Needleless Jet Injection in Comprehensive Pain Control and Applications to Oral Surgery William Greenfield, D.D.S.f Joseph F. Karpinsld, D.D.S.tf

Although jet injection devices have been The study was undertaken with several used in various fields for over 25 years, it is basic objectives in mind: relatively recently that instruments with 1. To determine the potential use of the practical applications to dentistry have Syrijet alone without additional local been made available.1 There have been in- blocks in performing various types of oral troduced several self-contained, automatic- surgical procedures. loading, spring-powered syringe devices 2. To determine the use of the Syrijet with a jet nozzle, in which local anesthetic in procedures under general anesthesia and solution is rapidly propelled into tissue by various forms of psychosedation. means of mechanical spring pressure with- 3. To determine patient acceptance of out the use of a needle. Since one of the the Syrijet with these techniques. authors (W.G.) has had the opportunity of working with virtually all of the devices Methods and Procedures that have been introduced for this purpose The use of the Syrijet prior to the ad- to date, a study was undertaken to deter- ministration of local anesthesia by conven- mine the potential of one of these instru- tional needle and syringe has been well ments which was felt to be the most precise documented2, 3, and was not a basic objec- and sophisticated of those currently avail- tive of this study. However, in those situa- able. This instrument, the Syrijet Mark II tions in which additional local blocks were (Mizzy, Inc., N.Y., N.Y.) has several required in order to perform the procedure, unique advantages in that it accepts all the effect of the Syrijet in this regard was standard 1.8 cc cartridges of local anesthet- also assessed. ic solution (thereby ensuring sterility of the Over a six-month period, 680 patients solution), permits the administration of a were treated utilizing the Syrijet, in various variable volume of solution from 0 to 0.2 cc types of applications. (Table I) and is completely autoclavable. (Fig. 1) Table I Category of Application No. of Patients 1. Syrijet alone . 380 2. Inhalation (N20-02) ------...-....---140 3. Intravenous sedation - 70 4. General anesthesia -65 5. Neuroleptanalgesia ... 25 Total ...... 680

fAssociate Clinical Professor, Mt. Sinai School of Medicine; Assoc. Attending Oral Surgeon, Mt. Sinai Hospital and City Hospital Center. + iChief of Oral Surgery, Auburn Mercy Hos- pital; Consultant, Geneva General Hospital and Willard St. Hospital. 94 ANESTIMSIA PROGRESS The patients were of both sexes, and the B. Procedures which may require addi- ages ranged from 5 years to 61 years. The tional local blocks include: local anesthetic solution used was lidocaine (i) Removal of deciduous posterior hydrochloride 2% (Xylocaine, Astra Pharm. teeth; (ii) Removal of permanent an- Co.) with 1:100,000 epinephrine. The Syri- terior teeth. jet was used and maintained in accordance C. Procedures which generally require with the instructions furnished by the man- additional local blocks- ufacturer. The procedures were standard Removal of permanent posterior teeth. oral surgery procedures, performed in In evaluating the success of the applica- either hospital out-patient clinics or in pri- tion of the instrument to surgical proce- vate of offices. Table I summarizes the cate- dures, the vagaries of patient management gories of application. In Category 2, nitrous must be taken into consideration. For ex- oxide and oxygen were utilized in sedation ample it should be pointed out that several mixtures in addition to the Syrijet to pro- of the procedures on children that could vide pain control in conscious patients. In not be performed with the Syrijet alone Category 3, various combinations of barbi- could not be performed at all under local turates, tranquilizers and narcotics were anesthesia due to lack of cooperation on the utilized intravenously in addition to using part of the patient, and required a general the Syrijet to provide pain control. Patients anesthetic. Also, the instrument performed in Categories 2 and 3 were grouped to- best when applied in accordance with prop- gether as regards results, since they were er technique as advocated by the manu- all conscious and the techniques used are facturer. While most posterior permanent various forms of psychosedation. When teeth required the addition of local blocks general anesthesia is used, it is often de- for extraction, it is of interest to note that sirable to make use of local anesthesia as (12) posterior permanent teeth were re- well, in order to provide vasoconstriction moved using the Syrijet as the sole means and to provide an analgesic effect extend- of local anesthesia. Predictably, there was ing into the postoperative period. In Cate- a higher degree of success when some form gory 4, therefore, the Syrijet was used al- of psychosedation was used in conjunction though the patients were treated at an un- with the jet injector. With regard to the re- conscious level with various general anes- moval of permanent anterior teeth, most of thetic agents. In Category 5, neurolept and those that required additional local blocks dissociative drugs were used in addition to were canines. the Syrijet, and since the patients were at In patients treated under general anes- times unconscious, Categories 4 and 5 are thesia, the Syrijet provided a convenient grouped together for purposes of this study. means of infiltrating tissue with local-anes- The evaluation of patient acceptance thetic solution. It is often desirable to de- was on a purely subjective basis, by means posit local anesthetic solution at multiple of patient response to the technique. sites for purposes of vasoconstriction and postoperative analgesia, and the jet injec- Results tor makes it possible to accomplish this with a minimum of effort and time. The conscious patients in Categories 1, 2 Patient reaction to the Syrijet was most and 3, are summarized in Table II, as favorable in virtually all cases, including in- follows: stances in which additional local blocks A. Procedures successfully performed were required in order to perform the pro- with Syrijet alone include: cedure. The instrument was found to be (i) Soft tissue procedures; (ii) Re- particularly useful in areas which are most moval of deciduous anterior teeth and sensitive to the insertion of a needle, such most permanent central and lateral as the incisive papilla. incisors; (iii) Various relatively dis- While no serious complications were en- comforting procedures, such as re- countered at any time during the study, moval of bone spicules, application two factors recurred with a fair degree of and removal of arch bars and ligature regularity. One of these was bleeding at the wires, etc.; puncture site on the labial and buccal JULY-AUGUST, 1972 95 Table II torted with jet injection as it often is with Category 1 Category 2 & 3 conventional needle injection, for example Patients Patients Not Not in the excision of a lesion. In general, the Per- Per- Per- Per- formed formed formed formed instrument performed reliably and effec- With With With With tively. Syrijet Syrijet Syrijet Syrijet Alone Alone Alone Alone Procedure Discussion Soft tissue surgery- While the use of jet injection is not meant Incision and drainage 4 3 to replace the conventional needle syringe Gingivictomy 7 5 Excision soft tissue lesions for all procedures, it does provide a useful (fibroma, papilloma, etc.) 14 2 8 adjunct to the standard armamentarium. Placement of sutures 3 5 Revision hypertrophic tissue 2 1 Patients' fear of pain is often more difficult Reduction tuberosity 3- 1 to manage than the pain itself and fear of Excision mucous retention "the needle" is a significant consideration. cyst (lip) 2 1 Exodontia- While this is presumed to be particularly Deciduous teeth- true in children, even in adults one would Anterior maxillary 56 6 35 4 often rather tolerate the discomfort of a Posterior maxillary 28 12 26 11 Anterior mandibular 42 9 22 4 relatively minor procedure than be sub- Posterior mandibular 32 23 17 8 jected to the puncture of a needle. The jet Permanent teeth- for ex- Anterior maxillary 19 7 13 6 injector offers a useful alternative, Posterior maxillary 6 11 4 11 ample, in the application or removal of Anterior mandibular 13 8 16 5 fracture arch bars or ligature wires in oral Posterior mandibular 1 6 1 4 Other- surgery. In a related area, the application of Post-op removal bone bands in orthodontics is often somewhat spicules 27 painful, and while few orthodontists use Application of arch bars & ligature wires 16 conventional local anesthesia, the Syrijet is Removal of arch bars being used effectively for this purpose.4 & ligature wires 20 The Syrijet has been found to be particu- TOTALS 295 85 157 53 380 210 larly useful in soft tissue procedures for dis- charging small controlled volumes of local mucosa, particularly when multiple punc- anesthetic solution quickly, effectively and tures were made; and the other was a com- automatically. This finding has been con- plaint on the part of the patient of a bad curred with in periodontics, where it is taste of the anesthetic. It was found that being used for the same purpose.5 both of these could be minimized by care- Studies on tissue penetration character- ful attention to details of technique. Bleed- istics produced by jet injection indicate ing can be minimized by proper position- that the circumferential spread and depth ing of the instrument with respect to the of solution is a function of the volume of surface of the tissue, and by allowing the lip solution injected and the nozzle pressure. to fall over the instrument at the time of The Syrijet Mark II has a nozzle pressure injection. The "bad taste", which is due to of 2,000 pounds per square inch (psi), and lateral splash of solution, can be eliminated at this pressure it was found that jet injec- by maintaining the volume of solution at an tion of local anesthetic solutions provides optimum level for each injection and by penetration and infiltration roughly com- keeping the tip of the instrument in gentle parable to that produced by needle injec- contact with the tissue. The tissue should tion to near 1 cm depth, with quantities up not be firmly compressed, and the area to 0.2 ml per injection.6 Studies are now should be dried prior to placement of the in progress to determine the applicability instrument. Also, for injections on the of modified instruments that can deliver palate, a gauze sponge wrapped around greater volumes of solution at various psi the head of the instrument leaving the pressures. nozzle exposed will eliminate any splash of solution. As noted, none of these complica- Summary and Conclusions tions was of any real consequence. It was An automatic jet injector (Syrijet Mark also noted that soft tissue was not as dis- II) has been investigated regarding its po- 96 ANESTHESIA PROGRESS tential in comprehensive pain control and REFERENCES its clinical applications to oral surgery. It 1. Hingson, R. A., and Hughes, J. G. Clinical was found to be particularly useful for soft studies with jet injection: a new method of tissue procedures and for the removal of drug administration. Anesth, Analg 26:221 most anterior teeth, as well as for a number Nov.-Dec. 1947. 2. Epstein, S. Pressure injection of local anes- of minor oral surgery procedures in which thetics: Clinical evaluation of an instrument. it is more convenient than conventional JADA 82:374 Feb. 1971. local anesthesia with needle syringe. In 3. Bennett, C. R., and Monheim, L. M. Production those situations in which the depth of anes- of local anesthesia by jet injection. Oral Surg., thesia produced by jet injection if found Oral Med., Oral Path. 32:4 Oct. 1971. to be inadequate due to its inherent limita- 4. Personal communication, Dr. Stanley L. Gibbs, tions, one simply supplements the initial New York, New York. effect with an injection, taking advantage 5. Personal communication, Dr. Sol. J. Ewen, New of the anesthetic effect previously pro- York, New York. duced. In addition to its use in treating 6. Bennett, C. R., Mundell, R. D., and Monheim, conscious patients, a new area of usefulness L. M. Studies on tissue penetration character- has been described in the application of istics produced by jet injection. JADA 83:625 the jet injector to Sept. 1971. procedures under gen- William Greenfield, D.D.S. eral anesthesia and various forms of psycho- 21 St. Marks Place sedation. Mt. Kisco, New York 10549

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JULY-AUGUST, 1972 97