How To Do a Supraperiosteal Infiltration

A painful dental condition (toothache) or its treatment:

• Fracture (bone, alveolar ridge, or teeth)

• Dental caries

• Dry socket

• Mild to moderate tooth abscess (only if the abscess is sufficiently small that local infiltration will provide adequate anesthesia; otherwise, a nerve block is used)

Absolute contraindications

• Allergy to the anesthetic agent or delivery vehicle (can usually choose different anesthetic)

• Absence of anatomic landmarks needed to guide needle insertion (eg, due to trauma)

Relative contraindications

• Infection in the path of needle insertion: Use nerve block, or other anesthesia.

• Coagulopathy*: When feasible, correct prior to procedure.

• Pregnancy: While many guidelines state that patients can be safely treated throughout the entirety of their pregnancy, truly elective treatment should ideally be deferred during the first trimester to prevent potential harm to the developing child (1).

*Therapeutic anticoagulation (eg, for pulmonary embolism) increases the risk of bleeding with dental procedures, but this must be balanced against the increased risk of thrombosis (eg, stroke) if anticoagulation is reversed. Discuss any contemplated reversal with the clinician managing the patient's anticoagulation and then with the patient.

• Allergic reaction to the anesthetic

• Toxicity due to anesthetic overdose (eg, seizure, cardiac arrhythmias)

• Intravascular injection of anesthetic/epinephrineIntravascular injection of anesthetic/epinephrine

• Hematoma

• Neuropathy

• Spread of infection, by passing the needle through an infected area

• Failure to anesthetize

• Needle breakage (rare)

Most complications result from inaccurate needle placement.

• Dental chair, straight chair with head support, or stretcher

• Light source for intraoral illumination

• Nonsterile gloves

• Mask and safety glasses, or a face shield

• Gauze pads

• Cotton-tipped applicators

• Dental mirror or tongue blade

• Suction

Equipment to do local anesthesia

• Topical anesthetic ointment* (eg, lidocaine 5%, benzocaine 20%)Topical anesthetic ointment* (eg, lidocaine 5%, benzocaine 20%)

• Injectable local anesthetic such as lidocaine 2% with or without epinephrine† 1:100,000, or for longer duration anesthesia, bupivacaine 0.5% with or without epinephrine† 1:200,000 Injectable local anesthetic such as lidocaine 2% with or without epinephrine† 1:100,000, or for longer duration anesthesia, bupivacaine 0.5% with or without epinephrine† 1:200,000

• Dental aspirating syringe (with narrow barrel and custom injectable anesthetic cartridges) or other narrow barrel syringe (eg, 3 mL) with locking hub

• 25- or 27-gauge needle: 2 cm long for supraperiosteal infiltration

* CAUTION: All topical anesthetic preparations are absorbed from mucosal surfaces and toxicity may result when dose limits are exceeded. Ointments are easier to control than less-concentrated topical liquids and gels. Excess benzocaine rarely may cause methemoglobinemia.* CAUTION: All topical anesthetic preparations are absorbed from mucosal surfaces and toxicity may result when dose limits are exceeded. Ointments are easier to control than less-concentrated topical liquids and gels. Excess benzocaine rarely may cause methemoglobinemia.

† Maximum dose of local anesthetics: Lidocaine without epinephrine, 5 mg/kg with total maximum dose of 300 mg; lidocaine with epinephrine, 7 mg/kg with total maximum dose of 500 mg; bupivacaine without epinephrine, 2 mg/kg with total maximum dose of 175 mg. NOTE: A 1% solution (of any substance) represents 10 mg/mL (1 gm/100 mL). Epinephrine causes vasoconstriction, which prolongs the anesthetic effect; this is useful in well-vascularized tissues such as the oral mucosa. Patients with cardiac disease should receive only limited amounts of epinephrine (maximum 3.5 mL of solution containing 1:100,000 epinephrine); alternatively, use local anesthetic without epinephrine.† Maximum dose of local anesthetics: Lidocaine without epinephrine, 5 mg/kg with total maximum dose of 300 mg; lidocaine with epinephrine, 7 mg/kg with total maximum dose of 500 mg; bupivacaine without epinephrine, 2 mg/kg with total maximum dose of 175 mg. NOTE: A 1% solution (of any substance) represents 10 mg/mL (1 gm/100 mL). Epinephrine causes vasoconstriction, which prolongs the anesthetic effect; this is useful in well-vascularized tissues such as the oral mucosa. Patients with cardiac disease should receive only limited amounts of epinephrine (maximum 3.5 mL of solution containing 1:100,000 epinephrine); alternatively, use local anesthetic without epinephrine.

• Stop the supraperiosteal infiltration procedure and use a different method of anesthesia if the patient is uncooperative.

• Supraperiosteal infiltration anesthetizes individual dental nerves.

• Injectable anesthetic is placed adjacent to the lateral (buccal) alveolar bone supporting the tooth, at the level of the root tip.

• The anesthetic diffuses across the alveolar bone to reach the dental nerves of individual teeth.

• Position the patient inclined, with the patient's head at the level of your elbows and the occiput supported.

• For the lower jaw, use a semi-recumbent sitting position, making the lower occlusal plane roughly parallel to the floor when the mouth is open.

• For the upper jaw, use a more supine position, making the upper occlusal plane roughly 60 to 90 degrees to the floor.

• Turn the head and extend the neck such that the injection site (upper or lower mucobuccal fold) will be accessible.

• Wear nonsterile gloves and mask and safety glasses, or a face shield.

• Instruct the patient to partially close the mouth and relax the jaw, lip, and cheek muscles.

• Using your thumb and index finger, grasp the cheek lateral to the tooth, and retract it away from the tooth, to delineate the mucobuccal fold.

• Use gauze to thoroughly dry the mucobuccal fold. Use suction as needed to keep the area dry.

• Apply topical anesthetic with cotton-tipped applicators and wait 2 to 3 minutes for the anesthesia to occur.

Inject the local anesthetic

• Again retract the lip laterally, to delineate the mucobuccal fold. Keep the mucosa taut.

• Hold the anesthetic syringe such that the needle bevel faces the tooth.

• Insert the needle into the depth of the mucobuccal fold and advance parallel to the tooth until it contacts bone, aiming for the apex (1 to 1.5 cm to contact the adult maxilla).

• Aspirate, to exclude intravascular placement. If aspiration reveals an intravascular placement, withdraw the needle 2 to 3 mm, then re-aspirate prior to injection.

• Slowly inject approximately 1 to 2 mL of anesthetic. During the injection, use a finger to apply external pressure to the cheek near the site of anesthetic deposition, to prevent local tissue ballooning.

• If anesthesia is not satisfactory after 10 minutes, inject a small amount on the palatal/lingual side. This is commonly required for a tooth extraction.

How To Do a Supraperiosteal In...

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• Have the patient rest, with mouth relaxed, while awaiting onset of anesthesia (5 to 10 minutes).

• To minimize the risk of needle breakage, do not bend the needle prior to insertion, do not insert the needle to its full depth (ie, to the hub), and instruct the patient to remain still, with the mouth wide open, and resist grabbing your hand.

• Distraction techniques (eg, talking to the patient or having the patient hold someone else's hand) may help to reduce patient anxiety.

• Inject the local anesthetic solution slowly (30 to 60 seconds) to reduce the pain of injection.

• Upper molars with thick overlying bone are sometimes not adequately anesthetized with supraperiosteal infiltration alone. If so, perform a posterior superior alveolar nerve block. Using a 25- or 27-gauge long (3-cm) needle, enter the mucobuccal fold over the second molar. Aim posteriorly, superiorly, and medially, toward the posterior wall of the maxillary tuberosity at the level of the root apices. Aspirate, and then inject 1 to 2 mL of anesthetic solution.