The Palatal Injection: Dentistry’s Most Painful Shot

Probably the most frequently commented upon topic on this blog involves what the majority of patients dread the most: the shot. As a result, I’ve posted many articles related to dental injections, including articles on novocaine (no, we don’t use it anymore), epinephrine (the racing heart does not mean you are allergic to it), why some people/teeth are hard to get numb (over ten different reasons), etc.

I’ve also done a two part series on what factors cause some dental injections to hurt more than others (located here and here). However, given the number of comments and questions about palatal injections, it was warranted to create an individual post on what can be considered dentistry’s most painful injection.

What is a Palatal Injection?

This may seem somewhat obvious but it is worth explaining. We’ll start with a photo.

palatal injection photo - most painful dental shot

Injection into the palate on the right side. If it looks painful, it’s because it is painful.

In a palatal injection, local anesthetic is injected into the soft tissue covering the hard palate, just adjacent to the tooth/teeth to be worked upon. It is not an injection into the soft palate nor the uvula. And it is only done for top teeth.

These types of injections are performed when you need the gum tissue on the roof of the mouth to be numb and/or when the procedure requires the tooth to be super numb (like an extraction or root canal). In my experience, for most fillings of upper teeth, palatal injections are NOT needed.

Why Palatal Injections Hurt so Darn Much!

There are two major reasons to explain why these hurt so much:

Tightness/Density – the tissue lining the hard palate is very dense and tight. There’s no “give” to it. The needle initially goes in and is accompanied by a pinch. That pinch is actually not the worst part. The worst part is when the local anesthetic fluid is forced in. There’s literally no room for it because the tissue is so dense. That forcible entry of fluid into this tissue is what causes the pain.

Topical anesthetic does not help with palatal injections

Traditional topical anesthetic does little to help with palatal injections.

Want an analogy? Imagine you have a turkey baster injector. Plunge the injector deep into the breast or thigh. Then try to inject. It will take GREAT force to get even a little fluid into this dense muscle. This is like a palatal injection. Next, move the tip of baster until it is just at the border of the thigh and skin. Then try to inject. There is little to no resistance. Fluid goes in with great ease, taking advantage of the looseness at the skin/muscle junction. This is like most other dental injections.

Traditional Topical Anesthetic Doesn’t Work Well – traditional topical anesthetic, a.k.a numbing jelly, doesn’t penetrate the tissue very easily, regardless of how long you wait. As a result, it exerts little to no effect, thus offering little to no pain relief.

How Palatal Injection Pain Can be Reduced

Fortunately, there are ways to reduce the pain associated with palatal injections. Note, however, that these are all done by the dentist himself/herself (except the last one which involves both dentist and patient).

  1. cotton applicator applying pressure can reduce pain of injection on the palate

    Application of pressure can reduce the pain.

    Waiting – in nearly all cases, if you are going to get an injection on the palate, you will also receive an injection on the cheek side. In many cases, if the dentist waits 10 minutes or so after the “cheek side” injection, some of that local anesthetic will work its way over and partially anesthetize the palate. This will make it so that the palatal injection is less painful.

  2. Pressure – placing firm pressure with a cotton applicator for at 30 seconds can slightly numb or obtund the pain sensation. The pressure is applied on the roof of the mouth right where the injection is going to go.
  3. Super Topical Anesthesia – some dentists will use a pharmacy compounded topical anesthetic that is several times more powerful than traditional topical. Using this correctly can also reduced the pain.
  4. Cold – application of a cold cotton applicator with pressure right before the injection can also reduce the sensation.
  5. Sedation – if you are sedated, you are unlikely to even feel the painful injection, let alone remember it. Sedation dentistry is very effective – I do it routinely in my office.

Not all dentists employ the above techniques. But all dentists are aware of the painful nature of this injection and do their best to only do it when necessary.