DEN 035: Anesthesiology (Lecture)

Student Activity Sheet Module #14

Name:______________________________________________________________ Class number: _______

Section: ____________ Schedule: ______________________________________ Date: _______________

LESSON TITLE: SUPPLEMENTAL TECHNIQUES MATERIALS:

Ballpens, erasers, pencils,
LESSON OBJECTIVES: highlighter, scratch paper and
At the end of the module, you will be able to: module
1. Familiarize the different supplemental techniques used in the field
of Dentistry. REFERENCES:
2. Know the specific indications for each technique.  Handbook of Local
Anesthesia 4th Edition,
Stanley F. Malamed. (1997)

PRODUCTIVITY TIP:
Good day! You are about to start your module. Do short stretching and breathing exercises. After you are done, sit
down, be comfortable and say a short prayer. You are now ready to start your work. Enjoy and learn!

A. LESSON PREVIEW/REVIEW
Introduction (2 minutes)
Welcome to DEN 035: Anesthesiology (Lecture) ! The module today will focus on the basic knowledge
on the supplemental techniques used aside from what has been previously discussed in SAS 12 and
13. This will aid you in other Dental procedures wherein supplemental techniques are required.

Activity 1: What I Know Chart, part 1 (3 minutes)

Kindly fill up the column “What I Know” only for Activity 1. The third column “What I Learned” should be
left blank as it will be answered later on when you reach Activity 4.

What I Know (Activity 1) Questions: What I Learned (Activity 4)

1. Why do we need to use
supplemental injection
techniques?
2.Give one example of a
supplemental technique.
3. Which among the supplemental
technique is painful upon delivery
of local anesthesia?

B.MAIN LESSON
Activity 2: Content Notes (10 minutes)

SUPPLEMENTAL INJECTIONS
It is not uncommon for different techniques and/or supplementation to conventional injection techniques to be
necessary. Diffificulty in anesthetizing a particular tooth due to pulpal inflflammation or a short procedure on a
single tooth where prolonged soft tissue anesthesia would be undesirable are examples of these type of
scenario.

This document is the property of PHINMA EDUCATION

 DEN 035: Anesthesiology (Lecture)
Student Activity Sheet Module #14

Name:______________________________________________________________ Class number: _______

Section: ____________ Schedule: ______________________________________ Date: _______________

The four supplemental injections that are most useful are:

1. Intraosseous
2. Periodontal ligament (PDL)
3. Intraseptal
4. Intrapulpal

The intraosseous, PDL and the intraseptal techniques all rely on local anesthetic either diffusing or being
deposited into the cancellous bone surrounding the tooth or teeth to be treated which effectively anesthetizes
the dental plexus of nerves innervating these teeth. When using these techniques, it must be appreciated that
only short procedures should be considered as the duration of pulpal anesthesia is short.

1. Intraosseous
Intraosseous anesthesia has been around for more than 100 years. This technique, until the 1990’s,
involved perforation of the cortical bone with a small round bur and then inserting a needle through this
perforation into the cancellous bone. Today however, intraosseous systems such as stabident and X-tip,
use a perforator that is placed in a slow speed contra-angle handpiece which penetrates the cortical
plate of bone. This is followed by delivery of anesthetic through the small perforation with an ultrashort
27 gauge needle.

Indications:
1. Failed anesthesia (i.e., “hot tooth”)
2. Can be used when pulpal anesthesia is desired without accompanying soft tissue anesthesia
3. Short procedures on 1 or 2 teeth
4. As an alternative to bilateral inferior alveolar nerve block
5. Use in areas of thick cortical bone

Disadvantages:
1. Inadequate interseptal bone between teeth
2. Special equipment/cost ( $1/delivery)
3. Inability to fifind “pilot hole” with needle
4. Short duration of anesthesia
5. Pronounced tachycardia if vasoconstrictor used

Technique:
1. Ideally the injection site should be just distal to the tooth being treated
2. Place topical and then inject a minimal amount of anesthetic to anesthetize the gingiva
3. Penetrate the tissue (2-3 mm below the facial gingival sulcus) with the pilot perforator until bone is
contacted. Carefully activate handpiece and penetrate cortical plate of bone and resistance is lost.
4. Insert 27 gauge needle into pilot hole and administer no more than 1/3 to 1/2 cartridge slowly

2. Periodontal Ligament Injection (PDL)

The PDL injection is a technique that has been utilized since the early 1900’s. Since the introduction of
the pressure syringes (Peripress, Ligmaject) in the 1980’s, the technique has gained in popularity. However,
complications are more likely with these syringes as extremely high pressures and excessive volumes can be
delivered. May be used for any tooth but may be more effective where the PDL space is wide such as: recently

This document is the property of PHINMA EDUCATION

 DEN 035: Anesthesiology (Lecture)
Student Activity Sheet Module #14

Name:______________________________________________________________ Class number: _______

Section: ____________ Schedule: ______________________________________ Date: _______________

erupted teeth or those with vertical bone loss due to chronic causes. Example: extracting mandibular bicuspids
for young orthodontic patients.

Indications:
Supplemental injection when pulpal anesthesia is incomplete
Short procedure on one tooth
Coagulopathic patient
Children
To avoid bilateral IA block

Technique:
1. Preliminary supraperiosteal injection is optional.
2. A 27 gauge needle penetrates gingival sulcus into the periodontal ligament space with the general
direction of the needle parallel with the long axis of the tooth and the bevel toward the tooth.
(separate injection for each root on multi-rooted teeth)
3. Advance the needle to the depth of the sulcus where resistance will be felt
4. Slowly deposit 0.2 ml of local anesthetic. Considerable resistance should be felt as the solution is
expressed. If this is not the case, then the needle should be redirected and another attempt made.
There should be minimal solution oozing out into the sulcus which would indicate poor needle
placement.
5. The onset of anesthesia is very rapid and the procedure can begin almost immediately.

3. Interdental (Intraseptal)
The Intraseptal injection technique is very similar to the PDL in principle, the difference being the site of
administration

Indications:
Periodontal Surgery (osseous and soft tissue anesthesia hemostasis)
Precursor to palatal injections (anesthetize lingual or palatal ginigiva)

Technique:
1. A short 27 gauge needle is inserted into the center and 2 mm below the apex of the papilla adjacent
to the tooth to be anesthetized.
2. The needle should be angled 45 degrees to the long axis of the tooth and perpendicular to the frontal
plane.
3. After initial penetration of the tissue a few drops of local anesthetic are deposited before advancing
the needle.
4. The needle is then advanced until bone is contacted. The needle is advanced another 1-2 mm into
the interseptal bone.
5. 0.2 ml of local anesthetic is deposited slowly. As with the PDL injection, considerable resistance to
injection must be encountered.

This document is the property of PHINMA EDUCATION

 DEN 035: Anesthesiology (Lecture)
Student Activity Sheet Module #14

Name:______________________________________________________________ Class number: _______

Section: ____________ Schedule: ______________________________________ Date: _______________

4. Intrapulpal
Indications:
 Provides pulpal anesthesia during endodontic procedures when other techniques have failed.
 May be used when sectioning a tooth for removal and other partial anesthesia has been obtained.

Technique:
1. A small 30 gauge needle is suggested but a 25 or 27 gauge short or long needle is still efficient as to what
needle has been used while performing the dental procedure.
2. A small exposure into the pulp chamber is ideal as injected local anesthetic is more likely to flflow
apically.
3. Once the needle is introduced into the pulp chamber, a few drops of local anesthetic are expressed
slowly into the pulp. After waiting a few seconds, 0.2-0.4 ml of local anesthetic can be administered
and treatment can commence immediately

Activity 3: Skill-building Activities . RESEARCH AND WRITE IT DOWN.

Write 5 descriptions or important information regarding each supplemental technique. You may write it
in a bullet form in the table provided.

Techniques Information

Intraosseous Injection
Technique

Periodontal Ligament
Injection Technique

Intraseptal Injection
Technique

Intrapulpal Injection
Technique

Activity 4: What I Know Chart, part 2 (2 minutes)

 Go back to the “What I Know Chart” in Activity 1 and answer the “What I Learned” column.

Activity 5: Check for Understanding (5 minutes)

In what specialization is the Intrapulpal injection technique used?

This document is the property of PHINMA EDUCATION

 DEN 035: Anesthesiology (Lecture)
Student Activity Sheet Module #14

Name:______________________________________________________________ Class number: _______

Section: ____________ Schedule: ______________________________________ Date: _______________

C. LESSON WRAP-UP

Activity 6: Thinking about Learning (5 minutes)

A. Work Tracker
You are done with this session! Let’s track your progress. Shade the session number you just
completed.

B. Think about your Learning:

Please answer the following questions:

1) Please rate your activity today by placing a check mark (/) before a choice. Please explain your
choice on the blank space beside the table:

1. Boring
2. Not informative
3. Challenging
4. Fair
5. Fun

2) “What details in the content and/or activities were not clear to you?”
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
D. FREQUENTLY ASKED QUESTIONS:
 How long does Pulpal anesthesia last?

The mean time of onset of pulpal anesthesia was 8.7, 7.4 and 7.7 min and the mean duration of pulpal
anesthesia was 61.8, 106.6 and 88.0 min for 2% lidocaine with 1:100,000 epinephrine, 4% articaine with 1:100,000
epinephrine and 4% articaine with 1:200,000 epinephrine, respectively.

 Why does local Anaesthetic not work in abscess?

As result, the anesthetic molecules are present mainly in ionized form. Because polar or electrically charged
chemical species cannot cross biological membranes, most of the anesthetic drugs penetrates slowly or poorly in
the target tissue affected by inflammation or infection.

___________________________
AMELIE MIRA E. GRAUEL, DMD,
Associate Professor
Southwestern University PHINMA - College of Dentistry

This document is the property of PHINMA EDUCATION