurt are not used. These words have a negative
connotation; tending to increase a patient’s fears. Their use should be avoided if at all possible. More
positive (e.g., less threatening) words can be substituted in their place. “Administer the local
anesthetic” is used in place of “Give an injection” or “Give a shot.”
 Commonly used by Canadian dentists is the word freeze, as in “I’m going to freeze you now.” A
statement such as “This will not hurt” should also be avoided. Patients hear only the word hurt,
ignoring the rest of the statement. The same is true for the word pain. An alternative to this is the word
discomfort. Although their meanings are similar, dis comfort is much less threatening and produces less
fear.
◆ Step 8: Establish a Firm Hand Rest
 Any finger or hand rest that permits the syringe to be stabilized without increasing risk to a patient is
acceptable. Two techniques to be avoided are (1) using no syringe stabilization of any kind and (2)
placing the arm holding the syringe directly onto the patient’s arm or shoulder

◆ Step 9: Make the Tissue Taut

 The tissues at the site of needle penetration should be stretched before insertion of the needle
 Techniques of distraction are also effective in this regard. Some dentists jiggle the lip as the needle is
inserted; others recommend leaving the needle tip stationary and pull ing the soft tissues over the
needle tip

◆ Step 10: Keep the Syringe Out of the Patient’s Line of Sight
  With the tissue prepared and the patient positioned, the assistant should pass the syringe to the
administrator out of the patient’s line of sight either behind the patient’s head (Fig. 11.14) or across
and in front of the patient

◆ Step 11A: Insert the Needle Into the Mucosa

 With the needle bevel properly oriented (see the specific injection technique for bevel orientation;
however, as a general rule, the bevel of the needle should be oriented toward bone), insert the
needle gently into the tissue at the injection site (where the topical anesthetic was placed) to the
depth of its bevel.

◆ Step 11B: Watch and Communicate With the Patient

 the patient should be watched and communicated with; the patient’s face should be observed for
evidence of discomfort during needle penetration. Signs such as furrowing of the brow or forehead
and blinking of the eyes may indicate discomfort

◆ Step 12: Inject Several Drops of Local Anesthetic Solution (Optional)

◆ Step 13: Slowly Advance the Needle Toward the Target.
 o Steps 12 and 13 are performed together. The soft tissue in front of the needle may be
anesthetized with a few drops of local anesthetic solution. After 2 or 3 seconds are allowed
for anesthesia to develop, the needle should be advanced into this area and a little more
anesthetic deposited. The needle should then be advanced again. These procedures may
be repeated until the needle reaches the desired target area.

o In most patients, however, injection of local anesthetic during insertion of the needle
toward the target area is entirely unnecessary.

◆ Step 14: Deposit Several Drops of Local Anesthetic Before Touching the Periosteum
o In techniques of regional block anesthesia in which the needle touches or comes close to
the periosteum, several drops of solution should be deposited just before contact.
Periosteum is richly innervated, and contact with the needle tip produces pain.

o Anesthetizing the periosteum permits atraumatic contact. The regional block injection
techniques that require this are the inferior alveolar, Gow-Gates mandibular, and anterior
superior alveolar (infraorbital) nerve blocks.

◆ Step 15: Aspirate

o Aspiration must always be performed before a volume of local anesthetic is deposited at
any site.
o Aspiration dramatically minimizes the possibility of intravascular injection. The goal of
aspiration is to determine where the needle tip is situated (within a blood vessel or
without).
o Adequate aspiration requires that the tip of the needle remain unmoved, neither pushed
farther into nor pulled out of the tissues, during the aspiration test. Adequate stabilization
is mandatory. Neophytes have a tendency to pull the syringe out of the tissue while
attempting to aspirate.
o When the harpoon-aspirating syringe is used, the thumb ring should be pulled back gently.
Movement of only 1 or 2 mm is needed.
o Any sign of blood represents a positive aspiration, and local anesthetic solution should not
be deposited at that site

◆ Step 16A: Slowly Deposit the Local Anesthetic Solution

 o Slow injection is defined ideally as the deposition of 1 mL of local anesthetic solution in not
less than 60 seconds. Therefore, a full 1.8-mL cartridge requires approximately 2 minutes to
be deposited. Through slow deposition the solution will diffuse along normal tissue planes
without producing discomfort during or following injection
 A more realistic time span in a clinical situation is 60 seconds for a full 1.8-mL
cartridge. This rate of deposition of solution does not produce tissue damage
during or after anesthesia and, in the event of accidental intravascular injection,
does not produce an extremely serious reaction.

◆ Step 16B: Communicate With the Patient (optional)

◆ Step 17: Slowly Withdraw the Syringe

o After completion of the injection, the syringe should be slowly withdrawn from the soft
tissues and the needle made safe by capping it immediately with its plastic sheath via the
scoop technique.

◆ Step 18: Observe the Patient

o After completion of the injection, the doctor, hygienist, or assistant should remain with the
patient while the anesthetic begins to take effect (and its blood level increases).
o Most true adverse drug reactions, especially those related to intraorally administered local
anesthetics, develop either during the injection or within 5 to 10 minutes of its completion.
o Patients should not be left unattended after administration of a local anesthetic.

◆ Step 19: Record the Injection in the Patient’s Dental Chart