Question: Minimising the pain associated with LA Administration: every dentist / doctor/ nurse uses the same disposable needles now a days, but pain inflicted while giving A drug varies from clinician to clinician?

Question: Minimising the pain associated with LA Administration: every dentist / doctor/ nurse uses the same disposable needles now a days, but pain inflicted while giving A drug varies from clinician to clinician?

Minimising the pain associated with LA Administration: every dentist / doctor/ nurse uses the same disposable needles now a days, but pain inflicted while giving A drug varies from clinician to clinician !!!! We all experienced this by ourselves when we were on the receiving end! So let’s start another discussion on Giving LA With minimal discomfort: you are welcome to add your ideas too:

Sridhar Reddy Arumalla: palatal infiltrations are very painful and hated by the most of our these conditions,anasthetic gel should be applied before infiltrations.

Sekhar Reddy: That’s a good start up point Sridhar, I appreciate your enthusiasm.

Sridhar Reddy Arumalla: dr sekhar reddy has started with simple topics, these topics are useful for general practitioners. I request all the members,pls participate in this debate.

Sekhar Reddy: Palatal infiltrations are horrible. There are a few ways in which you can minimise the discomfort : guys n ( gals) out there start thinking !!!

Raj Gangula: gud morning friends, comrades and my gurus here… first before any procedures.. check your armamentarium.. right needles for right places…right tecnique..

Raj Gangula: while giving palatal injections, the tech I follow is that I squeeze the cheeek of the pt gently.. to activate the D fibres.. the fibres of dull ache.. they say that the dull ache overcomes the C ibre sharp pain.. it works for me!!!!!!!!!!!!!!

Raj Gangula: Hey pardon me if I mix up D with C or the other way.. longtime that I ref Monheim’s…..

Sekhar Reddy: Welcome Raj! Dr Raj is a GDCH graduate with full UK registration. Currently in Hyderabad. Lets hope he will share his knowledge and his international experience with the members. Expecting a lot from you Raj Gangula ! You can start a new post of your own too.

Raj Gangula: Thanks Sekhar bhayya.. simple next point always the bevel of the needle faces the soft tissue and the pointy bit towards the bone. If you hit a bone the needle gets blunt which tears the tissue on retraction, be gentle and change the needle for teh next injection…

Ai’shah Khan: whilst Am giving palatal infiltration i compress the area of injection wit my gloved hand . This will help too.

Nripjeet Singh Anand: Pain perception differs from patient to patient,so in clinical practice you might never know what technique hurts more and what hurts less,sometimes men show so much of pain on the slightest of prick whereas in some cases even small children do not show a single reaction even if the LA is being injected palatally.

Mohammed Areekat: Great going sir ……..

Simarpreet Singh: do not fill the syringe with the needle with which you are going to inject so that it does not become blunt while piercing the rubber cap of la vial

Simarpreet Singh: Sekhar Reddy kindly tell me sir if this actually works or just a practice that i follow….

Nripjeet Singh Anand: As it is there should be one sterile needle injected into the LA bottle always just for the purpose of loading,reason being that many a times the patient is not anaesthetized properly and we have to reload the syringe to re inject,in that case without thinking sometimes we just re insert the already used needle into the bottle to re load and the whole of the LA solution is contaminated,in order to prevent this whenever giving a block we should open a new syringe,remove the needle,attach the syringe in the needle that is already there in the bottle,load the syringe,take out the syringe,attach the syringe to the already removed needle and go on,this way one will neither face the problem of contamination of LA solution ever,now will the problem of bluntness arises.

Raj Gangula: yes I commend the using of two different needles for loading and injecting… just to start of another improtant discussion.. how far is it right to keep the pierced bottle with a needle in it.. cause this is supposed to be a sterile injectible solution.. tech speaking we should be disposing a bottle a day even if the bottle is more than half full.. Supposed solutions for thsi problem 1. using cartridges for injections(as my friend and guru Dr. Sekhar Reddy uses) 2. disposing a bottle in a day/ per pt and put this costing as a different bill to our pts… Kidnly discuss

Raj Gangula: The reason this is started is that, as soon as the bottle of La is pierced it gets contaminated and contaminated injections can be sometimes painful…. kind of inoculation pain!!!!!!!!!!!!!!!!!!!!!!!

Nripjeet Singh Anand: Again that would have been ideal had this been US/UK/Canada where dentistry is followed perfectly,here in India where people are not ready to pay even the normal procedure fees and ask for concession in that,do you think you will explain this to the patient and he will understand and then pay you extra ?How will the injection be more painful on the 2nd day of the opening of the LA bottle,than what it was on the 1st day,even if a needle is continuously injected into it.

Nripjeet Singh Anand: We Indians have to manage a lot of things,we gotta be practical and not theoretical in everything,theoretical and ideal practice can only be followed in Foreign countries where the Patients and the Govt is aware of all the risks and and care is given to health of their citizens,that is why the cost there is too high and the quality of the treatment is perfect.In case of 3rd party insurance claims of health sector somebody was telling me that photographs have to be attached where the doctor should be seen opening a new pack of instruments for each patient and after the procedure is completed should be photographed destroying all the instruments,that much care is taken in those countries,details of each and every appointment have to be entered and what procedure was done when and how much time it took,if it took more time then why did it take that much time,all that has to be entered.

Raj Gangula: The La bottles are vaccum sealed for a purpose of maintaining the sterility. As soon as we pierce these bottles the chance of inoculating the LA bottle gets very high.. there are some audits doen on this and very good articles written..

Raj Gangula: Nirpreet lets leave theory and practical here for moment.. let me ask one question,, imagine ur mom came to your surgery.. and you were about to start a procedure.. would you just inject from the same bottle which was opened day before or would you ask your asst to get a new bottle!!!!????

Nripjeet Singh Anand: Small dentists in india would be running for bread and butter if they don’t manage themselves,and supposing they have only one patient on whom LA was used in a day then according to you the whole bottle should be thrown away,big dentists won’t have a problem with that,small dentists will suffer.

Raj Gangula: how much does a LA bottle cost Nirpreet— 27rs from warren and if you buy in bulk less than that.. even if a person throws one bottle a day.. its almost 750 rs for a month.. now dont tell me that a small dentist doest make that even!!!!!!!!!!!!!!

Raj Gangula: Around the World it is adviced to practice as you wer to practice the same on your MOM/ DAUGHTER!!!!!… FOR A definite reason isnt it!!!!!!

Anudeep Guptha Pulluri: The info given by u all are very useful , one thing I can add to it is …they say as period of deposition is more painful , one should deposit the LA slowly 1ml /60 sec if Iam not wrong .but usually dentists are in a hurry … For example if dey are gng to xtract a grade three mobile teeth they think only about the mobility nd ease of extracting it nd does in a hurry …bt not abt managing pain of the pt

Sekhar Reddy: This is a real problem in India. 20ml LA bottle costs around 18 rs. Catridges are expensive. It’s up to the individual dentists discretion what they prefer or can given the financial constraints etc. My posts are only for information. I just want to say a couple of things here. Once the LA bottle is pierced all the metabisulphite gets oxygenated. Once pierced and left longer the efficacy of the LA Agent decreases. Cross contamination is always an issue. Please do not think i am being rude if I don’t respond to all the comments as its not always possible with time constraints and discussions can become argumentative. Currently I also use LA Bottles, however I restrict myself to the use one bottle for one patient.

Nripjeet Singh Anand: ^^Good that you can manage the cost Sir,everybody cannot,we can end up giving the same pierced LA to patients but cannot afford a new bottle every time,even if it is a bit compromised.

Raj Gangula: Nripjeet Singh Anand, nothing intended if I have spelt your name wrongly.. apologies.. however How does me having a UK full registration or not has got soemthing to do with this… Please do not intend to divert teh discussion the sole purpose of this discussion was each person to give their ideas in causing less discomfort to our Pateints– whom we should thankkful to for providing us bread and butter… My ways suit not western countries my ways suit a dental practice.. If People have not researched their entire life .. U and neitehr would I be today talking here, practicing dentistry, nor would be injecting teh same LA that we are discussing here…

Raj Gangula: Before saying things that disgrace each one us dentist I kindly request you to sit back and relax and think what wouyld be us DENTISTS without out patients!!!!!!!!!!!….. A big zero.. Them happy we would have a living if not we would be nothing better than a bunch of learned fools!!!!!

Murali Krishna: what is “MIDA” AND “MADS’

Sekhar Reddy: Next main factor is the speed at which the deposition is done as some one rightly commented. Pain happens twice once at the time of needle penetration and secondly when you start depositing . Slow deposition helps with the degree of discomfort and also slows down systemic absorption too.

Abdul Hafeez: @NS ANAND,sorry to say but your reasoning is not justified,dr raj even though seems blunt he always speaks the right things, whatever little I know of him through posts.

Sekhar Reddy: Another thing that definitely helps for palate is making the area ischemic. We all experienced a frozen leg when we sit on the floor for long. Basically it’s ischemia making the leg insensitive to pain. Now apply the same analogy here. Apply firm pressure for about 60 sec with a blunt instrument like the other end of mouth mirror and inject into the blanched area. This really works. Try it n see.

Sekhar Reddy: When performing infiltrations over mobile tissues like in the buccal vestibule hold the area taught by stretching it out. Needle makes a sharp entry on taught mucosa opposed walking or scratching on a loose or saggy area . Hope u understood what I want to say.

Ravi Kumar Peratoti: i think the pharmaveutical companies should come with a vial of lesser quantity, as this ensures a bottle be used in a day and minimise wastage of LA.though smaller vials may cost u lil more …

Raj Gangula: At the sametime the temp gradient between LA and the tissues can cause a sudden jerk of shock like pain. U can always get the LA warmed up not heated.. this can be done by using old infant bottle warmers which has an option of temp control!!!

Raj Gangula: Ravi Kumar Peratoti its really a very gud option to be thought by the Pharma companies!!!!

Murali Krishna: why they are showing interest in manufacturing LA Cartridges.

Murali Krishna: i know only one company( septodent) their charges are very high.

Raj Gangula: Murali bhayya LA cartridges are a very gud option of La inj it reduces cross infection and also the needles used are of a very thin guage. It also gives great control on infiltration. They are self aspirating.. so no worry of retraction of needle on aspiration..

Murali Krishna: i know i am using

Nripjeet Singh Anand: Ok fellow doctors,if everybody is saying so i agree with the fact that LA might be contaminated after one use,my simple concern is that are we dentists ready to bear the cost of the loss that comes to us by throwing the 30ml bottles after each patient use,some of the big practitioners can as Dr Sekhar Reddy Sir has already mentioned that he does,question is how many of us can bear that loss because of the factors that happen to LA once it’s opened that Dr Sekhar Reddy Sir has already mentioned in the previous comment.Regarding my previous post i apologize to Dr Raj Gangula as i was a bit angry when he took to my family members to prove his point although i know unintentionally.

Murali Krishna: sekhar reddy why i am not able anaesthetise lower molars, frequently i am facing this problem. for extraction no problem but crown preparation and root canal treatment not able get sufficient anaesthesia.


Murali Krishna: i tried with intra ligament injection with a cartridge and gun , but not satisfied.




Nripjeet Singh Anand: What i have noticed is that giving LA in case of extraction,it is very effective,but in case of Root Canal,as soon as we try to open RC,patient starts to have pain and i have to give intra pulpal injections.



Virendra Kumar: HOW TO KILL FEAR

Nripjeet Singh Anand: ^^No matter how tense the atmosphere is,you lighten it all up,Good Work.

Virendra Kumar: “””TALK”””

Murali Krishna: with hypnotism you can do without LA, that is not the point hear, the point is how to minimise the pain with injection.

Raj Gangula: two things can be causing pain on opening a Rct.. 1. an inflammed PA area could be the cause of pain.. as soon as the bur touches teh tooth the vibrations from the bur reaches the PA tissues.. Thus causing pain.. solution to this support the tooth with ur mouth mirror/ suction if you do four hand dentistry. 2. could be because of a blunt bur/ ovr used handpiece with an unserviced cartridge.. check ur burs.. try and use a sharp bur as far as possible… check and get the hand pieces serviced regularly..


Raj Gangula: LA as we all know does not block the proprioception— sensation of touch

Raj Gangula: even most of teh crown preps are done just days after the RCT.. this again could cause pain due to same reasons.. Hence may be giving some time for tissues to recuperate can alleviate the pain of crown prep..!!! GURUS ADVICE!!!

Sreedhar Reddy: Cherukuri Murali Krishna garu, I overcome the problem by giving 5ml LA and waiting for 30 minutes before doing the RCT when doing a single sitting RCT. This helps but welcome to know more ways from others.

Murali Krishna: raj i tried everything i always use new bur for each patient, and i use good quality fiber optic titanium hand piece.

Sreedhar Reddy: Regarding Intra pulpal, its hell of a pain to the patient. Though I used to do it in college I dont much try it in my clinic. But Yes, its very effective.

Raj Gangula: I know about u bhayya, i have come across this problems myself many a times.. just trying to rule out the causes which are in our control- checking the armamentarium..

Murali Krishna: yes sreedhar it works some times, periostial infiltration also works, and intra ligament some cases.

Virendra Kumar: Murali Krishna when a patient comes to you , you greet him or you welcome him harsh words. First YOU SHOULD BE PLEASING , THEN YOU PROCEED WITH THE PROCEDURE. “”IAM A DOCTOR WHO LIKES TO SEE PATIENT SMILE WHEN HE/SHE LEAVES MY CLINIC””

Sekhar Reddy: Yes, talking to patient first and explaining things goes a longway. This is another important point. Suggested fear is better than imaginary pain.

Murali Krishna: i do agree with you virendra, everybody agrees with you but is this relevant hear.

Sekhar Reddy: One dentist I saw whenever he opens a bottle he empties all into 5 syringes and keep them at max for 24 hrs. I can see his point given the financial constraints and lack of availability of Catridges etc

Sekhar Reddy: Also when it comes to palatal infiltrations: perform the buccal or labial first and wait for some time before you give the palatal.

Murali Krishna: good idea but some patients suspects that ur not using sealed syringe


Murali Krishna: 2 ml in 5–6 mins, i can not hold that much of time

Sekhar Reddy: When it comes to the most painful injection of all the nasopalatine block: give the labial infiltration first and once the labial side is anaesthetised insert the needle in the maxillary suture near the apices of centrals and try n push hard local. You can only push a very tiny amount but it does help reducing pain of naso palatine block

Virendra Kumar: Then u “”Lack patience””.WHICH IS A MUST FOR..

Sekhar Reddy: Another important thing is as far as possible use isothermal solutions. It’s a normal tendency for ppl to keep the LA bottle in fridge. Very cold solution can be painful too

Murali Krishna: 1ml/60 sec is correct time as per my knowledge..

Sekhar Reddy: Avoid infiltrating near tendons, frenulum, inflamed areas etc

Murali Krishna: i don’t think anybody can hold inserted needle in the patient’s mucosa such a long time.

Sekhar Reddy: Gentle vibrations at ultrasonic frequency really helps

Murali Krishna: thank you dr. sekhar you raised a nice topic for discussion.

Sekhar Reddy: Vibrajet works on the same principle however it’s around 16k. But you try this cheaper one: just use electric tooth brush. Apply the back plastic surface of the brush over the cheek and switch on for a min or so before a buccal infiltration. Same principle could be applied for intra oral sites too, but you need a plastic sleeve to cover brush for cross infection control.

Sekhar Reddy: It should be ultrasonic brush

Murali Krishna: can we use local anaesthetic gels?

Virendra Kumar: Those r for topical applicationa

Murali Krishna: i know sir, i am asking how effectively these gels will aid in reducing injection pain.

Sekhar Reddy: Topical gels are very good to reduce the discomfort associated with injection.

Virendra Kumar: use chilled gel

Virendra Kumar: u know how to use them

Sekhar Reddy: There are 3 things that cause most of the pain 1) needle penetration through mucosa 2) deposition of solution 3) movement of needle

Sekhar Reddy: Gels help to decrease pain associated with insertion of needle

Virendra Kumar: I have never used them. Whether they should be used…… i don’t think so……..

Sekhar Reddy: WAND is another thing that needs mentioning here for completeness sake: it basically delivers solution very slowly at a constant pressure. Palatal injections with WAND: Studies have shown that infiltrations with WAND are very much appreciated by patients. However cost is a major issue.

Sarva Bowma Addepalli: Topical anaesthetic gel especially benzocaine 20percent, toothbrush ( electronic) massage together work wonders in a low budget. In a higher budget, WAND is the best.

Sarva Bowma Addepalli: And of course, slow injection with steady hands…

Sarva Bowma Addepalli: And passive fit in our palm is my technique…

Ravi Kumar Peratoti: i apply ice cube to pedo patients and some adults too .. believe me it works perfectly……

Ravi Kumar Peratoti: apply ice cube at the sight first and proceed with LA….

Sekhar Reddy: LA sprays. They can also be used for surface anaesthesia. However I find them cumbersome as its difficult to control the area of spread and often missing the target. I know an incident where dentist used quite good amount of spray to the patients palate but there was some inadvertent spread to the throat area. When dentist accidentally dropped a small instrument the patient aspirated it as his throat was numb. Just be cautious with sprays. I find gel is much better than a spray as its more user friendly and can be applied to the target area more efficiently.

Anthony Shieh: I have seen most dentists use the same needle to draw LA from the LA vial and inject it into the patient. When the needle is pressed into the LA rubber, it bends a bit and when it is introduced into the patient it tares as it enters causing more pain.

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