Do this for a painless Nerve Block!!!

Remember that patient from my first post whom I was administering Inferior Alveolar Block & Long Buccal Nerve Block for Extraction of a Mandibular second molar? How he was able to see how stressed I was?

If you don’t remember the patient, then get to know him here.

I was stressed not only because my Inferior Alveolar Nerve Block didn’t work, but also because the patient was jumping in the chair whenever I inserted the needle into the mucosa.

Being a beginner in the field of dentistry, it put a lot of pressure on me.

Again, in the hindsight, I understand what mistakes I had made while inserting the needle for injecting Local Anesthesia and how I could have rectified those mistakes.

I will not be talking about the basic injection technique in detail, that is very well explained in Chapter 11 (Basic Injection Technique) of Handbook of Local Anesthesia by Dr. Stanley F. Malamed. I will be talking about the things that I feel I should’ve known as a dental graduate.

So, without further ado, let's get started.

---

I didn’t tell the patient what to expect

Those days I used to just start with the injection technique without much communication with the patient. That was a huge mistake. Now I talk to the patient before getting started with the injection technique. I address the patient with his/her name. I explain to the patient what he/she should expect.

I explain to the patient that he/she might feel a little discomfort while administering Local Anesthesia but after that he/she won’t feel even a bit during the whole surgery. That eases the patient a bit.

Most of the patient's fear is alleviated by communication.

Topical anesthesia

Nowadays, I always use a topical anesthetic. For my patients, I prefer Lignospan-O (5% Lignocaine) Topical anesthetic ointment by Septodont. You can also use Mucopain Gel (20% Benzocaine) or Lox 10% Spray.

I prefer an ointment or a gel instead of a spray, as spray tends to get washed away. In situations when I have the option of only Topical Anesthetic spray, then I spray it on a small piece of cotton and then apply the anesthetic soaked cotton on to the site of the needle insertion.

Pressure Anesthesia

This point is in continuation with the previous point and is more useful in case of palatal anesthesia.

I use the same cotton; that I used to apply topical anesthetic; to apply pressure over the site of injection. I apply enough pressure for enough duration to cause blanching (white discoloration) of the soft tissue. The pressure applied should be tolerable and not cause pain to the patient.

Topical & Pressure Anesthesia being applied at the site of injection for Greater Palatine Nerve Block

Area where pressure was applied appears white (Blanched)

This pressure alone can cause some amount of anesthesia at the site of application. So, combined with topical anesthesia, this produces profound anesthesia at the site of the needle insertion.

Use sharp needle

This is a no brainer.

A sharp needle would easily pierce through the soft tissue with minimal discomfort. With the use of disposable syringes, this problem is rarely encountered.

But the problem came when I had to give multiple nerve blocks. With repeated use, the needle would become dull. The dull needle will then cause more pain and would also give more resistance while insertion into the soft tissue.

That is why now I change my needle after every 3 insertions.

Thickness of the needle

Those days I used the 24 Gauge needle that came with the syringe.

Now I use 27 Gauge needle.

As the value of Gauge increases, the diameter of the needle decreases

You may think that using a needle with the highest gauge number would be the least painful. But multiple studies have shown that we humans cannot differentiate between needle sizes beyond 27 Gauge. So 27G, 30G & 32G needles would produce the same level of pain or discomfort to the patient.

Also, if we use a higher gauge needle, the chances are that it may get blocked by the blood cells leading to a false negative aspiration.

Stretch the tissue

I did not realize the importance of stretching the tissue and making it taut for needle insertion. That lead to pushing & tearing of the soft tissue leading to more discomfort to the patient.

When the tissue is not stretched, the needle tip to tissue contact is prolonged which leads to a longer duration of discomfort. Red color shows area of discomfort.

When the tissue is stretched and is held taut, the needle passed through easily leading to less needle tip to tissue contact leading to less discomfort. Red color shows area of discomfort.

Whereas now I keep the soft tissue stretched so as to facilitate easy passage of the needle through the soft tissue with minimal discomfort.

Ask the patient to take a deep breath

To tell you about this point I will have to tell you a short story.

A few years back, my mom was admitted to a hospital for respiratory distress. I was at the hospital and there was a blood donation camp was going on.

Donated blood can only be stored for 42 days, so donate blood regularly

I too decided to donate blood but I was scared as hell at the thought of needle prick.

Still, I manned up and filled the form. I was assigned to a lady doctor for blood collection.

A tourniquet was applied over my right arm above the elbow. I was asked to squeeze the stress buster smiley ball for some time. As my veins inflated, the doctor applied spirit over the needle insertion site.

With my eyes closed, cursing myself, I was preparing for the agony of the needle prick. The doctor asked me to take a long & deep breath and hold it. I did that and waited for the pain to start. But the pain didn’t start. Instead, I felt the doctor applying tape over my arm.

I opened my eyes and to my surprise, I saw the needle already into my vein and blood being collected.

The doctor had inserted the needle while I was busy taking in a long & deep breath.

That day I learnt an important lesson.

I started using this in my patients. I ask my patient to take a long & deep while administering Local Anesthesia and to my surprise, it was pretty effective.

I tried looking for articles on this but I could not find any. My guess is, that it takes the patient’s mind off of the impending pain.

I must add, it is most effective in the Nerve block techniques where the needle doesn’t have to travel much distance. For example, in Local Infiltrations, Mental or Incisive nerve blocks, greater palatine nerve block & Long buccal nerve block.

Bevel towards the bone

This is something I did even during my earlier days.

But I felt that this should be included in this post as many of the dental students don’t know why we keep the bevel towards the bone.

Bevel is directed towards the bone so as to prevent any damage to the periosteum.

When bevel is directed towares bone, the needle slides over the periosteum (pink). This decreases the chances of periosteum tear

When bevel is directed away from the bone, the needle tears (red) the periosteum (pink) leading to pain.

Barb formation because of bevel directed away from the bone

Also, if the bevel is facing away from the bone then it will lead to barb formation. This will lead to pain while withdrawing the needle.

Speed of injection

Earlier, I used to just push the Local Anesthesia solution with speed and pressure. My injection speed would have been around 2 ml in 5 seconds.

I know many of you would be making cringy faces after reading the last line.

At this rapid rate of injection, the sudden introduction of solution within the tissue space leads to pain due to the sudden pressure to the surrounding tissue.

Dr. Stanley F. Malamed says that an ideal speed of injection should be 1 ml in 1 minute. That means a 2 ml solution should be deposited in 2 minutes.

No offense to the legendary Dr. Stanley F. Malamed, at this injection rate, I have found that even the patient (along with me) becomes restless. Imagine, having a needle inserted in your mouth for 2 continuous minutes.

So, my injection rate is 2 ml in 30 seconds. At this rate, I have found that the patient is comfortable and there is no pain as the pressure is applied gradually by the Local Anesthetic solution.

And throughout all these steps, you should keep talking to the patient to keep his/her mind off of the ongoing injection technique.

Also, never use psychologically traumatic words such as pain or hurt. Say things like "You might feel a little discomfort" or "This is going to feel like a mosquito bite".

---

So, these were the things that I follow to make my Nerve blocks least painful to the patient.

You should know that every patient is different. So, in different patients, the response to injection would be different with the same technique. But we can always try to make the injection technique as less painful as possible.

Let me know in the comment section, what all things you guys do to make the experience least painful for your patients.