2. Dr. William H. Lieberman D.D.S., M.B.A.
⢠Private pediatric practice in New Jersey
⢠Past-President American Society of Dentistry for
Children
⢠Past Trustee, American Academy of Pediatric
Dentistry
⢠MBA, Healthcare
⢠Coordinator Dental Continuing
Education, Monmouth Medical Center
⢠Associate Clinical Professor at New York University
Brief Bio.
9. American Academy of Pediatrics
American Academy of Pediatric
Dentistry
Recommendation:
Dental home by age 1
10.
11. ANTICIPATORY GUIDANCE â
What is it?
It is the process of providing practical, developmentally
appropriate health information about children to their parents
in anticipation of significant physical, emotional and
psychological milestones.
-Nowak and Casamassimo 1995
15. Airway Space
⢠The pediatric dentist can be the first to identify
airway structure issues.
⢠Learn how to incorporate this knowledge and
develop a medical/dental team approach for the
developing child
43. Characteristics of Reported Pain
Provoked : thermal, chemical, mechanical
⢠indicates dentin sensitivity, pulp in transitional stage
⢠usually acute inflammation and reversible
Spontaneous
⢠throbbing, constant
⢠indicates advanced pulp damage
⢠pulp usually non-treatable
⢠irreversible pulpitis or necrosis
⢠often nocturnal
44. Radiographic Examination
Internal resorption
⢠once internal resorption has become advanced to
be seen radiographically there is usually a
perforation of the root by the resorptive process
Pathologic bone and root resorption
⢠Indicative of advanced pulp degeneration. The
pulp tissue may remain vital even with such
advanced degenerative changes.
48. IPT Technique
⢠Gross caries removal
⢠Walls extended to sound tooth structure
⢠Infected dentin removed
⢠Affected dentin remaining
⢠Should have 1mm sound dentin over remaining pulp
⢠Base over remaining dentin
⢠Final restoration
⢠Must have good marginal integrity
⢠Recall for evaluation
49. IPT Protocol
⢠Local anesthesia and rubber dam placement
⢠Excavation of infected dentin
⢠Caries detector (Sable SeekŽ from Ultradent) utilized
⢠Cavity photographed
⢠Placement of 2.0% chlorhexidine gluconate viscous
solution, Consepsis VÂŽ (Ultradent Products, Inc) for 60
seconds
⢠Placement of a resin-modified glass ionomer (Fuji II-LCŽ
GC America) on the preparation floor
⢠Final restoration placement: internal or full coverage
⢠Final photograph
⢠Recall 3, 6 and 12 months
51. Radiographic findings of primary first molar
post-treatment
6 months post-treatment
12 months post-treatment
52. Findings:
⢠3 month recall 100% teeth were WNL
⢠6 month follow-up 93% teeth were WNL
⢠Failure of Class II composite and one SSC restoration
⢠12 month recall all remaining teeth were WNL
ProspectiveIPTinPrimaryMolarsusingRMGIand2%
CHX:A 12monthfollow-up
72. Step - 1
FRONT
⢠Attach Foot Control
⢠Tighten Securely
BACK
⢠Attach Power Cord
⢠Turn Power Switch On
⢠Wait 5 seconds for STA to
Self-calibrate
73. Step - 2
ANESTHETIC CARTRIDGE
⢠Insert cartridge into holder
⢠Press firmly until spike punctures the diaphragm
74. 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
75. Step - 3
Shorten length of
Wand Handpiece
⢠Remove tubing handpiece
⢠Shorten by âbreakingâ the length
of the handle
⢠Mark the bevel
76. Step - 4
⢠Insert wings of holder
into top of STA
⢠Turn counter-clockwise
Âź turn
⢠STA activates and purges
handpiece of air
⢠Lights are activated
Insertion of Cartridge Holder
77. Step - 4b
⢠Turn clockwise Ÿ turn ⢠Push cartridge out using
finger slots at top of cartridge
holder
⢠Remove cartridge and
continue
Removal of Cartridge Holder
78. ⢠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
âHold to Trainâ button for 4
seconds
Easy Learn: Training Mode
Step - 5
80. Lesson 2: Performing the
STA-Intra-ligamentary Injection
Learn the Injection of
Your Choice
Lesson 3: Performing the
AMSA â (Palatal) Injection
81. Lesson 2
Tools needed to perform
STA-IL Injection
⢠What you need to perform this injection:
⢠Bonded - 30-g ½ inch STA-WandŽ Handpiece
⢠The STA drive-unit set to âSTAâ mode
⢠Activate Training Mode feature (optional)
82. Lesson 2
Performing STA-IL
Injection
⢠What you need to learn:
⢠How to use Cruise-control feature
⢠Understand how DPSŽ works
⢠How to use STA aspiration to prevent back-spray of anesthetic into patients
mouth
84. 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, itâs 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 âCruiseâ
3. Immediately release foot off pedal
to remain in cruise mode
⢠How do you de-activate:
⢠Tap foot-control pedal to stop
Step - 1
85. 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 itâs 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
86. You need a slight bend to the needle to allow proper access.
91. ď Objective of Insertion:
1. Needle tip to entrance of PDL
ď Angle of Insertion:
1. 30 to 45 degrees
2. Bend needle, if necessary
3. Direct vision of needle
4. Needle shaft parallel to root
ď Movement of Insertion:
1. Very SLOWLY advance needle
producing Anesthetic Pathway
2. Needle is inserted like a
âPeriodontal Probeâ, gently
Easy Learn: Needle Insertion
Step - 3
30Âş
92. 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 âassumedâ correct
PDL injection location
4. Wait approximately 10-15 seconds in
âassumedâ correct location
5. Listen & Watch, âascending toneâ &
Increase of Pressure Scale through
âorangeâ LED zone
6. Maintaining the High âorangeâ or the
âgreenâ LED zone throughout confirms
proper needle location
Step - 4
93. Easy Learn: DPSÂŽ
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
94. AMSA Injection
⢠A new technique that enables us to anesthetize a maxillary
quadrant in the primary dentition with one injection.
95. Lesson 3
Tools needed to perform
AMSA - Injection
⢠What you need to perform this injection:
⢠30-g ½ inch â Bonded STA-WandÂŽ Handpiece
⢠Cotton-applicator with wooden-handle required
⢠The STA drive-unit set to âSTAâ mode
96. Lesson 3
How 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
97. 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
ď Bisect premolars
ď Midway between the free
gingival margin and
mid-palatine suture
Step - 1
98. 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
101. 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
103. 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
104. 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
106. Lesson 5
Tools needed to perform IA
Block Injection
⢠What you need to perform this injection:
⢠Smaller Children: 30-g 1 inch â Bonded STA-WandÂŽ Handpiece
⢠Adolescents : 27-g 1 Âź inch â Bonded STA-WandÂŽ Handpiece
⢠Normal Mode
107. 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
108. 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
110. Easy Learn: 2-Speed Operation
Step - 1
1
2
⢠Using âNormalâ 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 â Use
for the first Âź 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
111. 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
112. 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
113.
114. Lesson 7
Tools needed to Perform
Supraperiosteal/Buccal
Infiltration Injection
⢠What you need to perform this injection:
⢠30-g 1-inch Bonded STA-WandŽ Handpiece
⢠Normal Mode
115. Lesson 7
Performing 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
116.
117. 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
119. Cartridge Volume
⢠LED lights indicate
amount of anesthetic
solution remaining
⢠STA âbongsâ once when
Âź cartridge is
expressed, twice when ½
is expressed, and three
times when ž is used
120. Sound Volume Control
To Change Audible
Volume:
⢠Press up arrow to increase
volume
⢠Press down arrow to
decrease volume
121. Modes of operation:
STA, Normal, Turbo
âSelectâ button change
⢠A - STA Mode â 1 speed
ControlFlo only
DPSÂŽ (Dynamic Pressure
Sensing)
⢠B - Normal Mode â 2 speed
ControlFlo and RapidFlo
⢠C - Turbo Mode - 3 speed
ControlFlo, RapidFlo, and
TurboFlo
A
B C
122. Foot Control and Mode Selections:
⢠Depress Pedal Slightly
⢠ControlFlo Speed
⢠Used for Palatal and PDL injections
exclusively
⢠Start of all injections during the first
Âź cartridge
⢠Depress Pedal Moderately
⢠RapidFlo Speed
⢠Infiltration & Mandibular Block
⢠After first Ÿ cartridge only
⢠Depress Pedal Firmly
⢠TurboFlo Speed
⢠After first ½ cartridge only
123. DPSÂŽ - 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
124. STA-IntraligamentaryInjection
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
126. Behavioral Management
⢠CCLAD technology has improved the overall acceptance of the anesthetic
injection in the pediatric population leading to less disruptive behavior.
127. 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
140. Dr. Billâs Helpful Tips
â˘Needle choice
o 30 gauge for all
o1â for older children mandibular blocks
o žâ for infiltration and blocks in younger children
o ½â for STA (periodontal ligament injection)
141. ⢠Break the Wand for any injection to better
âcupâ the needle
⢠Mark the bevel with a permanent marker
⢠Bend the needle with caution, as needed, for a
better angle
Dr. Billâs Helpful Tips
142. Dr. Billâs Helpful Tips
⢠Instrument location - LEDâs 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
143. Dr. Billâs 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)
144. â˘Rule of 2âs for STA:
o20 seconds MAXIMUM time to be in one
location
o2 minute window to begin procedure
o20 minutes to complete treatment
⢠Watch the videos on the websiteâŚvery helpful!
www.STAis4U.com
Dr. Billâs Helpful Tips
146. Summary
ď Audible & visible assurance of pulpal anesthesia
ď Painless- minimizes disruptive behavior
ď Immediate onset of anesthesia
o no delay is important for a childâs short attention span
o saves chair time
ď Multiple quadrants at the same visit
ď No soft tissue numbness - no risk of lip biting