Updated: Dec 13, 2021
When providing anesthesia for treatment outside of typical hygiene services, hygienists need to do things a little differently.
As dental hygienists, we have an opportunity to be involved in several aspects of dental care. We are engaged with preventative, therapeutic and surgical procedures. We hold a unique position in the oral healthcare field. While the scope of practice is not yet standardized nationwide, most states allow hygienists to administer local anesthesia.
Due to the vast environments we serve our patients in, we need to be aware of the different types of injections, solutions, and dosage for each patient and procedure.
As hygienists, most of the injections we administer are for periodontal therapy services. These services require us to anesthetize a broad portion of the oral cavity at one time (you can learn more about injection techniques by visiting other blog posts associated with this page). Also, we are more concerned about soft tissue anesthesia than pulpal anesthesia.
However, if you are providing anesthesia for restorative care or an extraction, the type and amount of anesthetic solution may need to be altered. So in other words, you will need to give your patient more shots.
With restorative services pulpal anesthesia is crucial to the patient’s comfort. Have you had a filling or crown done and could feel it? I have, and it was not fun. The reason for this unfortunate event could be a couple of items. Not enough time was given for the anesthetic to take full effect, not enough solution was administered and/or the wrong type of anesthetic was given. When you pause to consider these items, your patient will thank you.
It is incredibly important to consider the patients’ health history, age and weight when selecting your anesthetic. These factors can impact your decision on how much anesthetic to use and the amount of vasoconstrictor the patient can tolerate. To learn more about different anesthetics read “What’s Your Anesthetic Type”
Consider using an anesthetic which has a vasoconstrictor associated with it. When anesthetic solution contains a vasoconstrictor, the pulpal anesthesia will last longer.. Don't forget anesthetics have a shorter pulpal anesthesia time than soft tissue. So, you must administer more anesthetic than you would normally give for perio therapy procedures. A good rule of thumb is that anesthetics with vasoconstrictor have a pulpal anesthesia time of about an hour. Articaine and Bupivacaine are outliers with anesthesia time of 45 min and nearly 3 hours, respectively.
When providing anesthesia for maxillary teeth to be restored you can easily infiltrate over the tooth to be treated, and it isn't unusual to give a full cartridge of anesthetic. This is vastly different than infiltrating for non-surgical periodontal therapy in which a quarter to a half of a cartridge will suffice.
For restorative work of mandibular teeth you may need to give two Inferior Alveolar injections especially if the procedure is on a molar. Some clinicians use a combination of anesthetic solutions for the IA injection. While research indicates using different anesthetic solutions does not provide increased sensation of numbness, there are several clinicians who swear by it. If you are preparing a premolar or anterior tooth you can administer an incisive injection. For an incisive I would give close to a full cartridge of anesthetic for restorative work. Just remember lingual soft tissue will not be numb. If this is of concern, the best bet is to give the IA injection.
When anesthetizing for extractions it is important to not only make sure the pulp of the tooth is numb but the surrounding soft tissue and PDL fibers as well. This means providing the appropriate injection to anesthetize the pulp. Plus, infiltrating facially and lingually including papillary injections around the tooth. Do not be surprised if you give more anesthetic than you are used to for these procedures. A full cartridge (maybe even two) for the pulp and another for local infiltrations around the tooth. Remember your goal is to make sure the patient is comfortable throughout the procedure.
If you are preparing a tooth for endodontic treatment. My best advice is to follow the rule of thumb for pulpal anesthesia regarding extractions. Plus, don’t be surprised if the doctor administers more directly into the pulp chamber.
Finally, let time be on your side. Soft tissue anesthesia begins quickly, usually within a couple of minutes. However, the onset for pulpal anesthesia can take up to 15 minutes (especially with mandibular teeth). I know this was the reason why I could still feel the drill on my tooth. Once we waited another 5 minutes I was comfortably numb.
Some other factors which can impact the effectiveness and onset of anesthesia is severe infection around the tooth to be treated. We’ve all heard about a person with a “hot tooth”. Due to the infection it can take more and sometimes stronger anesthetic to get the patient numb. Also, people aren’t always textbook anatomical prototypes. There could be variations of anatomy and metabolism rates.
Finally, having a discussion with the clinician performing the dental procedures is crucial. He or she probably has a specific philosophy of care. For example, one doctor I have worked with always have two IA injections, that was part of her standard process. Give one injection wait a couple minutes and then give another. She said it is easier to just go ahead and do two injections before the dental dam was placed. When the two of you are on the same page regarding the process of anesthesia it will make the entire procedure go smoother.
The importance of reviewing the patients’ health history (including medications) and understanding the procedure will help you know what type of anesthetic to use and which injections you should give. Include a little time and communication with the treating clinician will set you up to give YOUR BEST SHOT!
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Did you know you can get CE credit for all you are learning? Enroll in the course series HIT ME WITH YOUR BEST SHOT. Review injection techniques (with cued videos) and anesthesia management.