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Welcome to the

Local Anesthesia for Patients

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 ChildrenMBA, HealthcareCoordinator Dental Continuing Education, Monmouth Medical CenterAssistant Clinical Professor at New York UniversityBrief Bio.

1975-2011Then & NowPaper ChartsElectronic Charts

1975-2011Then & Now X-Ray FilmX-Ray Sensors

1975-2011Then & Now Amalgam RestorationsComposite (RMGI) Restorations

1975-2011Then & Now Curing LightLED Light

1975-2011Then & Now SyringesThe Wand / STA - Single Tooth Anesthesia System Instrument

8Table of Contents Set Up Basic operation Injection Techniques Maintenance Advanced optionswww.STAis4U.com

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19041884Drug choice and Volume4% Articaine HCLAdult: cartridgeChild: cartridgePreferred Vasoconstrictor Concentration1:100,000 epinephrine

2% Lidocaine HCLAdult: cartridgeChild: cartridgePreferred vasoconstrictor concentration1:100,000 epinephrine11What do you see ?

Prevalence of Dental Fear?

Agras, et al. 197920% Technology ?

1853 1904 2010150+ years

Computer-Controlled Local Anesthetic Delivery System

New Innovation

C-CLAD

1997

1997 1st Generation

2007 3rd GenerationComputer Controlled LocalAnesthetic Delivery System

Disruptive TechnologyAn innovation that alters a product or service in ways the market does not expect Allows you to do something you cant do any other way!

Simple mechanical system

Dynamic Pressure Sensing Technology - DPS

Monitors Exit-Pressure Real-Time, continuous informationVisual and audible feedbackSystem control: Exit-Pressure

No Feedback

FPO

TotalFeedback

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

NYS Dental Journal 1997 Method & Material50 patients (dentists)Palatal injectionEach patient served as a controlSubjects blinded to techniqueVAS scale, subjective pain scoring3 examiners performed testing

CCLADS: Fixed flow-rate = 0.005ml/sec = 2 minutesHandheld syringe: Maintained injection for 2 minutesHochman M, Chiarello D, Hochman C, Lopatkin R, Pergola S.Number of Subjects = 50RESULTS: Wand group - 82% reported No Pain or Minimal Pain Placebo group 10% reported No Pain or Minimal Pain

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

Histology: PDL injectionMETHODS & MATERIALS3 subjects / 32 sites;Control site1 hr, 1 day, 4 days, 7 days, 21 days & 49 daysDosage Volume = 1.0 mlData on Different Tissue Types and Dental InjectionsInterstitial Tissue Pressure Associated With Dental Injections: A Clinical Study Quintessence Int 2006; Vol 37: 469-476.

200 dental injections (50/group)Group 1 PDLGroup 2 - Palatal injectionGroup 3 - Buccal infiltrationGroup 4 - Mandibular blockMeasured pressure in real-timeFixed flow-rate: 0.005ml/sec

Hochman, Friedman, Williams, Hochman 25

Validation

Prof. Stanley Malamed

Prof. J. Meechan

Prof. Dionne

Prof. BassettProf. DiMarcoProf. NaughtonLesson 1 Set Up and Basic Operation27Step - 1 FRONTAttach Foot ControlTighten Securely BACK Attach Power CordTurn Power Switch OnWait 5 seconds for STA to Self-calibrate

28Step - 2ANESTHETIC CARTRIDGE

Insert cartridge into holderPress firmly until spike punctures the diaphragm

29Step - 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

30Step - 3Shorten length of Wand Handpiece

Remove tubing handpieceShorten by breaking the length of the handleMark the bevel

31Step - 4 Insert wings of holder into top of STATurn counter-clockwise turn

STA activates and purges handpiece of airLights are activated

Insertion of Cartridge Holder32Step - 4b Turn clockwise turn

Push cartridge out using finger slots at top of cartridge holderRemove cartridge and continue

Removal of Cartridge Holder

33The Training Mode provides an audible explanation of the various functions of the STAAllows one to become familiar with operating the STAEnable Training Mode by pressing and holding the Hold to Train button for 4 seconds

Easy Learn: Training ModeStep - 534Step 6 System is Ready

35Lesson 2: Performing the STA-Intra-ligamentary InjectionLearn the Injection of Your ChoiceLesson 3: Performing the AMSA (Palatal) Injection36Lesson 2 Tools needed to perform STA-IL InjectionWhat you need to perform this injection:Bonded - 30-g inch STA-Wand HandpieceThe STA drive-unit set to STA modeActivate Training Mode feature (optional)37Lesson 2 Performing STA-IL InjectionWhat you need to learn:How to use Cruise-control featureUnderstand how DPS worksHow to use STA aspiration to prevent back-spray of anesthetic into patients mouth

38Performing STA-Intra-ligamentary InjectionEasy Learn: Cruise ControlWhat is the Cruise Control feature:The feature allows you to deliver anesthetic solution without the need of continuously depressing the foot pedal, its analogous to cruise-control in your car in which you release the accelerator and continue to drive.How do you activate:Start injection by depressing pedalAfter 3 seconds voice prompt will say CruiseImmediately release foot off pedal to remain in cruise mode

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

Step - 140Easy Learn: STA-IL Insertion Site Area effected:Single Tooth AnesthesiaInjection site:Start on distalBend needle, if necessary, to gain accessIt is best to maintain a direct view of the needle and its entrance to the sulcus at all timesIt is important for the shaft of the needle to be parallel with the surface of the rootStep - 2

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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.

IncorrectCorrectUnbent needleBent 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 wellBuccal Approach Mesial Approach

Incorrect needleangle and entranceCorrect Proper angle and entrance can be achieved with bent or straight needle Incorrect

Objective of Insertion:Needle tip to entrance of PDLAngle of Insertion:30 to 45 degreesBend needle, if necessaryDirect vision of needleNeedle shaft parallel to rootMovement of Insertion:Very SLOWLY advance needle producing Anesthetic PathwayNeedle is inserted like a Periodontal Probe, gently

Easy Learn: Needle InsertionStep - 330Easy Learn: Dynamic Pressure SensingWhat 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:In STA-Mode onlyStart injectionInsert needle into assumed correct PDL injection location Wait approximately 10-15 seconds in assumed correct locationListen & Watch, ascending tone & Increase of Pressure Scale through orange LED zoneMaintaining the High orange or the green LED zone throughout confirms proper needle locationStep - 4

48Easy Learn: DPS technologyTrouble Shooting:Problem: Pressure not building:Insufficient hand pressure on STA/Wand handpieceDid not wait 10 -15 seconds to allow pressure to buildIncorrect needle position Over-Pressure Alert:Excessive hand pressure on STA/Wand handpieceBlocked needle tip with excessive hand pressure into PDL tissueIncorrect needle positionStep - 5

49Lesson 3 Tools needed to perform AMSA - InjectionWhat you need to perform this injection:30-g inch Bonded STA-Wand HandpieceCotton-applicator with wooden-handle requiredThe STA drive-unit set to STA mode

50Lesson 3 How to Perform AMSA- InjectionWhat you need to Learn:How to use Cruise-control featureHow to perform Pre-Puncture TechniqueHow to perform Anesthetic Pathway TechniqueHow to use STA-aspiration to prevent back-spray of anesthetic into patients mouth

51Easy 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:Imagine a line located between the 1st and 2nd PremolarMid-way along an imaginary line from the palatal suture to the free gingival marginApproach this site with the hand-piece from the contra-lateral premolars Bisect premolarsMidway between the free gingival margin and mid-palatine sutureStep - 1

52

Easy Learn: AMSA Insertion Site Injection site:Imagine a line located between the 1st and 2nd Premolar

Mid-way along an imaginary line from the palatal suture to the free gingival margin

Approach this site with the hand-piece from the contra-lateral premolars Step - 1

53

Clinical Technique: AMSA Injection54AMSA Injection A new technique that enables us to anesthetize a maxillary quadrant in the primary dentition with one injection.ReferancesFriedman MJ, Hochman MN. The AMSA injection: A new concept for local anesthesia of maxillary teeth using a computer-controlled injection system. Quintessence Int. 1998; 29:297-303Gibson RS, Allen K, Hutfless S, Beiraghi S. The Wand vs. traditional injection: A comparison of pain related behaviors. Pediatric Dent. 20