There is so much satisfaction in knowing when and where oral tissues are numb. And this is one of the injections you can actually see this happen. Even though palatal injections can be more uncomfortable for patients than others, I still really like giving this one. It is empowering to know my patient is numb when they are being treated for periodontal disease.
WHAT IS IT?
The Greater Palatine Injection (GP) anesthetizes the palatal soft and hard tissue of the posterior region. The area in which the Greater Palatine nerve innervates. This extends from the midline of the palate to the gingival margin of the molars. As a bonus this injection can aid in pulpal anesthesia for the molar teeth as well.
Often the GP nerve can provide additional innervation to the maxillary molars. Also, because the maxillary and palatal bones are thinner the anesthetic can diffuse through the bone and reach the nerve endings near the tooth easier.
HOW DO YOU ADMINISTER?
Set your syringe up with a 27- or 30-gauge short needle. Anesthetic choice really is up to you as the clinician. Don’t forget to review the patient’s health history to understand the factors which impact this decision.
The point of insertion is in the palatal fat pad near the first and second maxillary molars. Your goal is to deposit the anesthetic solution over the Greater Palatine foramen.
To locate the foramen, palpate (apply moderate pressure) the palatal fat pad near the horizontal and vertical junction of the hard palate. You should feel a slight indentation, this is the opening of the GP foramen. If you are having troubles identifying this structure you may need to press a little firmer. Also, you can usually find this near the second maxillary molar.
After finding the foramen place topical in that region. Traditional benzocaine will work but you may find the topical version of lidocaine may be more effective. After placing topical but before you insert your needle, apply some pressure to the area. This aids in alleviating the pain of needle insertion.
Align your syringe so the needle’s destination is over the foramen. The best approach is to come at an angle. Angle the barrel over the premolars of the opposite side and at about a 45-degree angle to the hard palate. Insert the needle until you contact bone then withdraw about 1-2 mm. The depth of needle insertion can be daunting. You could go about 10 mm. If you are lucky enough to get into the foramen you could go even deeper. Please note it is highly unlikely you will get into the foramen with this angulation technique.
Once you have reached your deposition site aspirate and deposit your solution. This is when you will see the tissue begin to blanch. Generally depositing about a half of the cartridge will work.
PROS AND CONS?
I think I'VE eluded to the pros of this injection a few times, but why not mention it again. With palatal injections one of the biggest pro’s is the ability to see where the anesthetic has taken effect. It is such a rare treat in dentistry that we can have a visual confirmation regarding anesthetic effectiveness.
Another pro is the potential for increased pulpal anesthesia for the maxillary molars. Especially for those moments when you have a troubled tooth that won’t get numb.
Even though this injection is comparatively easier on the clinician’s hand than the other palatal injections, hand fatigue can be an issue.
Something for us clinicians to keep in mind, is for patients who have a history of poor healing. Palatal injections given with anesthetics containing vasoconstrictors, could develop a post-operative ulcer. Due to the dense tissue and reduced vascular supply. It is a rare occurrence, but it is possible. I have only witnessed it once and the patient was severely immunocompromised.
Next time you are getting ready to provide therapeutic care for your patient, pull this review up so you can have all the confidence to give the GP. I hope you find the joy in watching the palatal tissue blanch when you give this injection. After all, it confirms you are giving your best shot!
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