DentaltownUK April 2017 - 31

Case Study

other anaesthetics anyway, it begs the question
why you would use it anyway.
Some clinicians suggest using Articaine
infiltration for lower teeth rather than a block.
This may work in some cases, but due to the
density of the mandibular bone, success can
vary between individuals. My preference is to
go for a block with lidocaine every time! Using
Articiane with the Wand STA can however
mean that IDBs, and 'collateral numbness'
can be avoided in some cases.
Whatever anaesthetic you choose- be aware
of the dose limits. These vary depending
on the anaesthetic, it's concentration and
presence of epinephrine (adrenaline). A recent
article on maximum doses can be read here:
http://onlinelibrary.wiley.com/doi/10.1111/
anae.12679/pdf

The injection
Look for and identify the landmarks- pterygo
mandibular raphe, buccal pad of fat, retro
mandibular triangle and feel with your thumb
for the coronoid notch.
Apply topical on the end of a cotton wool roll
(CWR) and get the patient to bite on CWR
thereby holding between teeth -then wait!
Lidocaine topical can take 2-4 minutes to work!
Remove the CWR and any excess topical
Ask the patient to open as wide as they
can - the wider they open the more comfortable
they will be. Get good retraction and pressure
with the thumb of the no- injecting hand, push
firmly with thumb and support the jaw with
the rest of your fingers.
Sometimes it is a good idea (especially with
anxious patients) to do a little rehearsal with the
cap on the syringe prior to actually injecting helps to prepare patient and gauge their reaction.
At point of penetration - get patient to

open their eyes (distraction). Instead of being
internally focused with eyes closed their senses
are swamped with light, and shade and colour!
This rehearsal and distraction technique is
outlined in a case study by Mike Gow and
can be read at http://bscw.rediris.es/pub/bscw.
cgi/d4531139/Gow-Hypnosis_31_year_old_
female_dental_phobia.pdf
Advance wide bore, long needle to 3/4 of
its length - it is not necessary to hit bone (this
actually damages the bevel of the needle).
Deposit 3/4 of the solution, withdraw to half
the length of the needle and deposit the final
quarter (lingual nerve and lingual mucosa).
Push firmly with the thumb of the noninjecting hand to prevent drag and a 'ping' of
the tissues as the needle is removed!
Massage with thumb (This may be partially
psychological - the pushing sensation the patient
feels is then related to your thumb and not the
injection but the massaging is likely helping
disperse the anesthetic into the foramen)
Wait a good 5 minutes - use this time to
chat to patient, give OHI, explain length of
analgesia etc
If lip is tingling - it is a good sign! I personally
would wait up to 10 minutes before giving
another block as it can take as long as this to
work for some people.
If I do another- it is a back to basics moment,
re-establish my landmarks, make sure my
retracting thumb is in the right place. I often use
my retracting thumb as a landmark - bisecting
my thumb, (providing it is in the right place)
is also a good indicator that you are in the
right place!
I often tell students that if they are sure of
their landmarks and have hit bone too soon,
they either have to come out and try again or
use the indirect approach. ■

One interesting adaptation I've adopted
along the way was a two injection - short
needle and long needle approach that I
learned from Chris Bell!
I had a patient with Reflex Anoxic Seizure.
She was referred to CDS as whenever
she experienced pain she collapsed- and
her heart stopped for approximately
3 minutes before restarting! She was
understandably terrified of dentistry! My
clinical director suggested some hypnosis
with me in the first instance. She was 16
years old and was happy to try, and after
a few sessions of hypnosis which included
ego strengthening and desensitization we reached the point where she was ready
to have her filling done. On a lower 6! I
had also used Mike Gow's 'Six Step Needle
Desensitisation' which I mentioned earlier.
I applied the topical anaesthetic as
usual but then used a short needle and
mepivacaine plain to inject half a cartridge
(as if giving a block but only to half the
depth of the needle)
The anaesthetic was left to work for five
minutes. Then with a long needle and
lidocaine an IDB was given as normal.
The mepivacaine successfully
anaesthetised the area that the 'long'
needle will travel through and as it has a
closer pH to the tissues it was therefore
far more comfortable.
In this case, it worked well and the patient
had her restoration carried out with no
pain or discomfort.
I have successfully used this approach for
several really anxious patients. One of the
problems treating anxious patients is that
they can have a high expectation of pain
and therefore can become hypersensitive,
which of course results in them feeling
tense instead of relaxed. It becomes a
vicious cycle and a self-fulfilling prophecy.
I run LA refresher and IDB courses for
Hygienists and Therapists (although
dentists do also attend and enjoy the
relaxed approach). It is always good to
have dentists in the group as many
hygienists and therapists feel terrified
about giving IDBs and it can be reassuring
for them to accept that we all lose a bit
of confidence at times and attending
a refresher course is a great way to
regain that confidence and refresh our
knowledge. ■

dentaltownuk.com \\ APRIL 2017

http://bscw.rediris.es/pub/bscw http://onlinelibrary.wiley.com/doi/10.1111/ http://www.dentaltownuk.com

Table of Contents for the Digital Edition of DentaltownUK April 2017