Palatal Anesthesia

Palatal Anesthesia

One of the things that really stands in the way of a fuller utilization of TADs is the need for anesthesia.  Since many orthodontists have never practiced general dentistry, they are especially fearful of of “the needle” maybe even more fearful than some of their patients.  Compounding this fear is that the palate is a better location than the maxillary buccal surfaces for miniscrews in many situations.  I once heard an idiot at an orthodontic meeting state that he did not believe in miniscrews because he had an office policy not to hurt patients.

Probably, the thing you don’t want to use is the traditional syringe.  The sight of that upsets a good number of patients and I find that it is hard for me to control the amount of anesthesia I try to deliver so I probably over do it which makes it painful.

My personal preference for palatal anesthesia is to use TAC Alternate 20% topical anesthesia from Professional Arts Pharmacy* followed by injection with Septocaine or lidocaine using a Septodont Paroject intraligamentary syringe.  This syringe looks like a pen and is less threatening than the traditional syringe.  I also use a 33 gauge needle.  The lever arm on this syringe makes the use of the 33 gauge needle feasible by easily overcoming back pressure.

Protocol:  Dry the area to be anesthetized and place the TAC Alternate 20% for 5 minutes.  Keep as dry as feasible while waiting.  Wash off and wait 3 more minutes.  Using the technique described by Dr S Malamed in his text, very, very slowly inject a small amount of Septocaine.  Usually 1/10 of a carpule is plenty.  That is three activations of the lever arm.  Go as slow as you can.  It should take at least one minute or longer.  If you place the anesthesia directly in the area of screw placement, you can begin to insert the miniscrew immediately.  This works very well.

Alternatives: Baumgaertel feels that the TAC Alternate 20% topical is enough without resorting to the any injection.  He would follow my protocol for 5 minutes and then 3 minutes and then insert the miniscrew.  If the patient feels uncomfortable at that point, you can reapply the TAC or resort to an injection.  I feel that, if Baumgaertel is right, then they should not feel the Paroject injection and that assures me that they will be comfortable for the screw insertion.

Razavi, who teaches with Baumgaertel at Case Western and speaks for Unitek on the IMTEC miniscrew system, tends to agree with Baumgaertel unless the tissue is more than 2 mm thick.  He feels that is the limit of topical anesthesia.  He will use a MadajetXL in areas of thicker tissue.  As a general rule, the tissue is 2 mm or less in most areas we would choose anterior to the mesial of the maxillary first molar in the palate.  Perhaps if you were more than 8 mm from the gingival margin of the first molar, tissue would be thicker than 2 mm.




Speaking of the MadajetXL, that is part of Jason Cope’s protocol.  He will use DepBlu** which is a variation of TAC Alternate.  After the DepBlu sits for 5 minutes + 3 minutes, he uses a MadajetXL routinely.  For those not familiar with a MAdajectXL, it is like a water pistol for local anesthesia.  It uses pressure but no needle to insert the local anesthesia under the tissue.  By doing that, the deeper tissues can be anesthetized although this might take several applications of the MadadjetXL.

*TAC Alternate 20% is available from Professional Arts Pharmacy in Lafayette, LA.
http://www.professionalarts.com/

**DepBlu is available from Stevens Pharmacy of Costa Mesa, CA.  There is a name change.  The dbg ( formarly depblu ) has lidocaine 10% prilocaine 10% tetracaine 4% and phenylephrine 2% sweetened with Stevia.
http://stevensrx.com/

The syringe I use is from Septodont.  It is called a Paroject.
http://www.septodontusa.com/products/paroject?from=10&cat=4

The Madajet XL is from Mada Medical.  It costs $600 but that compares very favorably with a Syrijet II which is $1800 and is similar.
http://www.madamedical.com/merchant.mv?Screen=CTGY&Store_Code=MM&Category_Code=MXD