Giving local anaesthetic: managing pain

OK. So that’s to extract them. What about the pain? And in most circumstances, it should be possible to give pain free local anaesthesia. And I think if your patients are regularly experiencing pain when you give injections, you’re probably doing something wrong. OK. And the most common issue for me is people don’t take the time. But let’s walk through in steps. First one, big one, obviously is topical. We put topical on with a cotton wool bud. Make sure it’s on for long enough, a good one to two minutes yet, and put it on and then bang stick the local in don’t wait. And maybe think about drying the mucosa before use as well.

Often that can make the topical work a little bit better. There’s lots of saliva around, that saliva wash the topical away. Clearly that’s not going to work as well. Put your local in when you inject, slow and steady. OK, take your time. If you put the local in quickly, it’s going to be more uncomfortable. If you take your time given the local it’s going to be more comfortable for the child. And remember to control the head. Make sure you’ve got their head in a good headlock. If they’re moving their head around, maybe your needle will touch the bone, they can feel that, maybe you’ll miss your injection spot. So it’s really important to get some good head control. OK.

Most injections, most infiltrations should be pretty straightforward to do. I do think avoiding touching the bone is an important one. One injection a lot of us have trouble with are palatal injections. And there are ways that are giving palatal injections that are non painful. Now I know the photo on the slide isn’t a palatal injection it’s of a lower 5 and six. But the principle I’m trying to illustrate here is giving that into papillary where you get that blanching. Because give a palatal you start off by giving a good buccal. Yeah, just put a buccal filtration in. Then you give intrapapillaries medially and distally to the teeth to get that blanching.

And you take your injection needle and you come in parallel to the occlusal plane. And you go through the papillar really slowly, squeezing as you go along. Until your needle is just under the mucosa on the palatal side. And that way you can give a palatal injection and get some palatal blanching. Once also got palatal blanching palataly, then you can go and give a proper palatal in a way that’s not uncomfortable. So there are ways of giving palatal injections that children won’t feel. Yeah. And actually you can do this on adults as well. OK. An important part of managing giving injections is also managing failure as well.

And actually, one thing that’s not on the slide, is sometimes if I’m giving an injection maybe you might just catch them or they might feel something. So I think it’s always important to be quick to react if that happens. And after, what I’ll do, is I’ll again, it’s a tip I’ve taken from someone else. I might say, oh, my nails are a bit long, maybe my now caught you. And that can distract them. But a more common error of failure is particularly if you have very abscessed teeth. And actually, if you’ve got a tooth with a really severe abscess, we know that sometimes the local anaesthetic won’t work.

And probably, in those circumstances, if possible, it’s better to resolve the abscess first. So that could be through incise and drained, or it could be through draining through the tooth, or it could be through antibiotics. But get the infection sorted out. And then try and take the tooth out. There’s nothing worse than a child who’s got a really big swollen face and a really big infection, and you’re trying to take it out and the local work. You’re just making things worse. So do anticipate failure. If the local doesn’t work, sometimes be patient. Maybe you need to wait a little bit longer. Particularly with ID blocks, maybe wait five minutes, 10 minutes.

And a tip I was often taught was pop them out to the waiting room for five or 10 minutes. Just let it work. And finally, try a different drug. So I usually start off with lignocaine, but if it’s really clear that’s not working, then I might switch and put some articaine on top. And talking about lignocaine and articaine, I think before we finish let’s just think about what’s the best local anaesthetic to use. And I think in most circumstances nowadays we would use lignocaine. We don’t tend to use prilocaine anymore. There’s not really any indication to use it with cardiac patients. And it tends to have a very short mode of action, perhaps a little bit too short.

There’s a review that I’m talking from here, and in that Cochrane review they suggest that articaine may have some benefits in posterity’s through irreversible pulpitis. But lignocaine possibly produces less post injection pain than articaine. So I think that lignocaine is probably the material would use in most circumstances. One other thing to touch on are thinking about these computer controlled injection devices, the ones the most commonly used one, but I think there are others manufacturers out there now. And what they do is that they deliver the local anaesthetic in a very slow measured way from a non-threatening machine. And it doesn’t look like an injection. Maybe think about those as well.

I don’t think I can recommend that you use them exclusively, but I think they’re a useful tool in our armamentarium when we’re trying to give local to children in a pain free non frightening way. So in summary, it’s really important. In fact, I think it’s probably the most important paediatric dentistry skill is being able to provide treatment in a pain free way. That means local anaesthetic. And for me, the essential, the key for getting a good local anaesthetic it’s all around distraction. So I think if you can master that, then I think you’re on your way to becoming a really excellent paediatric dentist. Good. Thank you very much.