I bet you that many orthodontic residents decided to pursue the specialty of orthodontics because they had hoped to avoid all those nasty dental things like local anesthesia. Unfortunately for them, since the advent of TADs, local anesthesia is a necessary skill in the orthodontic armamentarium. And now, to make matters worse, we have all the miniscrew gurus saying that the best location in which to place a TAD is to insert it into the anterior palate where the bone density is ideal for TAD retention. Oh no! Not only is this local anesthesia but it is in an area where most dentists fear to tread. Kind of like a double whammy.
I was lucky when I went through the orthodontic program at Tufts. I had the chance of working as a general dentist Tuesday and Thursday evenings and all day Saturdays. This was in a private fee for service practice where virtually every patient was an adult already treatment planned for restorative and they all were treated with local anesthesia. I became very comfortable with the concept so it was easy to transfer those skills to the use of miniscrews.
I think the first key to doing palatal anesthesia in a patient friendly manner is to use the smallest needle available which is not a 30 gauge as most think but a 33 gauge ultra short. A 33 gauge needle is approximately 30% smaller in diameter than a 30 gauge. That is a big difference.
The second key is to use a strong topical anesthetic. Some people claim that a strong topical is enough to allow you to insert a miniscrew without even local anesthetic. I am unwilling to be that brave, nonetheless, I figure, if that is true, I can use that kind of strong topical to prior to local anesthetic.
The third key is to realize that because of the extremely small diameter of the 33 gauge needle, there will be a fair amount of back pressure so instead of using a standard syringe, you will need to use a intraligamentary syringe. These typically have a lever arm and not a plunger. Also, the syringe looks more like a pen and I think that helps relax the patient.
I like the one from Septodont called a Paroject syringe. It has a lever arm to dispense the solution. It takes 30 activations of the lever arm to empty a 1.8 ml syringe and only 2 or 3 activations for adequate anesthesia to insert a palatal miniscrew.
Next time: Technique
