BASIC INJECTION TECHNIQUE

INTRODUCTION

• Local anesthetic administration need not, and should not, be painful.

• Several skills and attitudes are required of the drug administrator, the most important of which is probably
empathy.
• An atraumatic injection has two components: a technical aspect and a communicative aspect.
• Most dental students’ first injections were given to classmate “patients,” who then gave the same injection
to the student who had just injected them.

PREPARATION OF SITE OF INJECTION AND NEEDLE INSERTION

Syringe and Needles:

• Chose suitable type syringe and needle should be

• The syringe and needle should be carefully sterilized

Hands of the operator:

• Washed thoroughly with soap and water

• Dried with a sterile towel
• Wiped with 70% alcohol

Anaesthetic carpules:

• Carefully sterilized
• Warmed to body temperature

Patient’s mouth:

• Scaling if needed
• Rinsing with good antiseptic mouthwash
• Draping in the regular manner

Site of injection:

• Dried from saliva by a pellet of sterile cotton

• Wiped with a disinfectant as 5% tinctur

Step 1: Use a sterilized sharp needle

▪ Needles are already sterilized.

▪ Stainless steel disposable needles currently used in dentistry are sharp and rarely produce any pain on
insertion or withdrawal.

1|Page
 ▪ This results in atraumatic insertion of the needle

▪ Disposable needles are sharp on first insertion.

▪ However, with each succeeding penetration, their sharpness diminishes.

Remember:

▪ It is recommended that stainless steel disposable needles be changed after every three or four tissue
penetrations.

▪ After the third or fourth penetration, the operator can feel an increase in tissue resistance to needle
penetration.

Step 2: check flow of local anesthetic solution

▪ After the cartridge is properly loaded into the syringe, and with the aspirator tip (harpoon) embedded into
the silicone rubber stopper (if appropriate), a few drops of local anesthetic should be expelled from the
cartridge.

Notes: This ensures a free flow of solution when it is deposited at the target area.

▪ The stoppers on the anesthetic cartridge are made of a silicone rubber to ensure ease of administration.

▪ Only a few drops of the solution should be expelled from the needle to determine whether a free flow of
solution occurs.

Step 3: determine whether to warm the anesthetic cartridge or syringe

▪ The Philippines is a tropical country.

▪ 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 its injection into soft tissues.

▪ Most complaints concerning overly warm local anesthetic cartridges pertain to those stored in cartridge
warmers heated but in the Philippines it best to store anesthesia in a cool dry location.

▪ Refrigerators must be set to the appropriate temperature.

Step 4: Position of Patient

▪ Any patient receiving local anesthetic injections should be in a physiologically sound position before and
during the injection.

▪ It is recommended that the patient be in a supine position (head and heart parallel to the floor) with the
feet elevated slightly.

Notes: Although this position may vary according to the dentist's and the patient's preference, the patient's medical
status (CHF, COPD), and the specific injection technique, all techniques of regional block anesthesia can be carried
out successfully with the patient in this position.

2|Page
Step 5: dry the tissue

▪ Use 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)

▪ After the tissues are dried, a suitable topical antiseptic should be applied at the site of injection.

▪ This further decreases the risk of introducing septic materials into the soft tissues, producing inflammation
or infection.

▪ Antiseptics include Betadine (povidone-iodine) and Merthiolate (thimerosal). Alcohol-containing antiseptics

can cause burning of the soft tissue and should be avoided.

Step 7:

a) Apply Topical Anesthetic

▪ A topical anesthetic is applied after the topical antiseptic. As with the topical antiseptic, it should be applied
only at the site of needle penetration.

▪ Only a small quantity of topical anesthetic should be placed on the cotton applicator stick and applied
directly at the injection site

▪ Ideally the topical anesthetic should remain in contact with the tissue for 2 minutes to ensure effectiveness.
3|Page
 ▪ A minimum application time of 1 minute is recommended.

Notes: All too often, excessive amounts of topical anesthetic are used on large areas of soft tissue, producing
undesirably wide areas of anesthesia (e.g., the soft palate, the pharynx), an unpleasant taste, and, perhaps even
more important with some topical anesthetics (such as lidocaine), rapid absorption into the cardiovascular system
(CVS), leading to higher local anesthetic blood levels, which increase the risk of overdose.

b) Communicate with the patient

▪ During the application of topical anesthetic, it is desirable for the operator to speak to the patient about the
reasons for its use.

▪ Tell the patient, “I'm applying a topical anesthetic to the tissue so that the remainder of the procedure will
be much more comfortable.”

▪ This statement places a positive idea in the patient's mind concerning the upcoming injection.

Communicate

▪ Note that the words injection, shot, pain, and hurt are not used.

▪ These words have a negative connotation;they tend 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.”

Step 8: establish a firm hand rest

▪ After the topical anesthetic swab is removed from the tissue, the prepared local anesthetic syringe should
be picked up It is essential to maintain complete control over it at all times.

▪ To do so requires a steady hand so that tissue penetration may be accomplished readily, accurately, and
without inadvertent nicking of tissues. A firm hand rest is necessary.

▪ The types of hand rest vary according to the practitioner's likes, dislikes, and physical abilities.

A, Syringe stabilization for a right posterior superior alveolar nerve block: syringe barrel on the patient's lip,
one finger resting on the chin and one on the syringe barrel (arrows), upper are kept close to the
administrator's chest to maximize stability.

4|Page
 B. Syringe stabilization for a nasopalatine nerve block: index finger used to stabilize the needle, syringe
barrel resting in the corner of the patient's mouth.

Step 9: Make the tissue taut

▪ The tissues at the site of needle penetration should be stretched before insertion of the needle

▪ This can be accomplished in all areas of the mouth except the palate (where the tissues are naturally quite
taut).

▪ Stretching of the tissues permits the sharp stainless steel needle to cut through the mucous membrane with
minimal resistance.

▪ Loose tissues, on the other hand, are pushed and torn by the needle as it is inserted, producing greater
discomfort on injection and increased postoperative soreness.

5|Page
 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 or across and in front of the
patient.

▪ A right-handed practitioner administrating a right-side injection can sit facing the patient or, if administering
a left-side injection, facing in the same direction as the patient.

▪ In all cases, it is better if the syringe is not visible to the patient.

6|Page
 Step 11a: Insert the needle into the mucosa

▪ With the needle bevel properly oriented (see specific injection technique for bevel orientation; however, as
a general rule, the bevel of the needle should be oriented toward bone),

▪ Remember:

➢ B to B = Bevel to BONE

7|Page
 Note: insert the needle gently into the tissue at the injection site (where thea topical anesthetic was placed) to
the depth of its bevel.

With a firm hand rest and adequate tissue preparation, this potentially traumatic procedures accomplished
without the patient ever being aware of it.

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

8|Page
 REMEMBER

▪ The patient should be told in a positive manner, “I don't expect you to feel this,” as the needle penetrates
the tissues.

▪ The words, “This will not hurt,” should be avoided; this is a negative statement, and the patient hears only
the word (hurt)

▪ DO NOT SAY: “SAKIT BA???” or “INGON LANG IF SAKIT HA.”

Step 12: Inject several drops of local anesthetic solution (optional)

▪ Inject several drops of local anesthetic solution (optional).

Step 13: Slowly advance the needle toward the target

▪ The soft tissue in front of the needle may be anesthetized with a few drops of local anesthetic solution
(step 12).

▪ After 2 or 3 seconds are allowed for anesthesia to develop, the needle should be advanced into this area
and a little more anesthesia deposited.

▪ The needle should then be advanced again. These procedures may be repeated until the needle reaches
the desired target area.

▪ Use of a buffered local anesthetic will increase patient comfort during injection as a result of (1) the
increased pH of the anesthetic solution (7.35 to 7.5) and (2) the presence of CO2 in the buffered solution.
CO2 possesses anesthetic properties.
9|Page
 ▪ Pain is rarely encountered between the surface mucosa and the mucoperiosteum.

▪ If patients are asked post injection what they felt as the needle was being advanced through soft tissue (as
in an inferior alveolar or posterior superior alveolar nerve block), the usual reply is that they were aware
that something was there, but that it did not hurt.

▪ On the other hand, patients who are apprehensive about injections of local anesthetics are likely to react
to any sensation as though it were painful. These patients are said to have a lowered pain reaction
threshold

Step 14: Deposit several drops of local anesthetic before touching the periosteum

▪ 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.

▪ The periosteum is richly innervated and contact with the needle tip produces pain.

▪ Knowledge of when to deposit the local anesthetic comes with experience.

▪ With experience and development of this tactile sense, a small volume of local anesthetic solution may be
deposited just before gentle contact with the periosteum.

Step 15: Aspirate ×2

A, Negative aspiration. With the needle in position at the injection site, the administrator pulls the thumb ring of
the harpoon-aspirating syringe 1 or 2 mm. The needle tip should not move. Check the cartridge at the site where
the needle penetrates the diaphragm (arrow) for a bubble or blood.

B, Positive aspiration. A slight reddish discoloration at thediaphragm end of the cartridge (arrow) on aspiration
usually indicates venous penetration. Reposition the needle, reaspirate, and, if negative, deposit the solution.

10 | P a g e
C, Positive aspiration. Bright red blood rapidly filling the cartridge usually indicates arterial penetration. Remove
the syringe from the mouth,change the cartridge, and repeat the procedure.

Step 16a: Slowly deposit the local anesthetic solution

▪ With the needle in position at the target area and aspirations completed and negative, the administrator
should begin pressing gently on the plunger to start administering the predetermined (for the injection
technique) volume of a

▪ 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.

Step 16b: Communicate with the patient

▪ The patient should be communicated with during deposition of the local anesthetic.

▪ Most patients are accustomed to receiving their local anesthetic injections rapidly.

▪ Statements such as, “I'm depositing the solution (or “I'm doing this”) slowly so it will be more comfortable
for you, but you're not receiving any more than is usual” go far to allay a patient's apprehension at this
time.

▪ The second part of the statement is important, because some patients might not realize that there is a
fixed volume of anesthetic solution in the syringe.

Notes: Pang US ito; focus on the patient and over all apprehension due to the procedure AS A WHOLE. Usually first
time nila mag anes.

ie. Inform before you perform. ALWAYS MAM/ sir, magsisimula na po tayo. Ready na po? (wait for confirmation)

Lalagay ko na po anes para komportable po kayo sa buong procedure. May mga mararamdaman po kayo.

Step 17: Slowly withdraw the syringe. Cap the needle and discard

▪ 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.

▪ Concerns about the possibility of needle-stick injury and the spread of infection caused by inadvertent
sticking with contaminated needles have led to the formulation of guidelines for the recapping of needles
for health care providers.

11 | P a g e
Step 18: Observe the patient after the injection

▪ 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).

▪ 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.

▪ All too often, reports are heard of situations in which a local anesthetic was administered and the doctor
left the patient alone for a few minutes only to return to find the patient seizing or unconscious

Step 19: Record the injection on the patient's chart

▪ An entry must be made of the local anesthetic drug used, the vasoconstrictor used (if any), the dose (in
milligrams) of the solution(s) used, the needle(s) used, the injection(s) given, and the patient's reaction.

▪ For example, in the patient's dental progress notes, the following might be inscribed:

▪ “R-IANB, 25-long, 2% lido + 1:100,000 epi, 36 mg. Tolerated procedure well”

Step 20: Dispose properly

12 | P a g e