LOCAL

ANESTHESIA
O.R.GANESH
M.Sc.D ENDO
UNIVERSITY OF THE EAST
 LOCAL ANESTHESIA
What is local anesthesia?
• LA has been defined as a temporary loss of sensation in a
circumscribed area of the body caused by a depression of
excitation in nerve endings or an inhibition of the conduction
process in peripheral nerves.
•It produces loss of sensation without inducing loss of
consciousness
METHODS OF INDUCING LOCAL
ANESTHESIA
 Mechanical trauma
 Low temp
 Anoxia
 Chemical irritants
 Neurolytic agents ,eg: alcohol,phenol
 Chemical agents ,eg: local anesthetics
THE NEURON
 ELECTRO PHYSIOLOGY
1. Nerve consists “potential”. Here it is negative resting elec.pot
existing across the nerve membrane.

2. A stimulus produces excitation of the nerve, leading to the

following sequence of the events.
3 . Initial phase is slow depolarization. The electrical potential becomes
slightly less negative.

4. When the elec.pot reaches a critical level. An extremely rapid phase of

depolarization occurs- threshold potential or firing threshold
5. The phase of rapid depolarisation results in the reveral of the
electrical potential across the nerve membrane. The inside of the
nerve is +ve.
6. After depolarization- repolarization occurs.
7. The process requires 1 msec (2 thru 6 stage)
8. Depolarization 0.3sec(2 thru 5)
9. Repolarization 0.7sec( 6 stage)
ELECTRO CHEMISTRY
INITIAL MANAGEMENT
1. Psychologic approach : 4c
 Control
 Communication
 Concern
 Confidence
2. PAINLESS INJECTIONS
 Patients generally have a fear of dental injections. A good
practice builder and method of winning confidence and
cooperation is to master injection techniques that are nearly
painless.
 Although most injections cannot be pain-free, there can be
minimum of discomfort
 Obtaining patient confidence is critical
 Before injection, a dentist should establish communication and exhibit
3.OBTAINING PATIENT
empathy .
CONFIDENCE
4. TOPICAL ANESTHESIA
 As an adjunct to painless injection
 The most important aspect of using topical anesthesia is not primarily
the actual decrease in mucosal sensitivity but rather the demonstrated
concern that everything possible is being done to prevent pain
1. Topical anesthesia gel is used , a small amount on a cotton applicator is
placed on the dried mucosa for 1 – 2 mints before the injection.
2. An intraoral adhesive, 20% lidocaine patch. It is placed for 5 mints..later
it was shown to reduce the pain of needle stick
Draw back-
poor adhesive to mucosa
extra time
5. SOLUTION WARMING
A common belief is that an anesthetic solution warmed or above
body temp are better tolerated but in clinical trials, patients could not
differentiate between prewarmed and room temp.

so it is not necessary to warm

the anesthetic cartridges.
6. NEEDLE INSERTION
Insert gently in to the mucosa.
7. SMALL GUAGE NEEDLES
 Misconception --that smaller needles cause less pain.
 Patients cannot differentiate between 25,27 and 30 gauge.
 a 27 gauge needle is recommended for conventional dental injections.

8. SLOW INJECTIONS
 Slow injection decreases pressure and patient discomfort .
 A technique for slow injection is to use a computer controlled
anesthetic delivery system.
 This device delivers 1.4 ml of
the An.solu
over 4 mints 45 secs.
9. TWO STAGE INJECTION
 Decreases the pain of needle placement in infe.alv.nerv.bl .
 This is in indicated in pediatric , anxious and apprehensive patients.
------ a two stage injection consists of initial very slow administration of a
approximately a quarter cartridge of anesthetic just under the mucosal
surface.
after regional numbness, the reminder of the cartridge is deposited to the
full length at target site
10.GENDER DIFFERENCES
 women try to avoid pain more than men, accept it less , and fear it more.

11. WHEN TO ANESTHETIZE

 Instruments can be used painlessly with out anesthesia in canals with
the necrotic pulp and periradicular lesions. But if the vital tissue is
present in apical few millimts of the canal, then pain results.
 The inflamed tissue contains nerves and is sensitive. so anesthesia
should be given at each appointment.
 Sometimes pressure is also created and it gives discomfort to patient.
 Working length can be determined in an non anesthetized patient by
passing an instrument in to a necrotic canal until patient shows an “eye
blink response”
 Unfortunately ,patient perceptions and responses are too variable for
accuracy.
 Many think that after cleaning and shaping ,there is no need of
anesthetizing the tooth but during obturation, pressure is created and
small amounts of sealer may be extruded beyond the apex which is
quite uncomfortable.
12.ADJUNCTIVE THERAPY
 Sedation may enhance local anesthesia, particularly in patients who
want to co operate but are extremely apprehensive
CONVENTIONAL ANESTHESIA
1. MANDIBULAR ANESTHESIA
2. MAXILLARY ANESTHESIA
 MANDIBULAR ANESTHESIA
1. Anesthetic agents
 Most commonly used agent is 2% lidocaine with
1: 100,000 epinephrine
 Lidocaine is safe and effective drug
2. Related factors
a. Lip numbness- 5 to 7 mints, it indicates that injection blocked the nerves to
the soft tissues of the pulp.
b. Onset of pulpal anesthesia- 10 to 15mints
c. Duration - persists apprx 2 and half hours
d. Success - the incidence of successful mandibular pulpal anesthesia tends
to be more frequent in molars and premolars and least in anteriors
 ALTERNATIVE TECHNIQUES
 Increasing the volume:
increases the volume of anesthetic from 1 – 2 cartridges will not increase
success rate .
 Increasing the epinephrine concentration :
there is no improvement in anesthesia with a higher concentration of
epinephrine in an inf.alv.nerv.blk.
 Alternating solutions: lasts atleast 1hr
1. 2% mepivacaine with 1: 20,000 levonordefrin
2. 4% prilocaine with 1: 200,000 epi
3. Solutions without vaso constrictors
 Articaine :
 recently introduced in united states.
 Safe and effective
 Clinical trials failed to detect any superiority of articaine over lidocaine.
(mand. Block)
 Incidence of paresthesia is rare
 Alternative injection techniques:
 Neither Gow Gates nor vizarani akinoski technique is superior to standard
inf.nerv.block .
 They are usefull only when normal approaches cannot be used
 Incisive nerve block at the mental foramen:
This is successful in anesthetizing the premolars but not central and lateral
 Infiltration injections:
1. labial or lingual infiltrations alone are not effective for pulpal anesthesia in
mandible
2. Combination of labial and lingual are effective- lower ant. Teeth
3. Articaine is effective than lidocaine for buccal infiltration
 Long acting anesthetics:
1. bupivacaine and etidocaine provide prolonged analgesic period and are
indicated when post operative pain is anticipated.
2. Bupivacaine has slower onset than lidoccaine but has double the duration of
pulpal anesthesia in mandible … apprx 4 hrs.
 Accuracy of needle placement :
1. Accurate anatomic positioning is no guarantee of a successful block.
2. Even after locating the inf.alv.nerve with ultra sound before the injection did
not improve success.
 Needle deflection:
1. This deflection has been theorized as a cause for failure with infe. Alv.nerv
block
2. Needle bevel does not effect the success of the inf.alv.nerv.blk
 Accessory innervation
1. An experimental study using mylohyoid injection lingual and inferior to
retro molar fossa in addition to an inf .alv.nerv.blk showed no enhancement
of pulpal anesthesia
2. The contribution of mylohyoid nerve to pulpal sensitivity is insignificant.
 Cross innervation :
1. cross innervation from the contra lateral inferior alveolar nerve has been
implicated in failure to achieve anesthesia in ant.teeth after an inferior
alveolar injection
2. Cross innervation does not occur in incisors
 Pain and inflammation :
patients who have symptomatic pulpal or periapical pathosis present
additional problems.
 MAXILLARY ANESTHESIA
1. Anesthetic agents
2%lidocaine with 1:100,000 epi
2. Related factors
a. Lip numbness: in few mints.
b. Success: high incidence of successful pulpal anest.
c. Onset : of pulpal anesthesia occurs in 3-5mints.slower in molars.
d. Duration: problem in max.infiltration
 pulpal anesthesia in ant.teeth declines after 30mints and loses by
60mints
 In premolars and 1st molars no pul.anes at 45mints
and half losing by 60mints
 Volume:
ALTENATIVE TECHNIQUE
1. increasing the volume increases the pulpal
anesthesia.
2. Anterior teeth and premolars – give two cartridges initially or one, and
inject another apprx after 30mints
3. Molars- two cartridges initially will sped up the the onset and prolong the
duration.
 Alternative solutions:
1. Prilocaine , mepivacaine, Articaine and lidocaine act similarly.
2. Solutions without vasoconstrictors provide shorter duration.15 – 20 mints
3. Long acting anesthetics do not provide prolonged pulpal anesthesia ( as
they do in mandibular block)
 Other techniques:
1. Posterior superior alveolar nerve block anesthetizes the 2nd,3rdand 1st
molars.
2. Middle.sup.alv.nerv. does not supply the 1st molars
3. An additional mesial infiltration injection may be necessary to anesthetize
1st molar.
4. PSA in indicated when all the molar teeth require anesthesia .
5. For single tooth – infiltration is enough
 Infra orbital nerve blk:
1. Similar to infiltration over premolars
2. results in lip numbness
3. does not anesthetize incisors pulp
4. Anesthetizes premolars but duration is less than an hour
 Second division blk:
1. Anesthetizes pulp of the molars and some 2nd premolars
2. Does not anesthetize anterior pulps
3. High tuberosity technique is preferred to greater palatine approach
because it is easier and less painful
 Palatal ante.sup.alve.nerv.blk:
1. Anesthetize all maxillary incisors with a single palatal injection in to the
incisive canal
2. Did not provide predictable anesthesia for ant.teeth .
3. Often painful.
 Anterior mid.sup.alv.nerv.blk:
1. Unilaterally anesthetizes the maxillary central and lateral
incisors,canines,1st and 2nd premolars with a single palatal injection in to
the premolar region
2. Did not provide predictable anesthesia for anterior teeth
3. Often painful.
 ANSTHESIA DIFFICULTIES
1. The anesthetic solution may not penetrate to the sensory nerves that
innervate the pulp, especially in the mandible.
2. The anesthetic solution may not diffuse in to the nerve trunk to reach all
nerves to produce an adequate block.
3. Lowered pH of inflamed tissue reduces the amount of the base form of the
anesthetic available to penetrate the nerve membrane. Consequently,
there is less of ionizes form within the nerve to achieve anesthesia.
 the injection site is distant from the area of inflammation, changes in tissue
pH would be unrelated to the anesthesia problem
4. Hyperalgesia of nociceptor is more plausible explanation.
 This theory states that the nerve arising in inflamed tissue have altered
resting potentials and decreased excitability thresholds.
 These changes are not restricted to the inflamed pulp itself but effect the
entire neuronal membrane , extending to the central nervous system .
 Local anesthetic agents are not sufficient to prevent impulse transmission,
owing to these lowered excitability thresholds
5. Patients in pain often are apprehensive , which lowers
their pain threshold.
6. The dentist may not allow sufficient time for anesthetic to
diffuse and block the nerves.
 SUPPLEMENTAL ANESTHESIA
 Indications:
1. If the standard injection is not effective
2. Only useful to repeat if the patient is not showing the classical signs of soft
tissue anesthesia
3. There are 3 supplemental injections
a. Intraosseous
b. Periodontal ligament
c. intrapulpal
IO and PDL are preferred approaches
IP injection reserved for special situations
 Anesthetic agents:
2% lidocaine with 1:100,000 epi
INTRA OSSEOUS ANESTHESIA
Used in cases like pulpitis in mandibular posterior teeth
IO injection allows a placement of a local anesthetic directly in to the
cancellous bone adjacent to the tooth.
IO with 2 components – on part is slow speed hand piece driven perforator ,
which drills a small hole through the cortical plate.
 the anesthetic solution is delivered in to the cancellous bone through a
matching 27 gauge ultra short injector needle
Another IO system uses as a guide sleeve that remains in the perforation
.this serves as a guide for the needle and may remain in place through out
the procedure.
Another innovation is an IO system that combines a slow speed hand piece
with an anesthetic cartridge dispenser system and a rotating needle or drill.
 Technique :
 the area of perforation and injection site is on a horizontal line of buccal
gingival margins of the adjacent teeth and a vertical passing through the
interdental papilla distal to the tooth to be injected.
A point 2mm below the intersection of these lines is selected as perforation
site.
Soft tissue 1st anesthetized by infiltration.
The perforator is placed through the gingival perpendicular to the cortical
plate.
 Then with light pressure , resting against the bone the handpiece is activated
with full speed.
 ACTION CONTINUED TILL THE BREAK THROUGH IN TO THE
CANCELLOUS BONE(2-5sec)
 Pen gripping fashion – syringe to be held
 Anesthetic solution is slowly delivered over 1-2mints with light pressure.
 If back pressure encountered then needle should be rotated apprx a quarter
turn and deposition is reattempted.
 Injection discomfort:
1. when Io injection is used as primary injection, neither perforation ,needle
insertion nor solution deposited is painful for most patients
2. If used in irreversible pulpitis then moderate pain may occur.
 Selection of perforation site:
1. Distal perforation and injection – best anesthesia
2. Exception in 2nd molars – mesial site is preferred
3. Lingual approach may also be successful
 Anesthetic agents:
1. 2%lidocaine with 1:100,000 epi
2. 2%mepivacaine with 1:20,000 levonordefrin
3. 1%etidocaine with 1:200,000epi
4. Etidocaine and 0.5%bupivaciane should not be used because of adverse
cardiovascular reactions.
 Onset of anesthesia
Rapid and no waiting period
 Success
1. As primary injection success rates are good
2. For 3%mepivacaine success rates are low
3. For irreversible pulpitis success rates are high(sup.inj)
 Failure :
if the anesthetic solution squirts out of the perforation then there will be a
failure.
 Duration :
1. As Primary IO injection pup.anes declines over an hour
2. Supplemental IO injection (to IA block ) is painless and duration is very
good.
3. 3%mepivacaine –shorter duration
4. For irreversible pulpitis, the IO injection should provide anesthesia for
entire debridement appointment.
 Post operative problems:
with primary and supplemental techniques ,the majority of patients report no
pain or mild pain
 Systemic effects:
1. With both primary and supplemental techniques using anesthetics with a
vaso constrictor, most patients perceive an increased heart rate.
2. No significant heart rate is increase occurs with 3% mepivacaine plain.
3. The venous plasma levels of lidocaine are the same for an IO injection as
for infiltration injection. Therefore same precautions for IO injection.
 Medical contrandications:
1. Moderate to severe cardiovascular disease
2. Tricyclic anti depressants
3. Non selective β adrenergic blocking agaents
4. 3%mepivacaine is preferred
 PERIODONTAL LIGAMANET INJECTION
1. The PDL injection is useful if the conventional injection is
unsuccessful.
2. The technique is clinically effective and is a valuable adjunct
3. Particularly useful when a rubber dam is in place
 Technique:
A standard syringe or pressure syringe is equipped with a 30 gauge ultra
short needle or 27 or 25 gauge short needle.
The needle is inserted in to the mesial gingival sulcus at 30 degree angle to
the long axis of the tooth.
The needle is supported by fingers or hemostat
Heavy pressure is slowly applied on syringe needle for apprx 10-20sec or
trigger is slowly squzeed once or twice with resistance
Back pressure is important.
 Mechanism of action
The PDL injection forces anesthetic through the cribriform plate in to the
marrow spaces and in to the vasculature in and around the tooth
 Injection discomfort: as primary injection
In anteriors – painful
In posteriors- insertion and injection are mildly uncomfortable
 Onset
Rapid –no waiting period
 Success
As primary injection – good success rates
High success rates in posteriors teeth than in anterior teeth
Without vasoconstrictors or with less vasoconstrictors are not effective
As supplemental injection – good success rates
And reinjection increases success rate
Use of computer controlled local anesthetic delivery system for supplemental
injection was successful in irreversible pulpitis.
 Duration :
10 – 20 mints of pulpal anesthesia
Dentist must work quickly and be prepared to reinject
 Post operative discomfort:
When PDL injection is used as primary technique ,post operative discomfort
usually occurs with a duration of 14hours to 3 days
 Selective anesthesia:
It has been suggested that PDL injection may be used in differential
diagnosis of poorly localized painful irreversible pulpitis.
How ever adjacent teeth are often anesthetized with PDL injection of a single
tooth.
Therefore this injection is not useful for differential diagnosis.
Systemic effects:
Some authors have found that PDL increases heart rate , human studies
have shown that PDL injections do not cause significant changes in heart
rate.
 Safety to peridontium:
Minor local damage is limited to the site of needle penetration .
This subsequently undergoes repair
In rare cases infection occur
 Safety to the pulp:
No adverse effects on pulp after PDL injection
 Safety to the primary teeth:
Minor enamel hypoplasia of succedaneous teeth has been reported.
Caused by the cyto toxicity of the local anesthetic rather than the injection
 INTRAPULPAL INJECTION:
 Indications:
When IO and PDL do not produce profound anesthesia.
Pain persists when pulp is entered.
Without giving IO and PDL 1st , IP should not be administered because it
leads to pain.
The IP injection may also be useful in injecting into the individual canals ,
when anesthesia is not adequate or touch up anesthesia would be helpful.
 Advantages and disadvantages:
The advantage is predictability of profound anesthesia if the IP injection is
given under back pressure
Onset is immediate
No special syringes or needles required
Different approaches are necessary
 Disadvantages:
Needle is inserted directly in to the vital and sensitive pulp
Effects of injection are not predictable if it is not given under pressure.
duration of the anesthesia is only 5 – 20 mints
Therefore bulk of the pulp must be removed
Another disadvantage is that the pulp must be exposed to permit direct
injection .
 Mechanism of action:
Strong back pressure has been shown to be major factor in producing
anesthesia
Depositing anesthetic passively into the pulp chamber is not adequate. The
solution will not diffuse throughout the pulp .
So it depends on pressure
 Technique:
The patient must be informed that a little extra anesthetic will ensure comfort
and that there will be a sharp sensation.
One technique creates back pressure by stoppering the access with a cotton
pellet to prevent backflow of anesthetic
Other stoppers – gutta percha,waxes, pieces of rubber dam have been used.


If possible, the roof of the pulp chamber should be penetrated by a half
round bur, thus the needle will then fit snugly in the bur hole
another approach is an injection in to each canal after the chamber is
unroofed
A standard syringe is usually equipped with a bent sharp needle with fingers
support the needle shaft to prevent buckling.
The needle is positioned in the axis opening then moved down the canal.
Max.pressure 5- 10 sec
 Irreversible pulpitis:
ANESTHETIC
Most difficult MANAGEMENT
to anesthetize is mand.molars, mand OFand
PULPAL OR
max. premolars,
PERI RADICULAR
max.molars,Mand and max. ant PATHOSIS
teeth.(in order)
The vital inflamed pulp must be invaded and removed
The pulpal tissue has a very concentrated sensory nerve supply particularly
in the chamber.
In some cases, inflamed vital tissue exists only in the apical canals and the
tissue in the chamber are necrotic and does not respond to pulp testing. But
when a dentist attempts to place a file in to the canal ,Pain is encountered .
Irreversible pulpitis must be differentiated from a symptomatic apical pathosis
because IO , PDL. IP are contra indicated.
 General considerations
Conventional anesthesia using primary techniques is administered.
 Mandibular posterior teeth:
Conventional inf.alv.injections is administrated, usually in conjunction with a
long buccal injection.
 Mandibular ant.teeth:
 An inf.alv.injection is given.
 If pain is felt IO is administrated.
 If IO is unsuccessful then IP is administered..
 Maxillary post teeth:
 Approaches are the same as those outlined under general considerations
except that the initial dose is doubled for buccal infiltration(3.6ml)
 Maxillary anterior teeth:
Labial infiltration Is administrated
Occasionally palatal infiltration for rubber dam retainer.
IO injection needed rarely
And PDL injection is also not very effective
Duration less than one hour
 SYMPTOMATIC PULP NECROSIS
 This diagnosis indicates pain and swelling and therefore peri radicular
inflammtion.
 Mandible – long buccal and inf. Alv . Nerve bloc
 Maxillary- if no swelling then conventional infiltrations or block
 If soft tissue swelling is present( cellulites or abscess) – regional block +
infiltration.
 Access is begun slowly –pulp chamber is entered without discomfort if the
tooth is not torqued.
 File placement and debridement also can be performed
without much pain f the instruments gently.
 IO,PDL and IP injec are contraindicated. although effective
for vital pulps these injec are painful and ineffective with
apical pathosis.
 In patients with severe preoperative pain without driange
from the tooth----- long acting anesthetic may help control
post operative pain in mandibular teeth.
 Asymptomatic teeth are the easiest to anesthetized
ASYMPTOMATIC PULP
 Mandible- conventional injec-inf alv nev,blc and long buccal
infiltation.
NECROSIS
 Maxillary-infiltration or PSA block
 If patient is uncomfartable than IO or PDL are adminstered.
 IP is contraindicated .
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