around the palatal gingival margin (184HFigs. 5.11, 185H5.12, and 186H5.13). With practice this
technique can be used without the needle breaching the palatal mucosal surface,
which prevents the unpleasant-tasting solution inadvertently appearing in the mouth.
This method usually provides sufficient anaesthesia for extractions; however, it may
be supplemented by a painless gingival sulcus injection on the palatal side.
Mandibular anaesthesia
Inferior alveolar nerve block injections can be uncomfortable, but infiltration
anaesthesia is not successful in the posterior permanent dentition. Alternatively,
intraligamental (pdl) injections may be employed to anaesthetize the posterior
mandibular teeth. This technique is not very successful in the lower permanent
incisors. This is probably due to a paucity of perforations in the cribriform plate of
lower incisor sockets. As mentioned above infiltration anaesthesia is the method of
choice for the incisor teeth. Lingual anaesthesia can be obtained by chasing through
the buccal papillae as described for palatal injections above.
Studies in adults have suggested that pdl techniques are less unpleasant than
conventional methods, but many children find delivery of anaesthetic solution via the
pdl uncomfortable. The discomfort can be overcome by using the following methods.
The mesial buccal papilla can be treated with topical anaesthetic applied with
pressure. While pressure is still being applied, a papillary injection is administered
followed by the intraligamental injection. As conventional topical local anaesthetics
are not very effective on attached gingiva this method is not successful with all
children. Alternatively, a small-dose buccal infiltration is given apical to the tooth
(this can be given as one depression of the pdl syringe). This is followed by a
papillary injection, which now should be painless, and finally by the intraligamental
injection (187HFigs. 5.14, 188H5.15, and 189H5.16). Lingual gingival anaesthesia is obtained via the
pdl by directing the needle through the interdental space (190HFig. 5.17).
The techniques described should produce minimal discomfort during local anaesthetic
administration in children. When these methods are combined with relative analgesia
the production of injection pain is even less likely to arise. When pain-free reliable
local anaesthesia is achieved in children confidence is gained both by the child and
the operator, and a sound basis for a satisfactory professional relationship is
established. This means that many of the treatments traditionally performed under
general anaesthesia (such as multiple-quadrant extractions and minor oral surgery)
can readily be performed in the conscious sedated child.
191H
Fig. 5.9 Buccal infiltration injection in
the upper primary molar region. (By
kind permission of Dental Update.)