Successful local anesthetic administration and subsequent profound anesthesia may be the number one behavioral management tool a dentist can employ that will lead to a successful appointment with your pediatric patient. The most common reasons for referral to the pediatric dentist are that the child would either not cooperate for the local anesthetic injection or was in pain once the dentist started treating the tooth. My experience with children over the last seven years has made it very clear to me that great local anesthetic technique is the key to a rewarding and successful treatment session of a youngster, or any patient for that matter. Once a child feels pain or discomfort, it often becomes increasingly difficult to bring the patient back to a “happy” place. It may then require additional behavioral management techniques and a strong understanding of child psychology to accomplish that goal. More than 60% of the time, profound local anesthesia and good technique are all it takes to eliminate stress, fear, and anxiety for everyone involved. Here are some tips that can make you and your next pediatric patient feel more comfortable for their dental treatment.
TIP #1 USE YOUR WORDS VERY CAREFULLY
This means relating to the age of your patient. For instance the word “shot” is a four-letter word for a reason. The connotation of this word invokes fear into the hearts of almost everyone, especially children. I’m not telling you to lie, but I suggest you soften the wording by using words such as “sprayer” so that you may “spray” some of the sugar bugs to sleep. Keep in mind that this verbiage will not be the same for the older kids.
The word “hurt” and “pain” are more examples of four letter words that I stay away from. Most of the time, young children coming to the dentist for their first treatment do not have a preconceived notion of what is about to take place. This is your chance to positively shape their future dental experiences, as well as their immediate experience, in your chair. We have the capability to make this a fun visit or, at the very least, a comfortable visit. It all starts with the words you choose to use. I learned this early in my career from Dr. Don Duperon at UCLA who is a master of words when it comes to behavioral management of the pediatric dental patient. Choose your words carefully.
TIP #2 TOPICAL OR NOT TO TOPICAL, THAT IS THE QUESTION
I know there are a lot of dentists out there who feel that topical anesthetic is the key to a painless injection. My personal opinion, and the opinion of over 50 years of combined experience in our group practice, is that it is not the number one prelude to a painless injection. The application of topical anesthetics, including 10%-20% Benzocaine, EMLA creams and patches, sprays, etc., can be a nice adjunct to the delivery of the local anesthetic, however, it can also be the first step in “losing” your child patient if they taste it or swallow it. For this reason, I do not employ the routine use of topicals for mandibular block injections for young children. I will consider its use for older children and adolescents if I can isolate the field well enough with a 2X2 cotton gauze to allow the topical to stay in place for a minimum of 20 seconds. The real benefit of using the topical anesthetic comes from drying the mucosal tissue and leaving it in place between 20 seconds and one minute. This can readily be achieved for maxillary injections, especially in the anterior region. I vote for great technique over the application of topical anesthetics any day.
TIP #3 STRETCH IT OUT
This is where the technique is critical and needs to be practiced. For any injection, the mucosa should be stretched thin, to the point that you can see the capillaries webbed just beneath the mucosal surface. For maxillary infiltrations, place the thumb and forefinger around the lip, with the index finger placing light pressure in the vestibular area. Apply direct pressure with the index finger in the vestibular area toward the maxilla while slightly pulling the lip out laterally. Have your patient tilt their head up by lifting the chin. This will not only allow for better visibility for you, but it will also prevent you from having a conversation with your patient about what that shiny thing is doing in your hand. Place the tip of the needle just above the mucosa and lift the mucosa into the bevel of the needle. Express a few drops and resume your initial position. This may be accompanied by a host of distraction techniques described in tip #4. Sometimes I will walk away after the few drops have been expressed and return to finish the anesthesia in a couple of minutes after the initial site has been numbed. Septocaine for children over age 4 works very fast in these areas. This technique works the same for the mandibular block. In this case, use your thumb to stretch the mucosa in the retromolar area and pull forward into the bevel of the needle.
TIP #4 DISTRACTION
Distraction techniques may include massaging or shaking the patient’s lip during local administration, talking to the patient about unrelated events, and using visual aides such as video games, which we employ in our office. Recent studies show that video games and television can reduce children’s anxiety and fear related to undergoing medical and dental treatments. I like to call it “video game analgesia.”
TIP #5 MAPQUEST YOUR LANDMARKS
Feel your way to success with local anesthetic. For the mandibular block, the most reliable way to get there is to hold the anterior ramus with your thumb and the posterior ramus above the notch with your middle finger, and aim for an inch anterior to your middle finger. Aim for this target while using the mesial of the first primary molar as a starting point. Since a child’s mandibular nerve exits through the foramen at a slightly lower level than in an adult, aim lower but parallel to the occlusal plain. Always feel for bone. Don’t sound for bone prior to unloading 1/8 to 1/4 carpule of lidocaine (or equivalent) close to your end point, or the child may feel it.
I know I may get some flack for this next one, but I would be holding out on you if I didn’t tell you to occasionally bend the needle at the hub at about 20 degrees and reinforce your block if you did not feel bone. Sometimes you need to “swing” the needle around the lingual to get your mark. Every child’s anatomical landmarks are different, which means you have to not only be visually aware of the differences, but also feelthe differences. Be very gentle. A good mandibular block technique will save you time, money, and create goodwill with your patients.
Most of you use one or more of these tips described above but haven’t mastered the art of putting it all together. Stay tuned for a part II to Local Anesthetic Tips for the Pediatric Patient. Next time we’ll discuss how to extract a tooth without giving a palatal injection, “guiding” the anesthetic where you want it to go, a cheap alternative to expensive automatic local anesthetic delivery systems, and alternatives to a mandibular block for the pedo patient.