Paediatrics and I have a love hate relationship. It's still one of the few things on my schedule that I see and I dread. It's not that I don't like kids. It's more that I can't predict the outcome, my inner control freak cannot handle it.

Yet more often than not I find this can be the most rewarding part of Dentistry. An uncooperative anxious paediatric patient who leaves smiling and confident is an achievement like no other.

Managing kids is as much a performance as a procedure and many nuances go into a successful outcome. Yet the quickest way to a failed appointment is painful anaesthesia.




In the case above, our patient was a cooperative yet understandably nervous 9 year old girl. She has retained lateral incisors and her Orthodontist has recommended extraction.

A few years ago, at a different practice, she had a terrible experience.

She had a retained deciduous tooth and it was recommended that they extracted it. I suspect (hope!) it was quite loose. The dentist placed topical only and proceeded to remove the tooth, causing significant pain and distress. When I was treating her I said "you may hear some clicks and cracks which are all normal". She responded saying that she never heard clicks and cracks last time because she was screaming too loud.

My heart sank!


How to Give Painless Palatal or Lingual Anaesthesia

  1. None of this is possible without cooperation. Brush up on good behaviour management and crucially, build rapport throughout the appointment.
  2. Use topical. Dry the mucosa and rub the topical in for best effect.
  3. Give a buccal infiltration. Ensure the first few drops is just below the surface without touching bone. Very slow at the start. Try to talk about something at the same time. I like to say "make sure you let me know if i'm in the way of the TV!", then go on to talk about the show in some way.
  4. Stop, give it a few minutes. Talk about the TV or something else you found out about when chatting with the child.
  5. The aim now is to inject within the anaesthetised area, spreading it to the palatal/lingual. Inject under pressure into the papilla on the buccal side (see number 2)
  6. After a few seconds, inject on the lingual/palatal within the blanched area. Watch the blanched area expand.
  7. Usually you need another 1 -2 injections within the blanched area to spread the anaesthetic around the palatal/lingual. Crucially - stay within the blanched area!



Of course, we do not know the whole story from the above situation. However I believe some may attempt removing a deciduous tooth with just topical because they're afraid to use proper LA in kids. Sure, it takes longer, but whats more important - your time or a child's ongoing dental anxiety over their lifetime?

Try this technique, especially on a cooperative yet anxious child. When it works it is fantastic.

David is a recent graduate dentist working in private practice in regional NSW, Australia. Read more at

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