Tina is an assistant professor in the dental hygiene department with Oregon Institute of Technology. She has been practicing dental hygiene since 2001 and entered dental hygiene education in 2007. She continues with clinical care in a general dental practice. Tina is actively involved with the American Dental Hygienists’ Association serving at the local, state and national level. She has a passion for dental hygiene that is fueled by her work with students and continuing education for her peers.

Tina Clarke BSDH, MEd

	In the world of oral anesthesia, this injection is fairly new. If you have been practicing for more than five years, you may not have been introduced to it in your pain management course. It is gaining popularity particularly for its potential uses in cosmetic dentistry.  

	The Anterior Middle Superior Alveolar (AMSA) injection is a palatal injection that anesthetizes pulpal tissue of incisors from the midline thru premolars, including the facial periodontium and the palatal tissue from the midline to molars. This affects the Anterior Superior Alveolar (ASA) and the Middle Superior Alveolar (MSA) nerves. It was introduced to the dental field around 1997 when the Computer-Controlled Local Anesthesia Delivery system (CCLAD) emerged.   

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	The AMSA can be described as a field block. It effects the terminal branches of the ASA nerve and the MSA nerve when present (approximately 30 to 50 percent of individuals lack this nerve). Because the anesthetic is deposited on the palate, the nerves innervating the upper lip are not affected, therefore allowing for normal lip function, which is ideal for when the patient needs to maintain upper lip function.

	This injection can be done manually or with a computer-controlled delivery device. Using a 27 or 30 gauge short needle is best. The point of insertion is halfway between the gingival margin of the maxillary premolars and the palatal midline raphe (this is where the horizontal and vertical portions of the maxilla join), and between the first and second premolars. Insert the needle until bone has been contacted, after a negative aspiration deposit desired amount of local anesthetic typically 2/3 to a full cartridge (1.4-1.8 ml). As the anesthetic is deposited the palatal tissue will begin to blanch, allowing the clinician to see the extent of the tissues affected. The delivery time is rather slow when performed manually due to the nature of the palatal tissue. The use of a computer-aided delivery device is usually recommended due to clinician fatigue because of the duration of deposit time. However, this author has successfully used manual deposition for this injection with great success.

	There are several pros with this injection. Because of the wide field of tissue anesthetized, few injections are needed for quadrant anesthesia. A traditional approach to anesthetizing the entire quadrant would require four to five injections. The posterior superior alveolar (PSA), MSA and ASA, nasopalatine (NP) and greater palatine (GP) injections would be required. If using the AMSA, the clinician may only need to perform two injections: the PSA and the AMSA. Another benefit is the patient’s upper lip will retain normal sensation and function, making it easier for restorative esthetic dentistry and for the patient’s ease of life after the procedure. Perhaps the patient has a meeting he or she needs to attend after the dental appointment. Now, he or she can continue on with the day with normal lip function. Due to fewer injections, the potential to use less anesthetic is a great bonus.

	In my opinion, the use of 4% Articaine with 1:100,000 mg of epinephrine and the AMSA are a match made in oral anesthesia heaven. Due to the potency of this anesthetic, the clinician can achieve profound anesthesia with less anesthetic than 2% Lidocaine with 1:100,000 mg of epinephrine.

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	The drawbacks to this approach are important to consider as well. Due to the dense palatal tissue, manual deposition can take longer than expected and the clinician may develop hand fatigue. Also, incomplete anesthesia with the central incisors due to cross-over innervation are of concern. Depositing more anesthetic using the infiltration technique easily remedies this problem.

	Something for the clinician to keep in mind is for patients who have a history of poor healing, palatal injections given with anesthetics containing vasoconstrictors could develop a post-operative ulcer. This has been seen in patients whom are severely immunocompromised.

	When you first begin to use this injection, you may not have success with it right away. Be patient as you progress. You will find that this injection is very forgiving regarding deposit site unlike many of the other injections we administer.

Reference: Bassett, K.B., DiMarco, A.C., Naughton, D.K., 'Local Anesthesia for Dental Professionals,' 2nd ed.

	Photo Credit: Taken by Tina Clarke RDH MEd. Clinician: Erik Rojas, Senior DH Student (Oregon Tech) Patient: Kelsey Leon Senior DH Student (Oregon Tech)

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Taking a look at the Anterior Middle Superior Alveolar injection and the impact it has on patient care.In the world of oral anesthesia, this injection is fairly new. If you have been practicing for more than five years, you may not have been introduced to it in your pain management course. It is gaining popularity particularly for its potential uses in cosmetic dentistry.

Is this newer anesthetic injection technique better for patients?

	Evaluating your patient’s health history is extremely important. After all we know that the mouth is connected to the rest of the body. We witness the oral systemic connection on a regular basis. Understanding your patient’s health history not only helps prevent a medical emergency from happening but will also help you as the clinician provide the best care possible.

	The following are some topics you should be addressing with your patient. By no means is this list exhaustive, but these topics should be discussed to help alleviate the potential of an emergency and limit the exposure to opportunistic infections.

	The cardiovascular system is big rent territory. There are so many conditions that fall into this category. Issues such as angina, infarction of the heart or brain, blood pressure and atherosclerosis are some of the most common diseases to be aware of. Not only is it important to ask about these diseases to help prevent the potential of a medical emergency, but it will also help you as an oral health care provider to properly diagnosis oral health conditions and dispense the appropriate treatment and medications necessary. These issues can have a direct impact on the selection and dosage of local anesthetics and other medication dispensed.

Related reading: Why dental practices need to condust risk assessments of patients 

	A simple addition to evaluate the patient’s cardiovascular health-which should be standard practice at every dental appointment-is taking the patient’s blood pressure. Blood pressure allows the clinician to understand the patient’s ability to tolerate the different types of care we provide. This may be one of the only times your patient has his or her blood pressure checked by a health care provider. One important aspect to remember is high blood pressure is a hallmark precursor to a stroke.

	Diseases and systemic issues that fall in this category include diabetes, cancer treatment and rheumatoid arthritis. There has been a lot of discussion about the link of oral health to diabetes. We know this disease has a direct impact on periodontal health. It is also important to know that this disease and the medications involved can impact the patient’s treatment and choice of anesthetic. If your patient has diabetes, make sure you follow up with questions such as the type of diabetes, the last known A1c level, when the last time medications were taken and if he or she ate prior to the appointment.

	Patients with a current or past history of cancer should have more frequent intra and extra oral evaluations since their risk of head and neck cancers has increased. Also, patients currently undergoing cancer treatment may develop opportunistic infections such as oral candidiasis and have increased risk for decay due to medications and xerostomia.

	Up next: Questions to ask about joint health...

	Arthritis and joint replacement are the big ones in this category. Arthritis will affect how well our patients can implement their oral health care routine and may impact their TMJ. Joint replacement is of greater consideration. The protocols on how to care for these patients in regards to prophylactic antibiotic coverage changes regularly. It is highly recommended to be in contact with the patient’s primary doctor and/or orthopedic surgeon to assess his or her risk for secondary joint infections.

	Allergies to medication may be the first thing that comes to mind, but allergies to metals and other substances need to be considered, too. This impacts the patient’s ASA status as well, placing him or her at a minimum of an ASA II. Potential harm could result in an allergic reaction, which has the potential to be a life-threatening event.

	Clinicians need to understand why the patient is taking the medication and how it affects the body. As we know, the most common side effect of medications is xerostomia, which has a tremendous impact on oral health. We also need to make sure there aren’t any drug interactions with medications we may prescribe or with any local anesthetic agents administered. It is highly recommended for dental professionals to use drug reference material. There are several online resources available that are updated on a regular basis.

	This is a given, right? However, it is amazing how often we forget to ask our patients about past dental experiences and current issues they have.

	Take a moment and evaluate your office’s health history form. Does it address these issues and do you ask the appropriate follow-up questions? Doing so can help to ensure you are providing your patients with effective care.

Understanding a patient’s health history can help you provide the best care possible.

Are you asking the right questions about your patient’s health history?

	There is something special about being a dental hygiene educator. Having the opportunity to shape the future of our profession is an honor and a tremendous responsibility.

	People often wonder what is the best thing about being an educator. You may hear educators talk about the “lightbulb” moment, when a student finally understands a topic or skill-set they have been struggling with. For me, it is the opportunity to help someone make his or her dream become a reality. The ability to guide and coach an individual’s journey to being the best hygienist they can is a blessing. People often ask me, “what do I need to do to become a dental hygiene educator?” I thought I would share with you some strategies on becoming and educator and what skill sets you must possess to perform well in this arena.  

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	First let’s look at what skill set one must have to be in the educational environment. According to some students informally polled there are certain qualities and characteristics which make for an excellent dental hygiene educator. The person should be passionate about dental hygiene and teaching. When an instructor has a love for what they do it energizes the learner and keeps them engaged in the learning process. Other qualities include the ability to work with several different learning styles with the ability to clearly explain theories and skill sets needed for the profession. A person who can identify a student’s strengths and weaknesses providing balanced feedback of both. Students also stated working with instructors who empower the student and set realistic goals creates a positive learning environment.

	There are also the physical abilities that should be considered. If you have decided to leave clinical hygiene because you can no longer handle the physical strain of chairside care transitioning into education may not be the reprieve you are looking for. While you aren’t scaling teeth for 8-10 hours a day you are still on your feet often hunched over students as they work with patients. It can be physically demanding and exhausting.

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	The level of education you need to acquire depends on what courses you are teaching and what the dental hygiene programs policies are. Per the Commission on Dental Accreditation (CODA) full-time faculty must have a baccalaureate degree or higher and part-time faculty teaching didactic courses should also have the same level of education. All dental hygiene program faculty members must have current knowledge on the subject matter, a background in educational methodology, and if they are a dental hygienist, have graduated from a CODA accredited dental hygiene program

. It is best to check with the educational institution in which you would like to work to understand their minimal educational requirements. In regards to the focus of one’s degree there are a plethora of choices. A degree in dental hygiene, education, public health or some science based degree are fantastic options. Again, some institutions may have strict requirements on which degree is required, while others may only require you to have a bachelor degree

	As stated earlier educational methodology is a requirement. Opportunities to engage in these courses are endless. The American Dental Hygienists’ Association and the American Dental Educators Association have numerous resources available. Being a member of professional associations is necessary, if you aren’t a member I highly encourage you to become one. ADHA supports all the efforts of dental hygienists and has several resources to help you take your career to any direction you want. ADEA connects you with all dental educators to be an effective resource for your students and colleagues.

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	To see if the educational environment is the path for you, volunteer your time in the clinical setting. Schools have tight budgets but often need extra help coaching students. There may be a special clinical exam in which hygienists from the community can come to assist in the process. Or, perhaps you have a topic of interest you would like to share as a guest speaker. Volunteering your time not only helps you decide if the educational setting is right for you, but it allows the other faculty to get to know you and keep you in mind if a paid position becomes available.

	Another way to explore the field of education is to host a dental hygiene student at your place of employment. Let them shadow you. Educate them on your role within your work setting. Become a resource and mentor to the student. I believe you will find this to be a rewarding experience.

	Being a dental hygiene educator is an amazing career. Whether you are clinical adjunct or a fulltime professor there is more to the job than just teaching. You are a coach, mentor and counselor. One of the best parts is getting to educate your future peer. I encourage you to reach out to the educational institutions in your area. Get to know the facility and the people who dedicate their time to guide the future of our profession.

 CODA  Accreditation Standards for Dental Hygiene Education Programs. Standard 3-7

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