Romanian Journal of Oral Rehabilitation

Vol. 9, No. 4 October- December 2017

IMPLEMENTATION OF METHODS OF LOCO-REGIONAL

ANESTHESIA IN DENTAL SURGERY
Oana-Elena Ciurcanu¹, Doriana Agop Forna¹ *, Cristina Popa¹, Mihaela Monica
Scutariu²
"Grigore T. Popa" University of Medicine and Pharmacy Iasi, Faculty of Dental Medicine
1. Department of Oral and Maxillofacial Surgery
2. Department of Implantology, Removable Prosthesis, Dental prosthesis technology
* Corresponding author. Email: dr.doriana.forna@gmail.com

ABSTRACT
Even the minor surgery, anesthesia, by interrupting the normal course of life, bringing the patient into a state
of dependence on the attending physician, the medical staff, the drugs, the preoccupation with the type of
anesthesia, the duration and the course of the intervention, its success or complications, logically inspires a
sense of fear. So, it is normal for the patient to be concerned about the method, technique and quality of
anesthesia and surgery, the possibility of deficiency in the installation or the duration of anesthesia that could
cause pain during the intervention or immediately afterwards.
The problem of dento-alveolar surgery interventions in a dental practice ward presents multiple aspects and
needs, in the context of increasing dental care both in private or state practice. Loco-regional anesthesia is the
method by which chemical, physical or electric current are used to temporarily insensify the anatomical region
on which it is intervening, while keeping the consciousness intact; in this kind of anesthesia only painful
sensitivity is abolished, the thermal, tactile, and pressure sensitivities being retained, referred to by the American
authors as "loco-regional analgesia". In recent years new intraosseous anesthesia techniques have been
developed and introduced on the market: the Stabident system; X-type; Quicksleeper; Intraflow; Hypo. With
regard to injection methods of anesthetics, computerized electronic systems for the administration of anesthetics
have appeared on the market. Intraoral application sites influence the time of installation and the duration of
anesthesia after application of the local anesthetic.
Key words: loco-regional anesthesia, methods of anesthesia, anesthetic substances, dento-alveolar surgery.

INTRODUCTION
A good local anesthetic or locally-
regional must be harmless to tissues, have no
local or general toxicity, have to determine
aquality or durable anesthesia, will not cause
damage to the nerve endings, is water
soluble, will not cause allergic reactions [1-
3].
Anesthesia nowadays allows the
adaptation of individual methods and
techniques for each patient so that the
patient benefits from perfect anesthesia and
as few risks as possible using substances as
close as "ideal anesthetic" [4].
Considerable progress made in recent
decades in anesthesiology was made
possible by the pharmacology,
pathophysiology and clinical researches,
which allowed both the discovery of new
substances with well individualized shares
with high efficiency and low toxicity, and a
more accurate indication to prevent and
effectively treat local and general accidents.
In the current international context, the
medical focus is mainly on prevention of
incidents, accidents and complications in
surgical techniques, we’ll try to contribute to
optimizing the method of anesthesia with
immediate results in reducing of anesthetic
and surgical risk and the comfort of pre-,
during and post -surgery of the patient in
dental and dental-alveolar surgery [5,6]. A
modern, sustained attitude through clinical
trials and outcomes can provide a
practitioner dentist and oral surgeon a calm,
cooperative patient confident in maximum
comfort and safety, minimizing the possible
risks.
In modern medicine, a great importance is
attached to patient preparation for anesthesia
and surgery.

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Vol. 9, No. 4 October- December 2017
As far as possible, it is advisable to take
this period naturally, without exaggeration
and over-evaluation, so that the patient
reaches the surgery room being confident,
non-psychiatric and as well as possible
warned of the surgical operations he will
undergo[7].
The lack of adaptation to pain is an
important factor of alarm and protection
against possible injuries to the body. Painful
sensitivity generates a series of individual
manifestations that constitute a complex
behavioral act as a "friend" or "enemy" of
the state of health, depending on the
intensity and duration of excitatory
nociceptive (Melzack, 1986).
News on implementing new methods of
loco-regional anesthesia in dentistry:
Although the anesthesia modern
proceedings have changed, in the working
practices of dentistry and Oral and
Maxillofacial offices, excitement and
anxiety, fears persist yet with the patients
who will have to undergo dental care
treatments.
Under these circumstances, preventing and
fighting pain is an extremely important goal
for the dentist or oral surgeon [8,9].
The search, research and evaluation of
optimal loco-regional anesthesia methods
that can successfully address patients who
are anxious as alternatives to the combined
anesthesia-preanesthesia method in dental
medicine is not at all easy; requires thorough
knowledge of the physiological,
physiopathological and, last but not least,
psychological aspects of pain [10]. The
purpose of premedication should be
unconditionally determined by the anxiolytic
and analgesic effects to improve pain
tolerance. The main aim of our research was
Frequency
absolute
Valid cyst periapical
Periapical granuloma
Chronic peri-ossicular
osteitis
Apical periodontitis
Radicular intraalveolar
to establish, by clinical and statistical means,
incidence, prevalence and implementation of
loco-regional anesthesia methods in dento-
alveolar surgery; evaluating the
effectiveness of the proposed anesthetic
methods; the purpose of assessing the degree
of anesthesia as well as the degree of
intraoperative comfort.
The main objective of this paper is the
value of some alternative methods of
anesthesia for the patient's comfort and post-
operative comfort.
Intraosseous anesthesia makes possible to
reduce the amount of anesthetic injected on
the one hand and to immediately anesthetise
6 teeth by a single anesthetic puncture in
which an anesthetic capsule is injected ie 0.3
ml per tooth; it is a way to reduce the
toxicity of anesthetic procedures [11-13].
The novelty of our study consisted of the
intention to introduce in the dental practice
and dento-alveolar surgery the routine of
using intraosseous anesthesia as an
alternative to the classical methods of loco-
regional anesthesia.
MATERIAL AND METHOD
The study group comprised 228 cases
with intraosseous anesthesia and the
following results were obtained by analyzing
the type of diagnosis that required the
following surgical treatment according to the
diagnosis: periapical cyst - 25.9%; periapical
granuloma - 38.2%; chronic periapical
osteitis - 30.3%; apical periodontitis - 0.9%;
intraalveolar radicular rest - 0.9%; root
debris - 3.9% (fig.1).
Frequency Frequency
percentage P centual
cumulated
59 25.9 25
87 38.2 64.0
69 30.3 94.3
2 0,9 95.2
2 0,9 96.1
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 Romanian Journal of Oral Rehabilitation
Vol. 9, No. 4 October- December 2017
rest
228
Fig.1. Frequency of treatments
After analyzing the data collected from
the study group according to the type of
treatment that required the intraosseous
anesthesia we obtained the following
concrete processed statistical results;
studying a number of 228 cases according to
the type of treatment used, the following
percentage frequencies were recorded:
• cystectomy - 5%;
• cystectomy and dental extraction -
2.2%;
• cystectomy and apical resection -
18.0%;
• apical resection - 0.4%;
• endodontic drainage - 0.9%,
• alveoplastic extraction - 1.3%;
• dental extraction - 10.1%;
• gingivectomy and apical resection -
1.8%;
• apical pulpoma and resection - 3.1%;
• apical resection and channel obstruction
- 2.2%.
RESULTS
Studying a number of 228 cases,
depending on the type of anesthetic used and
the installation interval, the following
percentage frequencies were recorded:
- 1min - 18,9%,
- indices: intraoperative pain tolerance score;
2min - 34.2%,
+ epinephrine 1: 100000
- 3min - 15.4%,
- 5min - 1,8%,
- 2min - 28.1%,
- 3min - 1.8%.
The most commonly used anesthetic
substance in intraosseous technique is
articaine 4% in combination with
epinephrine 1: 200000 dilution (used in 78
patients).
Lidocaine 2% and articaine with
epinephrine 1: 100,000 were used in fewer
cases (35 and 43 respectively).
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100.0 100.0
We tried to identify the practitioner's
preferences for a certain anesthetic option - a
method proposed by us to be implemented in
practice - intraosseous anesthesia and to
establish a series of correlations with the
value indices chosen for assessing the
quality of anesthesia: emergency setting,
pain score and postoperative pain control.
Surgical work that ranks first in the top of
interventions was: dental extraction -
48.14%; apical resection - 25.32%;
odontectomy - 10.76%; periapical curettage
-6%; removal of small tumors - 5.28%; the
alveolar crest regularization - 4.5%.
The methods of anesthesia used were:
intraosseous anesthesia - administered with
Stabident system; loco-regional anesthesia;
loco-regional anesthesia + topical
anesthesia; loco-regional anesthesia + pre-
anesthetic medication.
The distribution of the 228 patients
solved on the variable type of anesthesia was
as follows: intraseuropathic anesthesia -
44%; loco-regional anesthesia - 21%; loco-
regional anesthesia + topical anesthesia -
20%; loco-regional anesthesia +
preanesthetic medication - 21%:
Demonstration of the value of anesthesia
methods was done by comparative cross-
section analysis based on the following
installing an unexpected medical event
(allergic, cardiovascular); the moment of
postoperative pain installation - patient's
statement.
Although the study included healthy or
apparently healthy patients, we analyzed the
database and found the medical emergency
during the interventions.
Of the total of 228 seen and treated as the
first stage of the study, we were interested in
distributing them on the medical emergency
variable.
The computerized statistical deductions
led us to the following percentage results:
93.43% did not trigger medical emergencies
 Romanian Journal of Oral Rehabilitation
Vol. 9, No. 4 October- December 2017
during dento-alveolar surgery; 6.57% - 15
patients have triggered medical emergencies
during dento-alveolar surgery.
At the level of patients who triggered
medical emergencies on dento-alveolar
surgery, we continued to focus on the
distribution of the type of medical
emergency that they triggered.
The computerized statistical deductions
led us to the following percentage results:
47.85% triggered acute hypotonic failure
(vaso-vagal sincope, orthostatic syncope,
pregnancy syncope, carotid sinus
syndrome); 52.15% triggered cardio-
circulatory emergencies (rhythm
disturbances, HTA attacks, angina pectoris).
Analysis of the data on the anesthetic
indication vs. the installation of medical
emergencies revealed the following
preliminary data: loco-regional anesthesia
vs. emergencies - 95%; regional loco
anesthesia+ topical anesthesia vs emergency
- 3%; loco-regional anesthesia + method actually translated and the
preanesthesia vs. emergencies - 1%.
The Spearman nonparametric correlation
test, based on the analysis of the emergency
value variance, verifies whether there are
statistically significant differences between
the mean values of the indices for the
studied groups. Both the Chi-square value
(x2 = 21.2, x2> 12.59) corresponding to the
Emergency Index (df = 6) and the value of
the significance level of the test indicate a
significant difference in the incidence of
anesthesia according to the anesthetic
indication = 0.00167).
The main purpose of our research, based
on the detected incidents, was to send an
alarm signal to dental specialists or dento-
alveolar surgeons, in relation to the
correctness of the anesthetic indication.
The equal percentages attributed to both
anesthesia methods - ALR + preanesthesia
and bone anesthesia in the installation of an
unwanted medical event motivate us to
affirm that intraosseous anesthesia is a
viable alternative to the combined anesthesic
method, the main argument being solving
the limits of dental practice practice.
Intraosseous anesthesia vs. anesthesia +
premedication (with approximately equal
123
computer environments) is the method that
can successfully replace the combined
method, translated into the effectiveness of
keeping the pain score within normal limits.
Another desideratum of the anesthesic
method in dental medicine is the control of
post-operative pain.
In intraosseous anesthesia the distribution
of the scores reported by the patients under
study was: in the first 24 hours - 18%;
absence of postoperative pain - 82%.
The correlation test demonstrates that the
absence of postoperative pain is correlated
with the implemented anesthesia method,
namely intraosseous anesthesia. The
calculated correlation coefficient r =
0.464842 indicates the close relationship
between the two variables.
Intraosseous anesthesia vs. anesthesia +
premedication (with approximately equal
computer environments) is the method that
can successfully replace the combined
effectiveness of postoperative pain control;
there is no pain installed postoperatively
immediately.
DISCUSSIONS
In order to evaluate how the proposed
anesthetic option manages to modulate the
patient's acceptance of painful maneuvers,
we have to adopt a system of assessment
of pain at operator's momentum;
a system based on independent
observation of perceived pain perception
on assessment indexes.
Loco-regional anesthetic techniques, as
well as the pharmacodynamic properties of
anesthetic substances, are based on
anatomical, physiological and histological
principles. Their basic principles and
clinical data supporting these anesthesia
techniques indicate that they can
advantageously replace the pain sensation
during surgery, depending on different
clinical situations, so that the patient's
comfort is optimally assured during the
 Romanian Journal of Oral Rehabilitation
Vol. 9, No. 4 October- December 2017
operation [14,15 ].
Progress has been made with anesthesic
injection methods, thus providing
electronic computerized computer systems
for their anesthesics. This is Dentsplay's
Comfort Control Syringe system, The
Wand system, SleeperOne system by
Dental Hitec [16]. Although the main way
of administration of local anesthesics is by
injection, they can be applied locally as
well.
The topically applied anesthetic is
absorbed and then reaches the blood
stream. This is important because their
incorrect use can induce toxicity by single
application or by association with injection
anesthesia. It has been reported that toxic
reactions are common after topical
application compared to other methods of
administration of anesthetics [17].
Although the plasma level is 1/3 of that
obtained by intravenous administration,
the rate of entry into the bloodstream is
higher. It is certain that toxic reactions
have also produced deaths in topical
applications.
Lidocaine and Benzocaine are the most
used topical anesthesics before anesthetic
puncture, being common in dentistry. The
effect of the anesthesic is not entirely
pharmacological, and there is also a
psychological effect.
Intraosseous anesthesia is the technique
of anesthesia whereby the anesthesic
solution is deposited in full spongy bone
tissue after pre-puncture of bone cortex;
makes it possible, on the one hand, to
reduce the amount of anesthesic injected
and, on the other, to immediately
anesthetize a number of 6 teeth by a single
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anesthetic puncture in which an anesthetic
capsule is injected, ie 0.3 ml per tooth.
This is a way to reduce the toxicity of
anesthesic procedures.
Intraosseous anesthesia technique
involves three essential steps: anesthesia of
the attached gum; perforation of the
cortical bone; determining the punch and
injection site; requires low doses of
anesthetic solution, which greatly reduces
the likelihood of complications and
toxicity from local anesthesics.
Intraosseous anesthesia is performed in
a well-vascularized tissue. The
consequence of this will be the rapid
elimination of the anesthetic solution. To
adjust the duration of anesthesia to
working time, the amount of anesthesic to
be injected or the concentration of the
vasoconstrictor may vary.
The systemic effects of intraosseous
anesthesia are minimal: temporary
tachycardia when the anesthetic contains
high concentrations of vasoconstrictors.
This tachycardia varies depending on the
patient and his stress level, but is generally
without consequences[19.20,21].
Although the duration of anesthesia
installed by the intraosseous anesthesia
technique is less than the duration of
anesthesia installed by conventional loco-
regional anesthesia techniques, this is
sufficient for the vast majority of dental
work performed in dental surgeries.
In our research we used the Stabident
system for intraosseous anesthesia. The
components of this system are a punch and
needles for injecting the anesthetic
solution.
One can choose 2% lidocaine with 1:
100000 epinephrine, which provides a 30
minute pulp anesthesia for 3%
 Romanian Journal of Oral Rehabilitation
Vol. 9, No. 4 October- December 2017
mepivacaine that provides 15-20 minutes
of pulp anesthesia or 2% mepivacaine with
1: 100000 epinephrine, in this case
working time is 30-45 minutes.
A good knowledge of the
pharmacology and pharmacodynamics of
sedative, analgesic and anesthesic drugs is
a major desideratum for the design of
alternative pre-anesthesia schemes.
Interventions of oral and maxillo-facial
surgery inevitably involve prior local,
regional or general anesthesia. This
involves various risks, which may be
limited by knowing both the patient's field
and the anesthesia techniques indicated
[18,22]. The experience of the practitioner
doubled by the clinical sense is the
premise of a correct approach of the
clinical case.
Although the number of incidents,
accidents and local or general
complications that may occur in loco-
regional anesthesia is high, we must insist
more upon the facilities and safety of these
anesthetics.
The issue of anesthetic risk and
implicitly the optimization of loco-
regional anesthesia methods in the sense of
risk mitigation is a complex reality that
must be viewed and addressed from
several points of view. In surgery, the
anesthesic is more dangerous to the patient
than the scalpel.
The novelty of the study consisted of
the intention to introduce in the dental
practice and dento-alveolar surgery the
routine of using intraosseous anesthesia as
an alternative to the classical methods of
loco-regional anesthesia; of new,
alternative anesthetic agents to minimize
intra and postoperative discomfort of the
125
patient; an own method of assessing the
degree of patient anesthesia by
externalizing the perception of pain by the
patient.
The optimization of loco-regional
anesthesia methods is proposed by:
substitution - technique - intra-anesthesia
or anesthetic agent; combination - topical
anesthesia or preanesthesic medication.
Knowing and improving all the aspects
that make up the anesthetic risk in dental
medicine must be grouped generically into
the first and most important step in
preventing a therapeutic failure.
Although preventive methods are
within the reach of the practitioner,
unfortunately it still falls into the
omnipresent mistake of neglecting the
well-known aspects. This is considered to
be a defense and justifies its attitude by
explaining that the chances of producing
incidents, accidents or possible immediate
or late complications are minimal.
CONCLUSIONS
Pain plays an important role in
modulating the patient's organic response.
Painful therapeutic maneuvers can produce a
strong cardiovascular reaction especially in
the group of anxious patients.
Intraosseous anesthesia reduces the
amount of anesthesic injected, thus reducing
the toxicity of anesthetic procedures; allows
the use of vasoconstrictors for the immediate
delivery of anesthesia to the pulp teeth
without the risk of necrosis; is the technique
of anesthesia that approaches the technique
of ideal anesthesia; thanks to the many
advantages it presents, can be a real and
viable alternative to conventional loco-
regional anesthesia techniques, but should
not be regarded as an imperative subtitle for
them.
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Vol. 9, No. 4 October- December 2017

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