china ppt 2
TRANSCRIPT
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.