Supraperiosteal infiltration is not effective for teeth surrounded by thick alveolar bone, such as the mandibular teeth and some upper molars of adults.
Indications for Supraperiosteal Infiltration
A painful dental condition (toothache) or its treatment:
Mild to moderate tooth abscess (only if the abscess is sufficiently small that local infiltration will provide adequate anesthesia; otherwise, a nerve block is used)
Contraindications to Supraperiosteal Infiltration
Allergy to the anesthetic agent or delivery vehicle
Absence of anatomic landmarks needed to guide needle insertion (eg, due to trauma)
Infection in the path of needle insertion: Use nerve block, or other anesthesia.
Coagulopathy*: When feasible, correct prior to procedure.
Pregnancy: Avoid treatment in the 1st trimester if possible.
*Therapeutic anticoagulation (eg, for pulmonary embolism Pulmonary Embolism (PE) Pulmonary embolism (PE) is the occlusion of pulmonary arteries by thrombi that originate elsewhere, typically in the large veins of the legs or pelvis. Risk factors for pulmonary embolism are... read more ) increases the risk of bleeding with dental procedures, but this must be balanced against the increased risk of thrombosis (eg, stroke Overview of Stroke Strokes are a heterogeneous group of disorders involving sudden, focal interruption of cerebral blood flow that causes neurologic deficit. Strokes can be Ischemic (80%), typically resulting... read more ) if anticoagulation is reversed. Discuss any contemplated reversal with the clinician managing the patient's anticoagulation and then with the patient.
Complications of Supraperiosteal Infiltration
Allergic reaction to the anesthetic
Toxicity due to anesthetic overdose (eg, seizure, cardiac arrhythmias)
Intravascular injection of anesthetic/epinephrine
Spread of infection, by passing the needle through an infected area
Failure to anesthetize
Needle breakage (rare)
Most complications result from inaccurate needle placement.
Equipment for Supraperiosteal Infiltration
Dental chair, straight chair with head support, or stretcher
Light source for intraoral illumination
Mask and safety glasses, or a face shield
Dental mirror or tongue blade
Equipment to do local anesthesia:
Topical anesthetic ointment* (eg, lidocaine 5%, benzocaine 20%)
Injectable local anesthetic such as lidocaine 2% with or without epinephrine† 1:100,000, or for longer duration anesthesia, bupivacaine 0.5% with or without epinephrine† 1:200,000
Dental aspirating syringe (with narrow barrel and custom injectable anesthetic cartridges) or other narrow barrel syringe (eg, 3 mL) with locking hub
25- or 27-gauge needle: 2 cm long for supraperiosteal infiltration
* CAUTION: All topical anesthetic preparations are absorbed from mucosal surfaces and toxicity may result when dose limits are exceeded. Ointments are easier to control than less-concentrated topical liquids and gels. Excess benzocaine rarely may cause methemoglobinemia.
† Maximum dose of local anesthetics: Lidocaine without epinephrine, 5 mg/kg; lidocaine with epinephrine, 7 mg/kg; bupivacaine, 1.5 mg/kg. NOTE: A 1% solution (of any substance) represents 10 mg/mL (1 gm/100 mL). Epinephrine causes vasoconstriction, which prolongs the anesthetic effect. Patients with cardiac disease should receive only limited amounts of epinephrine (maximum 3.5 mL of solution containing 1:100,000 epinephrine); alternatively, use local anesthetic without epinephrine.
Additional Considerations for Supraperiosteal Infiltration
Stop the supraperiosteal infiltration procedure and find a different method of anesthesia if the patient is uncooperative.
Relevant Anatomy for Supraperiosteal Infiltration
Supraperiosteal infiltration anesthetizes individual dental nerves.
Injectable anesthetic is placed adjacent to the lateral (buccal) alveolar bone supporting the tooth, at the level of the root tip.
The anesthetic diffuses across the alveolar bone to reach the dental nerves of individual teeth.
Positioning for Supraperiosteal Infiltration
Position the patient inclined, with the patient's head at the level of your elbows and the occiput supported.
For the lower jaw, use a semi-recumbent sitting position, making the lower occlusal plane roughly parallel to the floor when the mouth is open.
For the upper jaw, use a more supine position, making the upper occlusal plane roughly 60 to 90 degrees to the floor.
Turn the head and extend the neck such that the injection site (upper or lower mucobuccal fold) will be accessible.
Step-by-Step Description of Procedure
Wear nonsterile gloves and mask and safety glasses, or a face shield.
Instruct the patient to partially close the mouth and relax the jaw, lip, and cheek muscles.
Using your thumb and index finger, grasp the cheek lateral to the tooth, and retract it away from the tooth, to delineate the mucobuccal fold.
Use gauze to thoroughly dry the mucobuccal fold. Use suction as needed to keep the area dry.
Apply topical anesthetic with cotton-tipped applicators and wait 2 to 3 minutes for the anesthesia to occur.
Inject the local anesthetic
Again retract the lip laterally, to delineate the mucobuccal fold. Keep the mucosa taut.
Hold the anesthetic syringe such that the needle bevel faces the tooth.
Insert the needle into the depth of the mucobuccal fold and advance parallel to the tooth until it contacts bone, aiming for the apex (1 to 1.5 cm to contact the adult maxilla).
Aspirate, to exclude intravascular placement. If aspiration reveals an intravascular placement, withdraw the needle 2 to 3 mm, then re-aspirate prior to injection.
Slowly inject about 1 to 2 mL of anesthetic. During the injection, use a finger to apply external pressure to the cheek near the site of anesthetic deposition, to prevent local tissue ballooning.
If anesthesia is not satisfactory after 10 minutes, inject a small amount on the palatal/lingual side. This is commonly required for a tooth extraction.
Aftercare for Supraperiosteal Infiltration
Have the patient rest, with mouth relaxed, while awaiting onset of anesthesia (5 to 10 minutes).
Warnings and Common Errors of Supraperiosteal Infiltration
To minimize the risk of needle breakage, do not bend the needle prior to insertion, do not insert the needle to its full depth (ie, to the hub), and instruct the patient to remain still, with the mouth wide open, and resist grabbing your hand.
Tricks and Tips
Distraction techniques (eg, talking to the patient or having the patient hold someone else's hand) may help to reduce patient anxiety.
Inject the local anesthetic solution slowly (30 to 60 seconds) to reduce the pain of injection.
Upper molars with thick overlying bone are sometimes not adequately anesthetized with supraperiosteal infiltration alone. If so, do a posterior superior alveolar nerve block. Using a 25- or 27-gauge long (3-cm) needle, enter the mucobuccal fold over the second molar. Aim posteriorly, superiorly, and medially, toward the posterior wall of the maxillary tuberosity at the level of the root apices. Aspirate, and then inject 1 to 2 mL of anesthetic solution.