EARN This course was

2CREDITS
CE written for
dentists,
dental hygienists,
and assistants.

Pain-reducing techniques for

delivery of dental anesthesia
A Peer-Reviewed Publication
Written by Doctor Fady Haddad

PUBLICATION DATE: JUNE 2018

EXPIRATION DATE: MAY 2021

SUPPLEMENT TO
PENNWELL PUBLICATIONS
EARN

2CREDITS
CE This educational activity was developed by PennWell’s
Dental Group with no commercial support.

This course was written for dentists, dental

hygienists and assistants, from novice to skilled.

Educational Methods: This course is a self-

instructional journal and web activity.

Provider Disclosure: PennWell does not have

a leadership position or a commercial interest in
any products or services discussed or shared in
this educational activity nor with the commercial
supporter. No manufacturer or third party has had any
input into the development of course content.

Requirements for Successful Completion: To

obtain 2 CE credits for this educational activity you

Pain-reducing techniques for

must pay the required fee, review the material,
complete the course evaluation and obtain a score of
at least 70%.

delivery of dental anesthesia CE Planner Disclosure: Heather Hodges, CE

Coordinator does not have a leadership or commercial
interest with products or services discussed in this
educational activity. Heather can be reached at
ABSTRACT hhodges@pennwell.com
Dental anxiety is a major factor in the decision to delay dental procedures. “Dental Educational Disclaimer: Completing a single
fear is related to poorer oral health outcomes, and this might be explained by the continuing education course does not provide enough
information to result in the participant being an
less frequent dental visiting of many fearful people.”1 Fear of dental injections is expert in the field related to the course topic. It is a
frequently cited as the main source of dental anxiety. We, as practitioners, can take combination of many educational courses and clinical
experience that allows the participant to develop skills
simple and easily implemented steps to reduce the fear and pain of dental injec- and expertise.
tions. No special equipment or training is required. Following these techniques Image Authenticity Statement: The images in this
may result in more profound anesthesia, less pain on injection, and ultimately a educational activity have not been altered.

reduction in dental anxiety. A calm and comfortable patient will often result in less Scientific Integrity Statement: Information shared
in this CE course is developed from clinical research
stress for both patient and provider. and represents the most current information available
from evidence based dentistry.

EDUCATIONAL OBJECTIVES Known Benefits and Limitations of the Data:

The information presented in this educational activity
The objective of this article is to give the reader easy-to-follow techniques for de- is derived from the data and information contained
livery of dental anesthesia. Upon completion of this course, the dental provider in reference section. The research data is extensive
and provides direct benefit to the patient and
should have a clear understanding of: improvements in oral health.
1. The proper use of topical anesthetic Registration: The cost of this CE course is $49.00 for
2. The least painful method of injection 2 CE credits.

3. Effective use of psychological preparation of the patient to receive anesthesia Cancellation/Refund Policy: Any participant who is
not 100% satisfied with this course can request a full
refund by contacting PennWell in writing.

Go Green, Go Online to take your course

www.DentalAcademyofCE.com PennWell designates this activity for 2 continuing educational credits.

Dental Board of California: Provider 4527, course registration number CA# 02-4527-15319
QU I CK AC C E S S C O D E 15319 “This course meets the Dental Board of California’s requirements for 2 units of continuing education.”
The PennWell Corporation is designated as an Approved PACE Program Provider by the
Academy of General Dentistry. The formal continuing dental education programs of this
program provider are accepted by the AGD for Fellowship, Mastership and membership
maintenance credit. Approval does not imply acceptance by a state or provincial board of
dentistry or AGD endorsement. The current term of approval extends from (11/1/2015) to
(10/31/2019) Provider ID# 320452.
 DENTAL ACADEMY OF CONTINUING EDUCATION

INTRODUCTION applied with the edge of a mirror can provide significant pain reduction
A typical day for a dental provider will inevitably contain a patient who immediately prior to the injection. To accomplish this, apply pressure
has dental phobia. If a practitioner has been practicing long enough, on the injection site until the tissue it noticeably blanched. Maintain
an all-too-familiar pattern will emerge. It seems that the patients with the pressure for five seconds and start your injection while the tissue
the worst dental health are those who have the most anxiety. This is is still blanched. Release the pressure from the mirror slowly as you are
not likely a coincidence. Avoiding dental care is frequently a reaction giving the injection. This will give the tissue more space to accom-
for those who fear it. The consequence to the patient is often more modate the anesthetic solution.
decay, more periodontal disease, and, ironically, more need for dental Other modes of topical anesthetic delivery include sprays, creams, and
care. “Anxiety has a direct influence on oral health; it should be detected patches. It is advisable to try each method and evaluate which method
and accounted for in a treatment concept integrating dental and cogni- gives you the best results. When used properly, topical anesthetic can be
tive behavioral therapeutic approaches.”2 The consequences to the effective in reducing pain during a dental injection. “The use of topical
dental provider should not be overlooked. A stressed-out patient can anesthetic did reduce the pain of needle insertion with the maxillary
be less cooperative, less compliant, and can pose a challenge to the anterior injections (P = .0041).”4 It also provides the added benefit of a
delivery of ideal dental care. “Patients with dental fear tended only to psychological anticipation of less pain. Although studies conducted on
visit a dentist when necessary, avoiding regular visits.”1 Of all the reasons the effectiveness of topical anesthetic are conflicted, you are denying your
that patients state for fear of dental procedures, pain of dental injec- patient the placebo effect if you don’t use it at all. Combining topical
tions is always a major factor. If the dental provider can reduce that anesthetic with simple pain-reducing injection techniques will result in
pain, there will be immediate benefits to both provider and patient. A an improved dental experience for you and your patient.
relaxed patient will achieve more profound anesthesia, better coopera-
tion, and reduced fear of future dental visits. This can be accomplished PSYCHOLOGICAL PREPARATION
easily and immediately. No special equipment is required. Only a little The pain associated with dental injections begins before the needle is
extra time and TLC are needed. even in the patient’s mouth. Patients with high dental anxiety will
anticipate pain, which in turn will exacerbate the intensity of the pain.
TOPICAL ANESTHETIC “The high-AS group reported significantly more anticipatory fear and
Topical anesthetic is typically a gel solution of 20% benzocaine or lido- pain prior to the CPT, which appeared to aggravate subjective pain
caine with flavoring agents. “Topical anesthetic products are in the experiences.”5 Tissue pressure as a result of the bolus of anesthetic solu-
form of sprays, solutions, gels, and ointments. There is a wide range of tion can cause more pain than the penetration of the needle. Positive
indications for topical anesthesia in dentistry, and a specific agent reinforcement during the injection procedure can be beneficial in re-
should be chosen in accordance with the purpose of its use.”3 Topical ducing a patient’s anxiety. “It is suggested [that] needle penetration is
anesthetic is underutilized in many dental practices. Often, dental not the main reason of pain during injection. Inconsistent fluid pressure
providers will find it to be ineffective and abandon the use of it. While created by injected anesthetic solution on nerve fibers is more impres-
it does not provide complete pain relief of injections, it is just one sive in pain development.”6
method of making injections a little better. Topical anesthetic works Before starting the injection procedure, talking to the patient will
very well on mucous membranes. Dental care providers have a con- give the practitioner an estimation of the patient’s level of anxiety.
siderable advantage in that our injections are mostly started on mucous Positive reinforcement will reduce the patient’s anxiety and let them
membranes. In order for topical anesthetic to be effective, there are know what to expect. Telling the patient “This is not going to be very
some important steps to take before placing it. First, the mucous painful,” or “This will take a little bit longer than usual but will be almost
membrane must be as dry as possible. Before placing the topical an- painless,” will reduce the patient’s anticipation of pain. A simple dis-
esthetic, be sure to dry the injection site with an air/water syringe. This tracting statement right before injection will also help keep the patient
simple step will make a big difference. Applied to a wet site, topical from dwelling on nothing but the slightest sensation of pain. Asking
anesthetic will simply dissolve away with minimal penetration into the the patient to open as wide as possible just before injection is an excel-
tissue. The patient will likely complain of the taste and the throat going lent way to both distract the patient and create tension in the tissue
numb. Drying the site will keep the topical anesthetic right where it at the injection site. Tissue tension on the injection site seems to reduce
needs to be—on the site of the impending injection. A cotton-tip ap- the pain of needle insertion significantly.
plicator is the ideal disposable tool for placing the topical on the injec- During the injection, it can be beneficial to the patient’s morale to
tion site. Once it is placed on the dry site with the cotton-tip applicator, tell them that everything is going well and that the procedure is almost
pressure should be applied to the site for thirty seconds. The pressure complete. Often, with the proper use of topical anesthetic, the patient
will allow the topical anesthetic to penetrate deeper into the mucous will not even feel the insertion of the needle, and therefore, not know
membrane, and give you the added benefit of reducing blood supply when the procedure has begun. By giving them the positive reinforcing
to the site of injection. This temporary reduction of blood supply will message that they are already being injected and not experiencing pain,
significantly reduce the pain of injection. the anticipation of pain will be all but eliminated.
Topical anesthetic is effective in most areas of the mouth. However, Once the injection is completed, it is important for the patient’s
due to the thickness of the epithelium on the palate, topical anesthetic peace of mind to let them know that it will take about five to ten minutes
is less reliable for palatal injections. For palatal injections, pressure for the onset of anesthesia.

www.DentalAcademyOfCE.com 3
 DENTAL ACADEMY OF CONTINUING EDUCATION

Box 1
is advisable to maintain the gating
ONSET OF DURATION
EFFECTIVENESS technique throughout the dura-
ACTION AFTER OF ACTION
tion of the injection.
Articaine 5 min 1-3 hours 3
Bupivacaine 8 min 3-7 hours 16 CONCLUSION
Managing dental anxiety is often
Lidocaine 5 min 1
/2-2 hours 4
the most challenging part of the
Mepivacaine 3 min 2-21/2 hours 2 clinician’s day. By implementing
these simple techniques, we can
Prilocaine 2 min 1
/2-1 hour 1 create a stress-free experience for
our patients and ultimately for
Pharmacology of local anaesthetics. A. L. Frankhuijzen ourselves. Once a patient loses the
By knowing that the practitioner is going to wait until the anesthetic fear of dental injections, future
takes full effect, the patient’s anxiety levels will be further reduced, thus appointments will become more
allowing a more profound level of anesthesia to take effect. acceptable, resulting in greater
case acceptance and fewer missed
INJECTION TECHNIQUES appointments. Use topical, inject
Immediately after insertion of the needle tip, injecting a small amount slowly, praise often, and have a
of anesthetic will reduce the pain of further insertion of the needle. great experience.
AUTHOR PROFILE
Advance the needle slowly while constantly injecting small amounts
of anesthetic. About one quarter of a standard size carpule can be used REFERENCES Doctor Fady Haddad is a
to reduce the pain of advancing the needle. Once the needle is near 1. Armfield JM. Predicting dental graduate of the University of
avoidance among dentally fearful Maryland Dental School class of
the targeted area, injection of the remainder of the carpule can begin.
Australian adults. Eur J Oral Sci 2000. After graduation Dr. Haddad
It should take about a minute to inject a carpule of anesthetic. The (2013) June;121:240–246. entered private practice. He
slower, the better. Injecting very slowly allows the tissue to absorb the 2. Eitner S, Wichmann M, Paulsen A, purchased a practice in 2001
anesthetic without creating a large bolus of solution. This will result Holst S. Dental anxiety – an and has since provided outstanding
in less pressure on the innervation of the target site. Once the desired epidemiological study on its clinical care to the Pasadena
clinical correlation and effects on Maryland area.
amount of anesthetic is injected, remove the needle following the same
oral health. Journal of Oral
path as insertion. The tissue around the needle should be sufficiently Rehabilitation (2006) 33:588-593.
anesthetized to allow for a painless ejection of the needle. doi:10.1111/j.1365-
Palatal injections are often cited as the most painful of the dental 2842.2005.01589.x.
injections. Since palatal injections are frequently given in conjunction 3. Hyo-Seol L. Recent advances in
topical anesthesia. J Dent Anesth
with alveolar injections, it is often better to start with the alveolar injec-
Pain Med. (2016) Dec;
tion and end with the palatal injection. Topical anesthetic does not 16(4):237-244.
absorb into the palatal tissue very well, but anesthetic injected in the 4. Nusstein JM, Beck M. Effectiveness
buccal area can often lead to some numbing of the palate. Applying of 20% benzocaine as a topical
pressure to the injection site on the palate with finger pressure or a anesthetic for intraoral injections.
Anesthesia Progress. (2003)
mirror head until the tissue blanches will result in a noticeably less
50(4):159-163.
painful experience for the patient. 5. Dodo N, Hashimoto R. The effect of
anxiety sensitivity on psychological
THE GATING TECHNIQUE and biological variables during the
The gating technique operates on the hypothesis that the brain cannot cold pressor test. Auton Neurosci.
(2017) July;205:72-76.
process the signals of pain and proprioception simultaneously. To utilize
6. Ghaderi F, Ahmadbeigi M. Pain
this technique, vibration of the needle should be applied in conjunction perception due to dental injection
with injection of the anesthetic. There are many devices available on by Smartject: split mouth design
the market to aid in accomplishing this technique. While these devices study. Journal of Dentistry. (2018)
are optimal for use in the gating technique, simply shaking the patient’s 19(1):57-62.
cheek with a mirror during the injection can mimic the effects of the
gating technique. Since patients are often most apprehensive about
the initial injection of the syringe, it may be beneficial to begin shaking
the patient’s cheek prior to initiating the injection. If the patient is
unfamiliar with the gating technique, the added distraction of trying
to comprehend your actions may be an additional welcome benefit. It

4 www.DentalAcademyOfCE.com
 DENTAL ACADEMY OF CONTINUING EDUCATION
ONLINE COMPLETION QUICK ACCES S CO DE 15319
Use this page to review the questions and answers. Return to www.DentalAcademyOfCE.com and sign in. If you have not previously purchased the program select it from the “Online
Courses” listing and complete the online purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the “Take Exam” link, complete
all the program questions and submit your answers. An immediate grade report will be provided and upon receiving a passing grade your “Verification Form” will be provided immediately for
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QUESTIONS

1. Dental anxiety is a major factor in the 8. topical anesthetic is less reliable in thick 14. Prior to placing topical anesthetic:
decision to epithelium such as is located in the a. soak the area with water
a. avoid local anesthetic a. palate b. dry the area with air spray
b. delay dental procedures c. apply pressure to the tissue
b. buccal vestibule
c. disregard vital signs d. rinse the mouth with a chlorhexidine
c. frenum
d. none of the above
d. none of the above solution
2. Which of the following was quoted as
9. Other modes of topical anesthetic 15. Prior to giving a palatal injection you
saying: “Anxiety has a direct influence on
should:
oral health…” delivery include
a. apply pressure to the site until the tissue is
a. Eitner et al. a. sprays
blanched
b. Eisner b. creams
b. position the patient in an upright position
c. Einstein c. patches
c. apply topical anesthetic for at least 15
d. GV Black
d. all of the above minutes
3. Topical anesthetic is typically a gel
10. According to Ghaderi and Ahmadbeigi d. none of the above
solution containing
a. 20% benzocaine what is created by injected anesthetic 16. Pain associated with dental injections:
b. 80% lidocaine solution on nerve fibers a. begins after half the carpule is injected
c. flavoring agents a. a loose bolus b. begins before the needle is even placed
d. a and c b. Inconsistent fluid pressure c. is not the concern of the provider
4. In many dental practices, topical c. high pressure systems d. is not a factor in the delay of dental care
anesthetic is often 17. Topical anesthetic:
d. b and c
a. underutilized a. is more effective than a placebo
11. Immediately after insertion of the
b. overutilized b. is less effective than a placebo
c. not used as directed
needle tip, the pain of further insertion
c. is equally effective to a placebo
d. abandoned of the needle will reduce by injecting a
d. varies in effective by flavoring agents
5. Topical anesthetic works well on a. bolus of saline
18. Once the injection is completed you
a. enamel b. large amounts of lidocaine should:
b. dentin c. i.v. drip a. begin the procedure right away
c. hard tissue d. small amount of anesthetic b. wait 8-10 minutes
d. mucous membranes
12. Which of the following operates on the c. have the patient walk around the waiting
6. For topical anesthetic to be effective, the
hypothesis that the brain cannot process room
mucous membrane must be
the signals of pain and proprioception d. wait 20-30 minutes
a. as dry as possible
simultaneously 19. Prior to injection, it can be beneficial to:
b. as wet as possible
a. talk to the patient
c. moistened with saliva a. Gow Gates
d. coated with a lubricant b. reprimand the patient for poor oral hygiene
b. The Gating Technique
7. Once the topical anesthetic it is placed c. play loud music
c. substance P
on the dry site with the cotton tip d. remove all staff from the operatory
d. a and c
applicator, pressure should be applied to 20. Drying the tissue prior to placement of
13.Topical Anesthetic can take the form of: topical anesthetic will:
the site for.
a. Gel a. activate the active ingredients
a. 30 seconds
b. 3 minutes b. Cream b. spread it more efficiently
c. 2 minutes c. Spray c. concentrate it where it is placed
d. 10 seconds d. All of the above d. none of the above

www.DentalAcademyOfCE.com 5
 PUBLICATION DATE: JUNE 2018 ANSWER SHEET

Pain-reducing techniques for delivery of dental anesthesia

EXPIRATION DATE: MAY 2021

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