How To Do a Supraperiosteal Infiltration

Fracture Tooth fracture Fractured and avulsed teeth are dental emergencies that require immediate treatment. Fractures are divided by depth into those that Affect only the enamel Expose the dentin Expose the pulp read more (bone, alveolar ridge, or teeth)

Dental caries Caries Caries is tooth decay, commonly called cavities. The symptoms—tender, painful teeth—appear late. Diagnosis is based on inspection, probing of the enamel surface with a fine metal instrument... read more

Dry socket Postextraction alveolitis (dry socket) Postextraction problems are a subset of dental emergencies that require immediate treatment. These problems include Swelling and pain Postextraction alveolitis Osteomyelitis Osteonecrosis of the jaw read more

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)

Allergy to the anesthetic agent Local anesthesia for laceration treatment Lacerations are tears in soft body tissue. Care of lacerations Enables prompt healing Minimizes risk of infection Optimizes cosmetic results read more or delivery vehicle (can usually choose different anesthetic)

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

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

Coagulopathy*: When feasible, correct prior to procedure.

Pregnancy: Avoid treatment in the 1st trimester if possible.

Allergic reaction to the anesthetic

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

Intravascular injection of anesthetic/epinephrine

Hematoma

Neuropathy

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

Failure to anesthetize

Needle breakage (rare)

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

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

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

Stop the supraperiosteal infiltration procedure and find 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.

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 about 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.

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, do 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.