Dr. William H. Lieberman D.D.S., M.B.A.

Pediatric

Dr. William H. Lieberman D.D.S., M.B.A.

Private pediatric practice in New Jersey

Past-President American Society of Dentistry

for Children

MBA, Healthcare

Coordinator Dental Continuing

Education, Monmouth Medical Center

Assistant Clinical Professor at New York

University

Brief Bio.

1975-2011

Then & Now Paper Charts Electronic Charts

1975-2011

Then & Now X-Ray Film X-Ray Sensors

1975-2011

Then & Now Amalgam Restorations Composite (RMGI) Restorations

1975-2011

Then & Now Curing Light LED Light

1975-2011

Then & Now Syringes The Wand / STA - Single Tooth Anesthesia

System Instrument

Table of Contents

Set Up

Basic operation

Injection Techniques

Maintenance

Advanced options

www.STAis4U.com

1904

1884

Drug choice and Volume

4% Articaine HCL Adult: ½ cartridge

Child: ¼ cartridge Preferred Vasoconstrictor Concentration

○ 1:100,000 epinephrine

2% Lidocaine HCL

Adult: ¾ cartridge

Child: ½ cartridge Preferred vasoconstrictor concentration

○ 1:100,000 epinephrine

What do you see ?

Prevalence of Dental Fear?

Agras, et al. 1979

20%

Technology ?1853 1904 2010

150+ years

Computer-Controlled

Local Anesthetic

Delivery System

“New Innovation”

“C-CLAD”

1997

1997 – 1st

Generation

2007 – 3rd

Generation

Computer Controlled Local

Anesthetic Delivery System

Disruptive Technology

An innovation that alters a product or

service in ways the market does not

expect

Allows you to

do something you

can’t do any other way!

Simple mechanical system

Dynamic Pressure Sensing

Technology - DPS™

• Monitors “Exit-Pressure”

• Real-Time, continuous

information

• Visual and audible feedback

• System control: “Exit-Pressure”

No

Feedback

FPO

Total

Feedback

Clinical ResearchComputerized local anesthesia vs. traditional syringe technique: Subjective pain response.

NYS Dental Journal – 1997

Method & Material

50 patients (dentists)

Palatal injection

Each patient served as a control

Subjects blinded to technique

VAS scale, subjective pain scoring

3 examiners performed testing

CCLADS: Fixed flow-rate = 0.005ml/sec = 2 minutes

Handheld syringe: Maintained injection for 2 minutes

Hochman M, Chiarello D, Hochman C, Lopatkin R, Pergola S.

Number of Subjects = 50

•RESULTS:

• Wand group - 82% reported No Pain or Minimal Pain

• Placebo group – 10% reported No Pain or Minimal Pain

0

5

10

15

20

25

30

35

None Minimal Slight Moderate Severe

Pain Perception Wand Injection

Syringe Injection

Froum, Tarnow, Caiazzo, Hochman J. Periodontology 2000,71:1453-59

Histology: PDL injection

METHODS & MATERIALS

3 subjects / 32 sites;

Control site

1 hr, 1 day, 4 days, 7 days, 21 days & 49 days

Dosage Volume = 1.0 ml

Data on Different Tissue Types and

Dental Injections

Interstitial Tissue Pressure Associated With Dental Injections: A Clinical StudyQuintessence Int 2006; Vol 37: 469-476.

200 dental injections (50/group)○ Group 1 – PDL

○ Group 2 - Palatal injection

○ Group 3 - Buccal infiltration

○ Group 4 - Mandibular block

Measured pressure in “real-time”○ Fixed flow-rate: 0.005ml/sec

Hochman, Friedman, Williams, Hochman

ValidationProf. Stanley Malamed

Prof. J. Meechan

Prof. Dionne

Prof. BassettProf. DiMarco

Prof. Naughton

Lesson 1Set Up and Basic

Operation

Step - 1

FRONT

Attach Foot Control

Tighten Securely

BACK

Attach Power Cord

Turn Power Switch On

Wait 5 seconds for STA to

Self-calibrate

Step - 2

ANESTHETIC CARTRIDGE

Insert cartridge into holder

Press firmly until spike punctures the

diaphragm

Step - 3

Wand Handpiece & Needle

Attach Luer-Lock needle to

handpiece, if necessary

Tighten securely

Place needle and cap into

holder on either side of STA

Step - 3

Shorten length of

Wand Handpiece

Remove tubing handpiece

Shorten by “breaking” the

length of the handle

Mark the bevel

Step - 4

Insert wings of holder

into top of STA

Turn counter-clockwise

¼ turn

STA activates and purges

handpiece of air

Lights are activated

Insertion of Cartridge Holder

Step - 4b

Turn clockwise ¼ turn Push cartridge out using

finger slots at top of

cartridge holder

Remove cartridge and

continue

Removal of Cartridge Holder

The Training Mode provides an audible explanation of the various functions of the STA

Allows one to become familiar with operating the STA

Enable Training Mode by pressing and holding the “Hold to Train” button for 4 seconds

Easy Learn: Training

Mode

Step - 5

Step – 6 System is

Ready

Lesson 2: Performing the

STA-Intra-ligamentary

Injection

Learn the Injection of Your Choice

Lesson 3: Performing the

AMSA – (Palatal) Injection

Lesson 2Tools needed to perform

STA-IL Injection

What you need to perform this injection:

Bonded - 30-g ½ inch STA-Wand® Handpiece

The STA drive-unit set to “STA” mode

Activate Training Mode feature (optional)

Lesson 2Performing STA-IL

Injection

What you need to learn:

How to use Cruise-control feature

Understand how DPS® works

How to use STA aspiration to prevent back-spray of

anesthetic into patients mouth

Performing

STA-Intra-ligamentary

Injection

Easy Learn: Cruise Control

What is the Cruise Control feature: The feature allows you to deliver

anesthetic solution without the need of continuously depressing the foot pedal, it’s analogous to cruise-control in your car in which you release the accelerator and continue to drive.

How do you activate:1. Start injection by depressing

pedal

2. After 3 seconds voice prompt will say “Cruise”

3. Immediately release foot off pedal to remain in cruise mode

How do you de-activate: Tap foot-control pedal to stop

Step - 1

Easy Learn: STA-IL Insertion

Site Area effected:

Single Tooth Anesthesia

Injection site:1. Start on distal

2. Bend needle, if necessary, to

gain access

3. It is best to maintain a direct

view of the needle and it’s

entrance to the sulcus at all

times

4. It is important for the shaft of

the needle to be parallel with

the surface of the root

Step - 2

You need a slight bend to the needle to allow proper access.

NOTE: You cannot access the distal of the lower

molars properly without bending the needle slightly.

Incorrect Correct

Unbent needle Bent needle

(allows proper angle and access to PDL)

• Important to maintain direct vision of proper needle

angle and needle entrance into the sulcus when using

either approach

• Distal-buccal requires needle to be bent as well

Buccal Approach

Mesial Approach

Incorrect needle

angle and entrance

Correct

• Proper angle and entrance can be achieved with bent or straight needle

Incorrect

Objective of Insertion:1. Needle tip to entrance of PDL

Angle of Insertion:1. 30 to 45 degrees

2. Bend needle, if necessary

3. Direct vision of needle

4. Needle shaft parallel to root

Movement of Insertion:1. Very SLOWLY advance needle

producing Anesthetic Pathway

2. Needle is inserted like a

“Periodontal Probe”, gently

Easy Learn: Needle Insertion

Step - 3

30º

Easy Learn: Dynamic Pressure

Sensing

What is the DPS feature: This feature provides real-time audible and

visual feedback to indicate when the needle is properly positioned when performing the STA-Intra-ligamentary (PDL) injection.

How to use:1. In STA-Mode only

2. Start injection

3. Insert needle into “assumed” correct PDL injection location

4. Wait approximately 10-15 seconds in “assumed” correct location

5. Listen & Watch, “ascending tone” & Increase of Pressure Scale through “orange” LED zone

6. Maintaining the High “orange” or the “green” LED zone throughout confirms proper needle location

Step - 4

Easy Learn: DPS® technology

Trouble Shooting:

Problem:Pressure not building:

1. Insufficient hand pressure on

STA/Wand handpiece

2. Did not wait 10 -15 seconds to

allow pressure to build

3. Incorrect needle position

Over-Pressure Alert:

1. Excessive hand pressure on

STA/Wand handpiece

2. Blocked needle tip with excessive

hand pressure into PDL tissue

3. Incorrect needle position

Step - 5

Lesson 3Tools needed to perform

AMSA - Injection

What you need to perform this injection:

30-g ½ inch – Bonded STA-Wand® Handpiece

Cotton-applicator with wooden-handle required

The STA drive-unit set to “STA” mode

Lesson 3How to Perform AMSA-

Injection

What you need to Learn:

How to use Cruise-control feature

How to perform Pre-Puncture Technique

How to perform Anesthetic Pathway Technique

How to use STA-aspiration to prevent back-spray of

anesthetic into patients mouth

Easy Learn: AMSA Insertion

Site Area effected:

The AMSA can produce pulpal

anesthesia from the Central Incisor to

the 2nd Premolar and the associated

hard and soft palatal tissues.

Injection site:1. Imagine a line located between

the 1st and 2nd Premolar

2. Mid-way along an imaginary

line from the palatal suture to

the free gingival margin

3. Approach this site with the

hand-piece from the contra-

lateral premolars

Bisect premolars

Midway between the free

gingival margin and

mid-palatine suture

Step - 1

Easy Learn: AMSA Insertion

Site Injection site:

1. Imagine a line located between

the 1st and 2nd Premolar

2. Mid-way along an imaginary

line from the palatal suture to

the free gingival margin

3. Approach this site with the

hand-piece from the contra-

lateral premolars

Step - 1

Clinical Technique: AMSA

Injection

AMSA Injection

A new technique that enables us to

anesthetize a maxillary quadrant in the

primary dentition with one injection.

Referances

Friedman MJ, Hochman MN. The

AMSA injection: A new concept for local

anesthesia of maxillary teeth using a

computer-controlled injection system.

Quintessence Int. 1998; 29:297-303

Gibson RS, Allen K, Hutfless S, Beiraghi

S. The Wand vs. traditional injection: A

comparison of pain related behaviors.

Pediatric Dent. 2000;22:458-462

Lesson 4 Performing P-ASA

Injection

What you need to Learn:

How to use Cruise-control feature

How to perform Pre-Puncture Technique

How to perform Anesthetic Pathway Technique

How to use STA-aspiration to prevent back-spray of

anesthetic into patients mouth

Clinical Technique: P-ASA

Injection

Easy Learn: P-ASA Insertion

Site Area effected:

The P-ASA can produce pulpal

anesthesia of the Central and

Lateral Incisors and the

associated hard and soft

palatal tissues

Injection site:1. Entry point is the incisive

groove surrounding the incisive

papilla

2. Final needle tip position is

within the incisive canal

Step - 1

Easy Learn: Anesthetic

Pathway What is the Pre-Puncture

technique: The technique allows you to penetrate

and advance the needle through the

palatal gingiva with minimal

discomfort to the patient

How to perform:1. Place bevel against surface

with cotton-applicator on-top

2. Wait 8 seconds- then rotate

and penetrate surface 1 - 2 mm

3. Advancement Pace: 1 - 2 mm

then wait 4 seconds to allow

anesthetic to proceed needle

4. Advance needle until bevel

contacts surface of bone

Step - 2

Clinical Technique: P-ASA

Injection

Lesson 5Tools needed to perform

IA Block Injection

What you need to perform this injection: Smaller Children: 30-g 1 inch – Bonded STA-Wand® Handpiece

Adolescents : 27-g 1 ¼ inch – Bonded STA-Wand® Handpiece

Normal Mode

Lesson 5

Performing IA Block

Injection

What you need to Learn:

How to change to Normal Mode

How to use Cruise-control feature

How to perform Anesthetic Pathway Technique

How to use Bi-Rotational Insertion Technique

How to use STA-aspiration

How to use 2 speed operation

Easy Learn: Bi-rotation

Insertion

Bi-rotation Insertion technique: This technique allows you to minimize needle

deflection during insertion.

How to perform: Rotate needle in a back-n-forth fashion

Rotational

Insertion

Linear

Insertion

Deflection

X X

Linear Rotational

Insertion Techniques

Easy Learn: 2-Speed Operation

Step - 1

1

2

Using “Normal” mode 2-

speed operation: You can more effectively and efficiently

perform the IA Block using the 2-speeds

How to use:1. Depressing the foot control lightly

allows you to start the injection using

the ControFlo (slower) flow rate –

Use for the first ¼ cartridge of IA

Block

2. Depressing the foot control all the

way down allows the second, more

rapid rate to administer the remaining

volume of anesthetic

Easy Learn: Aspiration

Step - 2

1

2

3

Using Aspiration to prevent

intravascular needle

placement: You can prevent needle placement into a

vessel by use of aspiration

How to use: After completion of needle

placement:

1. Press and then release foot-control

pedal to activate aspiration, which is

six beeps for the complete cycle

2. If you see blood in the needle

hub, re-position needle and re-

aspirate until negative observation

Easy Learn: Anesthetic

Pathway Anesthetic Pathway

technique: This technique allows you to

penetrate and advance the needle

through the mucosa and soft-tissues

with minimal discomfort to the patient.

How to perform:1. Penetrate mucosa

2. Advancement Pace: 1- 2 mm

then wait 4 seconds to allow

anesthetic to proceed needle

3. Advance needle until contact

against surface of bone

Lesson 6Performing Multi-

Cartridge Block

Multi-cartridge

technique

• Safe

• Effective

• Efficient

Single insertion

Multiple Cartridges

Lesson 7Tools needed to Perform

Supraperiosteal/Buccal

Infiltration Injection

What you need to perform this injection:

30-g 1-inch Bonded STA-Wand® Handpiece

Normal Mode

Lesson 7Performing Supraperiosteal/

Buccal Infiltration Injection

What you need to Learn:

How to change to Normal Mode

How to use Cruise-control feature

How to perform Anesthetic Pathway Technique

How to use STA-aspiration

How to use 2 speed operation

Easy Learn: Anesthetic

Pathway Anesthetic Pathway

technique: The technique allows you to penetrate

and advance the needle through the

mucosa and soft-tissues with minimal

discomfort to the patient.

How to perform:1. Penetrate mucosa

2. Advancement Pace: 1 - 2 mm

then wait 4 seconds to allow

anesthetic to proceed needle

3. Advance needle until contact

against surface of bone

Lesson 8Maintenance

What you need to Learn:

How to change to Lubricate and Service Plunger

How to clean and care for STA Drive Unit

Advanced Features

What you need to Learn:

How and Why to use Multi-cartridge feature

How to change to Manual Plunger Operation

How to change de-activate Aspiration

How to adjust the Sound Volume control

How to change Mode of operation

A - Anesthetic Level Indicator

B - Auto Purge/Retract/Hold to

Retract

C - Multi-Cartridge/Hold to Train

Mode

D - Dynamic Pressure Indicator

E - STA Mode

F - Select Mode (Normal or Turbo)

G - Aspiration Button

H - Volume Control

I - Power Light

C

A

D

I

E

F

GH

B

Advanced Lesson

Multi-CartridgeUsed for 2nd or 3rd Cartridge on Same Patient

While plunger is

retracted, press Multi-

Cartridge/Train Button

Indicator light turns ON

Remove empty cartridge;

replace with new one

Insert cartridge holder onto

top of STA; continue

injection

STA defaults to Multi-

Cartridge OFF after injection

Auto Purge / Manual Purge

Auto Purge: default setting

and will automatically

purge air from the system

when set up is complete

Manual Purge: press the

Auto Purge Button B then

depress the foot pedal to

purge air from the system

B

Plunger Retraction

Plunger Retracts Automatically: When Auto Purge/Retract

Light (A) is ON

When cartridge is emptied or when cartridge holder is removed

Plunger Retracts Manually: Push and hold Retract

Button (B) for 4+ seconds

B

A

AspirationAfter purging, STA

defaults to

Aspiration ON

If not needed, Aspiration can

be turned OFF, by pressing

Aspirate button

Cartridge Volume

LED lights indicate

amount of anesthetic

solution remaining

STA “bongs” once

when ¼ cartridge is

expressed, twice when

½ is expressed, and

three times when ¾ is

used

Sound Volume

Control To Change Audible

Volume:

Press up arrow to

increase volume

Press down arrow to

decrease volume

Modes of operation:

STA, Normal, Turbo

“Select” button change

A - STA Mode – 1 speed

ControlFlo only

DPS® (Dynamic

Pressure Sensing)

B - Normal Mode – 2 speed

ControlFlo and RapidFlo

C - Turbo Mode - 3 speed

ControlFlo, RapidFlo, and

TurboFlo

A

B C

Foot Control and Mode

Selections:

Depress Pedal Slightly ControlFlo Speed Used for Palatal and PDL

injections exclusively

Start of all injections during the first ¼ cartridge

Depress Pedal Moderately RapidFlo Speed

Infiltration & MandibularBlock

After first ¼ cartridge only

Depress Pedal Firmly TurboFlo Speed

After first ½ cartridge only

DPS® - Dynamic Pressure Sensing

Informs the Dentist of Correct Injection Site (PDL Space)

with Ascending Lights and Sounds

Informs the Dentist if the Needle has Left the Correct Site

Informs the Dentist if the Needle has been Blocked

All Feedback Information in Real Time

STA-Intraligamentary Injection

Technique: DPS - Dynamic Pressure

Sensing Hold needle steadily in place with minimal

pressure for approximately 15 seconds

Ascending tones and lights will indicate the needle is in the correct injection site, the periodontal ligament space

If ascending tones and lights are not initiated after 15 seconds, move needle slightly until the correct position is attained and lights and tones are seen and heard

Behavioral Management

CCLAD technology has improved the overall

acceptance of the anesthetic injection in the

pediatric population leading to less disruptive

behavior.

References

Lieberman, William H. Clinical Session:

The Wand. Pediatric Dent. 1999;21:2

Allen KD, Kotil D, Larzelere RE, Hutfless

S, Beiraghi S. Comparison of a

computerized anesthesia device with a

traditional syringe in preschool children.

Pediatric Dent. 2002 Jul-Aug;24(4):

315-20

Pediatric

Restorative Dentistry

Painless & Predictable

Bi-Lateral

Restorative Dentistry

Efficient

No Soft Tissue

Numbness

STA-IL Anterior Teeth

Bevel orientation

Mark the Bevel

Patient Compliance

Lack of Disruptive Behavior

Prevent “Dripping”

HAPPY PATIENTS

Cooperative Patients

Dr. Bill’s Helpful Tips

Needle choice o 30 gauge for all

o 1” for older children mandibular blocks

o ¾” for infiltration and blocks in younger

children

o ½” for STA (periodontal ligament injection)

Break the Wand for any injection to better

“cup” the needle

Mark the bevel with a permanent marker

Bend the needle with caution, as

needed, for a better angle

Dr. Bill’s Helpful Tips

Dr. Bill’s Helpful Tips

Instrument location - LED’s should be

clearly visible to operator & within reach

Start instrument prior to injection to avoid

startling the patient

Use cruise control- NEVER turbo w/

pediatric patient

Dr. Bill’s Helpful Tips

Avoid dripping the anesthetic in the mouth -

the bitter taste is the easiest way to lose a

compliant patient

Develop a consistent pattern of injection

site (distolingual is best due to anatomy if

manageable)

Rule of 2’s for STA: o 20 seconds MAXIMUM time to be in one

location

o 2 minute window to begin procedure

o 20 minutes to complete treatment

Watch the videos on the website…very

helpful! www.STAis4U.com

Dr. Bill’s Helpful Tips

Timeliness

Summary

Audible & visible assurance of pulpal anesthesia

Painless- minimizes disruptive behavior

Immediate onset of anesthesia

o no delay is important for a child’s short attention span

o saves chair time

Multiple quadrants at the same visit

No soft tissue numbness - no risk of lip biting

Thank You Dr. Mark

Hochman!

Infant Oral ExamAnticipatory Guidance

Infant Lap to Lap Exam

BRIGHT

FUTURES

Guidelines For Health Supervision of

Infants, Children, and Adolescents

C A M B R A

Caries Management by Risk Assessment

Prevention

Fluoride Varnish

Remineralization products

Recaldent

Novamin

Pro-Argin

Restorative Materials

RMGI

Resin Modified Glass Ionomer

Our office mission statement includes “to create an atmosphere that allows the pediatric patient to succeed”. Nothing helps more than successful, painless anesthesia with no risk of collateral soft tissue damage from lip biting.