Local anesthesia, an important procedure intended to provide pain control during nonsurgical periodontal therapy, is often the most feared procedure by patients. Yet, with empathy and proper technique, atraumatic injections are not only possible but should be a consistent reality. The fear and anxiety that can result in a medical emergency can be greatly reduced; in its place, there can be calm and trust.
During dental hygiene school, students first learn to provide injections on each other for several weeks. Not only does this result in a heightened appreciation for how patients may feel, but students take extra care to provide painless injections for their partners, and develop excellent technique. In addition, they are relieved to know that they can provide and receive comfortable injections. Some experts suggest that providing atraumatic injections may wane with time as administration of local anesthesia becomes routine for clinicians.1,2 Therefore, it is prudent to frequently review the basics, explore new approaches, and hone our techniques.
Make tissue taut.
Pre-puncture technique: Bow needle and place drops of anesthetic on surface of mucosa prior to penetration.
Anxiety reduction: Providing atraumatic injections requires both excellent technique and excellent communication throughout the procedures. It is essential to consider each step and communicate the process in terms that reassure the patient.
Armamentarium check: A cold syringe may evoke negative psychological feelings about receiving the injection. The syringe may be warmed in the clinician's hand for 30 seconds prior to use. Cartridges should be at room temperature but may be warmed if previously refrigerated. If too warm, however, the solution may be uncomfortable for the patient or the agent may become compromised.
In addition, studies have shown that buffering local anesthetic solutions immediately prior to their use decreases the stinging sensation associated with acidic injections.1,3,4 The use of 25- and 27-gauge disposable, sharp, stainless steel needles is recommended and should be selected based upon the type of the injection. Recall that hundreds of studies have shown that patients cannot tell the difference between 25-, 27-, or 30-gauge (not recommended) needles with or without the use of topical anesthetic.
If desired, during setup, the clinician may check the needle for a rare manufacturing error, a barb, which can cause discomfort during withdrawal. To do this, gently pull the needle backward against a sterile 2x2" gauze.1 If the needle does not snag the gauze, the needle should be free of barbs. After syringe setup, the harpoon should be checked for engagement and a few drops of anesthetic expelled to check flow.
Patient Positioning: Generally, patients should be positioned supine with head and heart parallel to floor and feet slightly elevated to facilitate the physiological support required during anxiety. Also, this is the preferred position recommended in response to syncope, the most common dental office medical emergency. Patients may turn their head to facilitate clinician access.
Procedural tips: Gentle palpation techniques should be used in identifying anatomical landmarks and preparing tissues. Applying topical anesthetic, making the tissues taut (except palatal tissues) and establishing a stable fulcrum prior to insertion, assist in a painless penetration.
During the one to two minutes of topical anesthetic application, the patient can be assured that the topical anesthetic and a slow administration procedure provide for a more comfortable experience. Avoid using the negative terms "injection," "shot," "pain," "hurt," etc. This is also a good time to advise the patient that they may raise their hand (opposite side of clinician) any time during the procedure to communicate any discomfort or need for a pause. This provides the patient with a sense of control during the procedure and reduces the chance of sudden movements that may result in an injury. The syringe should be kept out of the patient's view.
Making the tissue taut prior to penetration not only provides better visibility, but allows for more reliable and comfortable insertion because the needle can penetrate the mucous membranes with minimal resistance (see Figure 1). Because discomfort during advancement is rare, it is not necessary to deposit drops of local anesthetic during advancement (except during palatal injections). But, with extremely apprehensive patients depositing a few drops ahead of the needle, and advising the patient that this is being done to increase their comfort may be helpful. Avoid depositing more than a few drops as aspiration during this type of advancement is not required. Drops of anesthetic may also be deposited immediately prior to contact with the periosteum to assist with an atraumatic contact.
For palatal injections, special techniques including the use of pre-puncture deposition of anesthetic on the mucosal surface (see Figure 2) and creation of an anesthetic pathway by depositing a few drops ahead of the needle during advancement are important strategies for the provision of atraumatic injections.5
For safety and comfort, careful aspiration and slow deposition (1.0mL/min) are required.
For some palatal injections, such as the AMSA, even slower deposition is indicated. Patients should be reassured that they are receiving a normal dose of local anesthetic which is being deposited slowly to enhance their comfort. Slowly withdraw the needle from the tissue and make the needle safe. The patient should be observed for any adverse reaction. After three to four penetrations, a new, sharp needle should be used.
A little "TLC" goes a long way in providing a positive experience for patients. It begins and ends with good communication. Remembering that we can provide comfortable injections is key. Thoughtfully updating our own communication skills and clinical strategies to increase patient comfort before, during, and after injections facilitates not only the provision of atraumatic injections, but helps to build patient rapport and confidence. RDH
1. Malamed S. Handbook of Local Anesthesia, 6th ed, 2013, St Louis MO, Elsevier
2. Logothetis DD. Local Anesthesia for the Dental Hygienist, 2nd ed. St. Louis, MO, Elsevier; 2017.
3. Malamed S. Buffering local anesthetics in dentistry. 2011, The Pulse: 44 (1): 7-9
4. Malamed S, Tavana S, Falkal M. Faster onset and more comfortable injection with alkalinized 2% lidocaine 1:100,000 epinephrine. Compendium of Dental Education-Aegis. 2013; 34(1):10-20.
5. Webb, LJ. Pain control: the options -- Tips for providing less popular injections. RDH Magazine 2010; 30(4): 58-65
LAURA J. WEBB, RDH, MS, CDA, is an experienced clinician, educator, and speaker who founded LJW Education Services (ljweduserv.com). She provides educational methodology courses and accreditation consulting services for allied dental education programs and CE courses for clinicians. Laura frequently speaks on the topics of local anesthesia and nonsurgical periodontal instrumentation. She was the recipient of the 2012 ADHA Alfred C. Fones Award. Laura can be contacted at [email protected]