Armamentarium for Local Anesthesia

The Armamentarium
4 PARTS: 1) The Syringe 2) The Needle 3) The Cartridge 4) Preparation

THE SYRINGE

Types of Syringes
1) Non-disposable syringes a. Breech-loading, metallic, cartridge-type, aspirating b. Breech-loading, plastic, cartridge-type, aspirating c . Breech-loading, plastic, cartridge-type, self-aspirating d. Pressure syringe for periodontal ligament injection 2 ) Disposable syringe 3 ) Safety syrin ge 4 ) Computer controlled local anesthetic delivery systems

ADA Standards for Injection Syringes

1. They must be durable and able to withstand repeated sterilization without damage 2. They should be capable of accepting a wide variety of cartridges and needles from different manufacturers and permit repeated use 3. They should be inexpensive, self-contained, lightweight and simple to use with one hand 4. Provide aspiration so blood can be seen through the glass cartridge

Breech-Loading, Metallic, Cartridge-Type, Aspirating Syringe

-breech loading implies that the dental cartridge is loaded from the side -a needle is attached to the barrel of the syringe at the needle adaptor -the needle passes into the barrel and pierces the diaphragm of the local anesthetic cartridge

Aspirating Syringe
-the harpoon is a sharp tip attached to the piston and is responsible for penetrating the thick silicone rubber stopper (bung) at the other end of the cartridge - negative pressure is applied to the thumb ring by the administrator, if blood enters the glass local anesthetic cartridge (carpule) then the tip of the needle is inserted into the lumen of a blood vessel

Breech-Loading, Plastic, Cartridge-Type, Aspirating Syringe

Self-Aspirating Syringes
-incidence of positive aspiration is between 10-15% for some injections -aspiration before injection of local anesthetic is accepted in the practice of dentistry and is overlooked to a great extent

-these syringes use the elasticity of the rubber diaphragm in the anesthetic cartridge to obtain the necessary negative pressure for aspiration - multiple aspirations are possible with very little effort due to a small metal projection that applies pressure to the rubber diaphragm when the thumb ring is depressed negative pressure aspiration -this type of aspiration is as reliable as using the harpoon to check for blood aspiration

-Major factor for aspiration is the gauge of the needle being used
-Most doctors using the harpoon-type syringe, retract the thumb ring back too far and with excessive force which frequently disengages the harpoon from the silicone rubber stopper of the cartridge

-1st generation self-aspirating syringes required a thumb disk which forced the operator to remove their index and middle fingers from the thumb ring to the thumb disk to aspirate -2nd generation self-aspirating syringes have removed this thumb disk -Dentists only need to stop applying pressure to the thumb ring for aspiration; aspiration becomes very easy to do

Pressure Syringes
-PDL (intraligamentary) injections make it possible to achieve single tooth pulpal anesthesia in the mandible when, in the past, complete IANB was necessary

-pressure syringes can allow too easy of an administration of local anesthetic producing pain and post-operative discomfort -pressure syringes are expensive > $200.00 -can shatter glass cartridge if too much pressure is applied too quickly

2000 psi Jet Syringes ($1,600)

-needle-less injection -liquids forced through very small openings, called jets, at very high pressure can penetrate skin or intact mucous membrane -Syrijet is the most popular used today -Syrijet holds any 1.8 ml cartridge of local anesthetic

-Syrijet is calibrated to deliver .05 to .2 ml of solution at 2000 psi; traditional syringes deliver 600 psi maximum -primary use is to obtain topical anesthesia before using a needle -regional nerve blocks/supraperiosteal injections are still necessary -topical anesthetics provide the same effect at a fraction of the cost -patients complain of soreness where the 2000 psi hit their tissue

Disposable Syringes
Luer-Lok screw on needle Manual aspiration No cartridges Definitely preferred when diphenhydramine is used as LA

Safety Syringe

-Aspiration is possible -some brands come with an autoclavable plunger and disposable self-contained injection unit -all dental safety syringes are made to be single use items

-sliding the index and middle finger forward against the front collar of the guard makes the needle safe by sliding a protective plastic sheath over the needle tip that locks into place -more expensive than reusable syringe units -large disadvantage arises when it comes to re-injecting; complication ensues due to the needle tips newly acquired safety coping

CCLAD (Computer Controlled Local Anesthetic Delivery) The Wand

-designed to improve ergonomics and precision of injection technique -foot activated delivery of solution using finger tip precision -pen-like grasp offers increased tactile sensation -flow rates of solution delivery are computer controlled and remain consistent

- operator is able to focus attention on the position of the needle tip while the motor of the machine delivers local anesthetic at a preprogrammed rate of flow

-The Wand is less threatening to the patients visually -allows two rates of delivery: 1) Slow: .5 ml/minute 2) Fast: 1.8 ml/minute -releasing the foot rheo-stat will tell the machine to aspirate automatically; the aspiration cycle is approximately 4.5 seconds

THE NEEDLE

Parts of Needle

Important Factors
Bevel Gauge Length

Problems
Pain on insertion Breakage Pain on withdrawal Injury

CARTRIDGE

Cartridge
1.8 mL (United States) 2.2 mL (UK and Australia) should not be autoclaved stored at room temperature (21 C to 22 C (70 F to 72 F) should not soak in alcohol should not be exposed to direct sunlight

Problems
Bubble in the cartridge Extruded stopper Burning on injection Sticky stopper Corroded cap Leakage during injection Broken cartridge

Additional armamentarium
Topical antiseptic Topical anesthetic Applicator sticks Cotton gauze Hemostats