Professional Documents
Culture Documents
1.
Introduction
2.
The Syringe
3.
4.
5.
Types of Syringe
The Needle
-
Types
Anatomy of a Needle
Gauge
Length
The Cartridge
-
Components
Cartridge Contents
Additional Armamentarium
-
Topical Antiseptic
Topical Anesthetic
Applicator Sticks
6.
Hemostat
Self-aspirating syringe
7.
Conclusion
8.
References
Introduction
Effective local anesthesia is arguably the single most important pillar upon which
modern dentistry stands.
perhaps the greatest source of patient fear, and inability to obtain adequate pain
control with minimal discomfort remains a significant concern of dental practitioners.
Although the traditional aspirating syringe is the most common method by which
local anesthetics are administered, newer technologies have been developed that can
assist the dentist in providing enhanced pain relief with reduced injection pain and
fewer adverse effects.
delivery (C-CLAD) devices and intraosseous (IO) systems for local anesthetic
injection.
The equipment necessary for the administration of local anesthetics, includes the
syringe, needle, and local anesthetic cartridge, as well as additional items of
equipment. In additional to providing a description of the armamentarium the proper
care and handling of the equipment and problems that may be encountered with its
use. A proper technique for assembling and disassembling the equipment follows.
Types of Syringe
1.
Nondisposable syringes
-
2.
Disposable syringes
3.
"Safely" Syringes
4.
Nondisposable Syringes
Breech-loading, Metallic, Cartridge-Type, Aspirating -
The breech-loading,
metallic, cartridge-type syringe is the most commonly used in dentistry. The term
breech-loading implies that the cartridge is inserted into the syringe from the side of
the barrel of the syringe. The needle is attached to the barrel of the syringe at the
needle adaptor. The needle then passes into the barrel, where it penetrates the
diaphragm of the local anesthetic cartridge.
convertible tip) is removable and sometimes is discarded inadvertently along with the
disposable needle.
The aspiring syringe has a device such as a sharp, hook-shaped end (often called the
harpoon) attached to the piston that is used to penetrate the thick silicone rubber
stopper (bung) at the opposite end of the cartridge (from the needle).
The thumb ring and finger grips give the administrator added control over the syringe.
Almost all syringe manufacturers provide syringes with both 'regular' and 'small'
thumb rings.
Advantages and Disadvantages of the Metallic, Breech-Loading, Aspirating
Syringe
Advantages
Disadvantages
Visible cartridge
Autoclavable
operators.
Rust Resistant
care
Advantages and
Disadvantages
clinical look
care
during injection
Cartridge is visible
autoclaving
Disadvantages
Cartridge visible
Weight
Autoclavable
Rust Resistant
disc
Pressure Syringes
Introduced in the late 1970s, pressure syringes brought about a renewed interest in the
periodontal ligament (PDL) injection (also known as the intraligamentary injection
(ILI).
The original pressure devices, Peripress (Universal Dental Implements, Edison, NJ)
and Ligmajet (IMA Associates, Bloomington, Ind) were modeled after a device that
was available in dentistry in 1905- the Wilcox-Jewett obtunder. These first-genreation
devices, using a pistol grip, are somewhat larger than the newer, pen-grip devices.
The original pressure syringe looked somewhat threatening, having the appearance of
a gun.
Advantages and Disadvantages of the Pressure Syringe
Advantages
Disadvantages
Measured dose
Cost
Cartridges protected
Jet Injector In 1947 Figge and Scherer introduced a new approach to parenteral
injection the jet or needle-less injection. This represented the first fundamental
change in the basic principles of injection since 1853, when Alexander Wood
introduced the hypodermic syringe.
Jet injection is based on the principle that liquids forced through very small openings,
called jets, at very high pressure can penetrate intact skin or mucous membrane
(visualize water flowing through a garden hose that is being crimped). The most
frequently used jet injectors in dentistry are the Syrijet Mark II (Mizzy Inc., Cherry
Hill, NJ) and the Madajet (Mada Medical Products Incorporated, Carlstadt, NJ).
Advantages and Disadvantages of the Jet Injector
Advantages
Disadvantages
regional block
the injection.
Cost
May damage periodontal tissues.
Disposable Syringes
Plastic disposable syringes are available in a variety of sizes with an assortment of
needle gauges.
Disadvantages
cartridges
hands)
These syringes contain a Luer-Lok screw-on needle attachment with no aspirating tip.
Aspiration can be accomplished by pulling back on the plunger of the syringe before
or during injection. Because there is not thumb ring, aspiration with the plastic
disposable syringe requires the use of both hands.
Safety Syringes
Recent years have seen a move toward the development and introduction of safety
syringes in both medicine and dentistry. Safety syringes minimize the risk of an
accidental needle-stick injury occuring to a dental health provider with a
contaminated needle after administration of a local anesthetic.
Devices such as the UltraSafety Plus XL and the 1 Shot Safety Syringe were available
as of January 2011. The UltraSafety Plus XL aspirating syringe system contains a
syringe body assembly and a plunger assembly.
assembled and the injection administered, the syringe may be made 'safe' with one
hand by gently moving the index and middle fingers against the front collar of the
guard. Once 'guarded' the now contaminated needle is 'safe', so that it is virtually
impossible for dental health providers to be injured with the needle.
Dental safety syringes are designed as single-use items, although they permit
reinjection.
Advantages and Disadvantages of the Safety Syringe
Advantages
Disadvantages
opened
syringe
Nicholson and associates conducted a randomized clinical study using two operators
administrating four different types of dental injections to compare C-CLADs with the
standard syringe.
DPS technology
enables the precise monitoring and control of fluid pressure at the needle tip when a
subcutaneous injection is performed. Fluid exit-pressure at the needle tip is used to
identify a given anatomic location and/or a specific tissue type based on this
repeatable finding.
continuous basis in the form of spoken and/or audible sounds and visual indicators
emitted from the STA instrument, thus providing continuous real-time feedback while
a dental injection is performed.
Advantages and Disadvantages of The Wand/STA System
Advantages
-
Disadvantages
-
Cost
Advantages
-
Easy to see exactly how much local anesthetic solution has been dispensed,
just as on a manual syringe
Inexpensive disposables
Disadvantages
-
Cost
After each use, the syringe should be thoroughly washed and rinsed so as to be
free of any local anesthetic solution, saliva, or other foreign matter. The
syringe should be autuclaved in the same manner as other surgical
instruments.
2.
After every five autoclaving, the syringe should be dismantled and all threaded
joints and the area where the piston contacts the thumb ring and the guide
bearing should be lightly lubricated.
3.
4.
Although the harpoon is designed for long-term use, prolonged use will result
in decreased sharpness and failure to remain embedded within the stopper of
the cartridge. Replacement pistons and harpoons are readily available at low
cost.
Problems
1.
2.
Broken Cartridge
3.
Bent Harpoon
4.
5.
Surface Deposits
The Needle
Types
The needle is the vehicle that permits local anesthetic solution to travel from the
dental cartridge into the tissues surrounding the needle tip. Most needles used in
dentistry are stainless steel and disposable. Needles manufactured for dental intraoral
injections are presterilized and disposable.
Reusable needles should not be used for injections. Because the needle represents the
most dangerous component of the armamentarium, the one most likely to produce
injury to patient or doctor, safety needles are being developed.
Anatomy of a Needle
The needle is composed of a single piece of tubular metal around which is placed a
plastic or metal syringe adaptor and the needle hub.
All needles have the following components in common: the bevel, the shaft, the hub,
and the cartridge-penetrating end.
The bevel defines the point or tip of the needle.
manufacturers as long, medium, and short. Several authors have confirmed that the
greater the angle of the bevel with the long axis of the needle, the greater will be the
degree of deflection as the needle passes through hydro-colloid (or the soft tissues of
the mouth)
The shaft of the needle is one long piece of tubular metal running from the tip of the
needle through the hub, and continuing to the piece that penetrates the cartridge. The
hub is a plastic or metal piece through which the needle attaches to the syringe. The
interior surface of metal hubbed needles is prethreaded, as are most but not all plastichubbed needles.
The cartridge-penetrating end of the dental needle extends through the needle adaptor
and perforates the diaphragm of the local anesthetic cartridge. Its blunt end rests
within the cartridge.
Gauge
Gauge refers to the diameter of the lumen of the needle: the smaller the number, the
greater the diameter of the lumen. A 30-guage needle has a smaller internal diameter
than a 25-guage needle. In the United States, needles are colour-coded by gauge.
There is a growing trend towards the use of smaller-diameter (higher number gauge)
needles, based on the assumption that they are less traumatic to the patient than
needles with larger diameters. This assumption in unwarranted. Hamburg
demonstrated as far back as 1972 that patients cannot differentiate among 23-, 25-,
27-, and 30-gauge needles.
Length
Dental needles are available in three lengths: long, short and ultrashort. Ultrashort
needles are available only as 30-gauge needles. Despite the claim for uniformity of
length by manufactures, significant differences are found.
The length of a short needle is between 20 and 25 mm (measured hub to tip) with a
standard of about 20 mm, and is 30 to 35 mm for the long dental needle, with a
standard of about 32 mm.
1.
2.
3.
Needles should be covered with a protective sheath when not being used to
prevent accidental needle-stick with a contaminated needle.
4.
Attention should always be paid to the position of the uncovered needle tip,
whether inside or outside the patient's mouth. This minimize the risk of
potential injury to the patient and the administrator.
5.
Pain on Insertion
2)
Breakage
3)
Pain on Withdrawal
4)
The Cartridge
The dental cartridge is a glass cylinder containing the local anesthetic drug, among
other ingredients. The dental cartridge is, by common usage, referred to by dental
professionals as a carpule. The term carpule is actually a registered trade name for the
dental cartridge prepared by Cook-Waite Laboratories, which introduced it into
dentistry in 1920.
Components
The prefilled 1.8 mL dental cartridge consists of four parts :
1.
2.
3.
Aluminum cap
4.
Diaphragm
The stopper (plunger, bung) is located at the end of the cartridge that receives the
harpoon of the aspirating syringe. The plunger occupies a little less than 0.2 ml of the
volume of the entire cartridge. Glycerin was added in channels around the stopper as
a lubricant, permitting it to traverse the glass cylinder more easily.
In an intact dental cartridge, the stopper is slightly indented from the lip of the glass
cylinder. An aluminum cap is located at the opposite end of the cartridge from the
rubber plunger. It fits snugly around the neck of the glass cartridge, holding the thin
diaphragm in position. It is silver colored on most cartridges.
The diaphragm is a semipermeable membrane that allows any solution in which the
dental cartridge is immersed to diffuse into the cartridge, thereby contaminating the
local anesthetic solution.
Cartridge Contents
Component
Local anesthetic drug (eg. Lidocaine HCl)
Sterile water
Vasopressor (eg., epinephrine, levonordefrin)
Function
Blockage of nerve conduction
Volume
Depth and duration of anesthesia;
absorption of local anesthetic and
vasopressor
Antioxidant
Bacteriostatic agent
problems. Overheating the local anesthetic solution can lead to (1) discomfort for the
patient during injection, and (2) the more rapid degradation of a heat-labile
Problem
1.
2.
Extruded stopper
3.
Burning on injection
4.
Sticky stopper
5.
Corroded cap
6.
7.
8.
Broken cartridge
Additional Armamentarium
1.
Topical antiseptic
2.
Topical anesthetic
3.
Applicator sticks
4.
5.
Hemostat
Topical Antiseptic
A topical antiseptic may be used to prepare the tissues at the injection site before the
initial needle penetration.
bacterial population at the injection site, thereby minimizing any risk of postinjection
infection.
The topical antiseptic, on an applicator stick, is placed at the site of injection for 15 to
30 seconds. There is no need to place a large quantity on the applicator stick; it
should be sufficient just to moisten the cotton portion of the swab.
Available agents include Betadine (povidone-iodine) and merthiolate (thimerosal).
Topical antiseptics containing alcohol (eg., tincture of iodine, tincture of Merthiolate)
should not be used because the alcohol produces tissue irritation.
If a topical antiseptic is not available, a sterile gauze wipe should be used to prepare
the tissues adequately before injection.
Topical Anesthetic
With proper application, initial penetration of mucous membrane anywhere in the oral
cavity can usually be made without the patient's awareness.
Applicator Sticks
Applicator sticks should be available as part of the local anesthetic armamentarium.
They are wooden sticks with a cotton swab at one and they can be used to apply
topical antiseptic & anesthetic solutions to mucous membrane and compress tissue
during palatal injection.
Cotton Gauze
Cotton gauze is included in the local anesthetic armamentarium for (1) wiping the
area of injection before needle penetration and (2) drying the mucous membrane to
aid in soft tissue retraction for increased visibility.
A variety of sizes of cotton gauze are available for tissue retraction, but the most
practical and the most commonly used in the 2x2 inches size.
Note : That when gauze is placed intraorally to stop bleeding, it is recommended that
2x2 inches squares not be used. Larger 4x4 inch gauze squees are much preferred.
Hemostat
Although not considered an essential element of the local anesthetic armamentarium,
a hemostat or pickup forceps should be readily available at all times in the dental
office. Its primary function in local anesthesia is removal of a needle from the soft
tissues of the mouth in the highly unlikely event that the needle breaks off within
tissues.
2.
3.
Insert the cartridge, while the piston is fully retracted, into the syringe. Insert
the rubber stopper end of the cartridge first.
4.
Engage the harpoon. While holding the syringe as if injecting, gently push the
piston forward until the harpoon is firmly engaged in the plunger. Excessive
force is not necessary. Do not hit the piston in an effort to engage the harpoon
because this frequently leads to cracked or shattered glass cartridges.
5.
Attach the needle to the syringe. Remove the white or clear protective plastic
cap from the syringe end of the needle and screw the needle onto the syringe.
Most metal and plastic hubbed needles are prethreaded, making it easy for
them to be screwed onto the syringe; however, some plastic hubbed syringes
are not prethreaded, requiring the needle to be pushed toward the metal hub of
the syringe while being turned.
6.
Carefully remove the colored plastic protective cap from the opposite end of
the needle, and expel a few drops of solution to test for proper flow.
7.
stuck because the needle is now contaminated with blood, saliva, and debris.
Although a variety of techniques and devices for recapping have been suggested, the
technique recommended by most state safety and health agencies is termed the scoop
technique.
Various needle cap holders are available commercially made or self-made (from
arcylic) that hold the cap stationary while the needle is being inserted into it, making
recapping somewhat easier to accomplish.
Retract the piston and pull the cartridge away from the needle with your
thumb and forefinger as you retract the piston, until the harpoon disengages
from the plunger.
2.
Remove the cartridge from the syringe by inverting the syringe, permitting the
cartridge to fall free.
3.
Properly dispose of the used needle. All needles must be discarded after use to
prevent injury or intentional misuse by unauthorised persons.
Carefully
unscrew the now recapped needle, being careful not to accidently discard the
metal needle adaptor. The use of a sharps container is recommended for
needle disposal.
Placing an Additional Cartridge in a (Traditional) Syringe
On occasion it is necessary to deposit an additional cartridge of local anesthetic
solution. To do this, the following sequence is suggested with the metallic or plastic
breech-loading syringe :
1.
Recap the needle using the scoop (or other appropriate) technique, and remove
it from the syringe.
2.
Retract the piston (disengaging the harpoon from the rubber stopper).
3.
4.
5.
6.
Self-Aspirating Syringe
1.
2.
3.
While gripping the barrel firmly, fully insert the anesthetic cartridge into the
open end of the injectable system.
2.
Grip the plunger handle, putting the thumb behind the finger holder. Introduce
the handle tip into the barrel of the injectable system, behind the cartridge.
3.
Next, slide the sheath protecting the needle backward, toward the handle, until
it Clicks (the click is made as the sheath hits the handle and locks the unit
together).
4.
All movements now are away from the needle. Remove the needle cap and
discard. The system is now ready to use.
Aspiration
Passive Aspiration (Self-Aspiration): At the base of the cartridge barrel of the
injectable system, you will see there is a small protuberance. It appears as a blob of
glue holding the centered needle, the needle-end that penetrates the diaphragm of the
cartridge when inserted. At the start of the injection, the diaphragm is pressed against
the protuberance; a depression occurs, and when released (injection stopped), the
diaphragm moves back away from the protuberance and aspiration occurs.
Active Aspiration : Active aspiration is obtained by the silicone top of the plunger
handle creating a vacuum when, thumb in ring, the practitioner pulls back. The bung
follows the plunger tip, providing active aspiration, which is best observed when a
minimum of 0.25 to 0.3 ml of solution (providing space) has been expelled or used
form the cartridge.
Conclusion
The equipment necessary for the administration of local anesthetics, includes the
syringe, needle, and local anesthetic cartridge, as well as additional items of
equipment. In additional to providing a description of the armamentarium the proper
care and handling of the equipment and problems that may be encountered with its
use. A proper technique for assembling and disassembling the equipment follows.
The introduction of computer-controlled local anesthetic delivery (C-CLAD) systems
has enhanced the delivery of local anesthetic for many dentists and their patients.
These devices have demonstrated great utility in the painless delivery of dental local
anesthetics.
References
1)
2)
Monheim's Local Anesthesia & Pain Control in Dental Practice (7th Edition)
- C. Richard Bennett