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Make your patient say “That was the BEST shot I’ve ever had”

When your patients say you gave them the best shot they ever had, what do you think they normally mean? Well friends, it usually means they didn’t experience any pain while the injection was going on. They didn’t feel the needle go in or the uncomfortable burning that can often happen. Plus, they knew you cared about their comfort.

Below are seven strategies you can implement to ensure your patient continues to say, “You are the BEST!”


This is an obvious point, but still worth mentioning. Placing 20% benzocaine topical for about one minute will numb the first few millimeters of the soft tissue. Making the initial pinch of the needle not so bad. If your patient cannot handle benzocaine there are other options available like a lidocaine gel. (Info on topicals here). Remember a little topical goes a long way. Using too much and having it placed for prolong periods of time can cause the tissue to slough, creating an ulcer in the area.


Proper tissue retraction will make the mucosa tight, which makes it easier for the needle to penetrate. Often when the mucosa is in a “relaxed” state the needle has to push the tissue out of the way to penetrate it. This can cause more pain and discomfort for the patient. Often resulting in a tissue tear instead of a small puncture point. So, pull the tissue away from the alveolar

process. The vestibule will have a more open “bowl” like appearance making it easier for you to see and penetrate.


A needle that has been used several times or has contacted bone will have a dull edge. This makes penetrating the mucosa more challenging. Even if the tissue is retracted properly. There is a greater opportunity to tear the tissue or have that noisy “pop” sound when the needle does break through the mucosa. Don’t forget needles can bend when recapped. Even if you don’t see an obvious bend, if you have touched the inside of the cap with the needle tip, it is possible to have a small, barbed end.

To avoid painful injections due to needles, make sure you change your needle if you have contacted bone, penetrated a couple of times, or had challenges recapping your needle.


Often our patients experience burning and stinging when depositing anesthetic solution. One way to combat this phenomenon is to monitor your deposition rate. Depositing the solution slowly helps reduce the sting of the solution. Because the solution is acidic it tends to leave a burning sensation. When expressing your anesthetic, especially the first few drops (1/4 cartridge), GO SLOW. This allows the anesthetic to diffuse into the nerve. When the nerve near the deposition site starts to go numb the burning sensation goes away. The advised flow rate is about 1-2 min for the entire cartridge.

My advice is to start off really slow (rate of 3 min/cart) for the first ¼ of the cartridge, aspirate again, if negative, increase your flow rate back up to 1 min for the cartridge. As a bonus side note slowly depositing and confirming a negative aspiration, is a great way to reduce local anesthetic overdose.


As mentioned above, the sensation of burning is a common experience for our patients. The other factor leading to this sensation is the acidity of the anesthetic solution. In general anesthetics with vasoconstrictors are about 3-4 on the pH scale while plain anesthetics tend to be about a pH of 6. Normal, healthy tissue has a pH of about 7. This means when the anesthetic is delivered into this neutral environment the feeling of burning will happen. Ways to resolve this issue are to use plain anesthetics which are not as acidic or to use a buffering agent with your anesthetic.

Please note that buffering agents must be mixed with the anesthetic and used quickly, as it will reduce the shelf life of the anesthetic solution. The buffering agent creates a higher pH (bringing it closer to neutral), which reduces the sting and can increase the effectiveness of the anesthetic.


If you have inserted to close to the bone or if you happen to over angulate, the potential to skid across bone is a lot higher. If you have ever experienced this before as a patient, you already know how much it can hurt. I will never forget when I was a student, over 20 years ago, and my partner was practicing an injection on me and was skidding along my maxilla with the needle. It was like someone skipping rocks on the lake. Every little bump was so painful!

To avoid this, make sure you are inserting a few millimeters away from the alveolar process and keep the barrel/needle parallel with the angulation of the maxilla or mandible.

Another aspect to be aware of is, muscle and frenum attachments. If you insert into a muscle, not only is it painful for our patients but trismus is more likely to occur. The same can be said in regards of pain for inserting into a frenum.

To avoid these situations, make sure you review your anatomy and palpate the region you are anesthetizing. Understanding where the muscles are will help you avoid them with your needle. The great thing about frenum’s is they are easily moved. When you retract the lip, move it forward or backward and notice the position change of the frenulum. It’s such an easy fix!

These tips are applicable for most injections. However, there are a few extra tips for reducing pain with palatal injections. Check out “Four Steps for Successful Palatal Injections” to learn more.


Talk with your patient about the injection process. Take a moment to understand his or her concerns and address them. Coach them through breathing techniques and other anxiety reduction methods. Doing this simple act reinforces the confidence your patient has in you.

When you implement these seven steps, I know your patient will say you “HIT THEM WITH YOUR BEST SHOT”



To get your FREE anesthesia placement guide click HERE

You can also get CE on anesthesia along with Head and Neck Anatomy at

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