MECHANISMS OF ACTION  FOR ANESTHETICS:

1-block TTx VGSCs , therfore , inhibtie flow of sodium

2- inhibit the G-alpha-q (Gαq) class of GPCRs will block

hyperalgesic receptor “receptor on GPCR activated by inflammtory
mediator”

3-activate G-alpha-i (Gαi) class of GPCRs cause vasoconstrction

which play role in analgesic

G protein–coupled receptors (GPCRs)

Two main group of L.A:

1-aminde , most common type which metabolize by liver

2-ester , cross link allergy , metabolize by liver & plasma by estears

enzyme that some pt may do not have it , so ester containg L.A stay
blood plasma causing allergy

Traditional Methods of  Confirming Anesthesia:
Probe numbness. Cavity test will not effect for determining
pulpal L.A

Determining Pulpal Anesthesia in Asymptomatic Vital Teeth:

Cold test “not reliable” , electric test “ more reliable cause

we have reading “

Determine ID block by EPT in asymptomatic pulp test :

two consecutive nonresponsive readings on electrical pulp testing

within 15 minutes and continuously sustain this lack of
responsiveness for 60 minutes.

Mean we want to achieve anesthsia withn 15 min & L.A affect

last for 60min
We start with x current lest supposed its 5 , pt have no response
this is the first reading

Secound current its 20 pt having response so wait some minutes &

take another reading until pt have to response , those two reading
must be within 15m , and pt still have no response last for 60m on
80 current

Having response or not , pt have positive lip sign

If there is lip numbness , pulp dose not anesthsia ‫والعكس ليس صحيح‬
In mand posterior have more success rate than anterior
In maxilla:

Infiltration results in a fairly high incidence of successful pulpal

anesthesia (around 87% to 92%).

To remeber :
This test on asymptomatic pulp , testing pulpal anesthsia , this
test we don’t do it clinicaly (“ vitro pulp test”) , these studies
on 2% lidocaine , 1:100,000 epi
We must know the
Duration :-in mand 2. 1/2h duration for emergency
-in max ant. 20x30m , cass , u must achieve ur
post. 40-45m goal of pulp removal
during this period
Duration in max is less due to high
vasculariztion
Onset : -in mand: 10-15 m
-in max: 3-5m
If anesthatize start after this period called late onset or
slow onset
So success anesthesia in mand effect strat with 15m , in max
5m , pt have no response on 80 current with this period

19-27% slow onset common in mand While 20% in max

‫النسب مطلوبة؟‬
 Peak : -in max at 30m
-in mand at 1h

Time course :
-in max : rapid onset wih high success rate , short
duration , peak after 30 m andthen effect decrease

-in mand : most pt achieve the effect within 15min with

duration at least 1hour

Faliure :
-in mand: When never achieved two reading with 60 min , in
other word pt still have response & pain with 60min at
60current

-in max : because of individual variations in response to the

drug administered, operator differences, and variations of
anatomy and tooth position.
‫الدراسه انه تضل ل مدة ساعه هاي بس للماندبل؟ النه بالكتاب نشرحت تحت عنوان‬
‫ د ملدة نص ساعه؟‬٥ ‫منادبل ومفروض نجاح املخدر باالبر تكون القراءة خالل‬
‫ النه بال ابر‬، ‫هاد الحكي بس للماندبل؟‬
‫مفروض خالل نص ساعه‬
‫ انه ناخد قرائتني خالل القترة املوجودة وال انه فش‬onset ‫ال‬
‫ خالل هديك الفترة ؟‬٧٠ ‫ريسبونس على‬
‫ خلص مهو فش وجع لي اخدر‬، ‫ انا اصاللي اعمل تست ل بيشنت اصال مش حاسس‬: ‫السؤاااال‬
‫اصالة‬
Determining Pulpal Anesthesia in Symptomatic Vital Teeth:
If the patient responds to the stimulus, pulpal anesthesia has
not been obtained, and supplemental anesthetic should be
administered.

painful vital tooth (e.g., symptomatic irreversible pulpitis), the

lack of a response to pulp testing may not guarantee pulpal
anesthesia , pulp may necrotic coronaly & u made the access
without pain then pain on filling then supplementray
anesthisa is indicated
When coronaly is necrotic & canal is vital no objective pulp
test can predicte

Failure to Achieve Anesthesia in  Patients with Pain:

Failure happen becuse of acid inflamatory enviroment which

prevent acid L.A to penetrate nerve membrane but this theory
true for infiltartion otherwise in ID with molar pulpitis there
is some distance between so this therory exclude of lower

Other : lowering thresholds due to pain , anxiaty or from

inflamed tissue
TTX-R receptor which resistant for L.Ain normal & sensate
for prostaglandine but with inflammtion prostaglandine will
increase with inflammtion

Two studies demonstrate that anesthetics were unable to

prevent impulse transmission

Central core theory :

Nerve bundle have core bundle “center bundle” innervate anterior ,

mental bundle “peripheral bundle” innervate posterior teeth
We give the anesthesia around the nerve which make it absorbed
more from mental then core , this thery explane faliure of IAL
block in anterior compared with posterior , do not explain
failure to painful teeth
 Use of Topical Anesthetics:
Psycological affect which reduce anxiouty then decrease the
threshold
Alternative anesthsia solution :

3% mepivacaine & 4% prilocaine :

Equivalent for ID , rapid absorbtion & shorter duration in max

Using when epinehpren is contraindication

2%mepivicaine with 1:200,000 lenovodrifrine

4%prolicaine with 1:200,000 epinephren

Same affect as 2%lidocaine but lenovodrifrine is more attractive

than epinephren due to high alpha concentration

4% Articaine

Same with 2% lidocaine but classifed as amide & extra ester cross
linkage which need estease enzyme , highly bone penetration
espcialy compact bone & this amke more effect with upper lateral
incisor

0.5 bupvicaine :
In max: success rate for lateral incisor compared with premolar
more than 2%lidocaine but short duration than 2% lidocaine
equivielant duration of first molar with 2%lidocaine

In mand : called long acting anesthtic but slower onset than 2-

lidocaine with prolong effect for 4h
Idiction for cases with expective postoperative pain
Bupvicane cause CNS & CVS effect and the alternative is
Ropivacaine
 Reversing of action of L.A :

Phentolamine (oraversa) counteracte the anesthsia affect , affect

disappear from pulp then soft tissue

Increase success of inferior alveolar nerve secound thing by volum :

In mand : no effect on IAL block

In max : increase effct with douple cartilage but not for 60min

Increasing the Epinephrine Concentration

In mand : no effect
In max : increase duration but not for 60min

Accuracy of injection:

No effect on success anesthesia

Needle&bevel :

Bevel toword the mandibular ramus did not affect the success rate

Speed of injection & success :

Slow injection increase success rate but not in pt with irreversable

pulpitis

Cross inervation :

More common in mandible anterior , lowering the success of

anesthsia

Needl deflection :

Cause faliure of ID block

Pt told u history of multible injection & still have pain

respons , go for supplementry
 Articaine infiltartion :

Is better than lidocaine in infiltration of lower buccal first

molar but as supplementry , alone will not give pulpal anesthsia

In anterior teeth buccal & lingual infiltraion of articaine

provide pulpal anesthsia

~ Lidocaine are not affect in lower infiltration

What supplemental we have ?

Supplemental Articaine Infiltrations
Supplemental Intraosseous Anesthesia
Supplemental Intraligamentary Anesthesia

3 Success: as a primary injection,success rate of about 75%

in mandibular and maxillary posterior teeth, with a
duration of pulpal anesthesia of 10 to 15 minutes
Success rates are low in anterior teeth due to
caniculaous bone
as a supplemental injection good success rates are
achieved, but the duration of pulpal anesthesia is
approximately 23 minutes.

MOA: through the cribriform plate into the marrow spaces

&

around the tooth , primary route is not via the periodontal

ligament, and unlike the intrapulpal (IP) injection

the mechanism of action is not a pressure anesthesia.

The IL injection should be considered an intraosseous

injection.

Back-pressure : injection is injection under back-pressure

-
Anesthtic solution : 2%lidocaine or 4% Articaine is the same
effect
Bupvicaine have no effect
Vasoconstrctive significaly increase the eefect but
upadminstrating only vasoconstructive is contraindication

Amount of solution deliverd : on mesial & distal 0.2ml with

each injection

Injection discomfort : using as primary very painfull especialy

on upper anterior teeth so use it as secoundry

Onset of anesthsia : immeditaly of injection

Duration : 10-15min as primary , 20min as supplemntury ,

30-34min in wond technqiue

CCLAD : 1.4 ml within 1min as fast , slow rate 1.4ml within 4min
:45s
Success rate is 30-34min , 10min longer than conventional

Posoperative discomfort : as primary will cause pain for 14h to 3

days , tooth feels high in occlusion

Systmic effect : do not cause significant affect in heart rate in

human beings

Safty of periodontum : minor damage & undergo repair in

little cases may cause a pocket , rare case with prrio abcess &
bone loss
Localized area of root resorption have been reported

Safty on pulp

Safty on primary teeth , not the technique itself but from cytotoxic
bonuded to enamle matrix cause enamle hypoplsia
Interosseous injection :

Success: Supplementry injections of lidocaine and mepivacaine

with vasoconstrictors allow quick onset and increase the
success of ID for 60min , in cases epinephren is
contraindication , injection of 3% mepvicaine increase
successrate 30min

IO is for pasterior lower & upeer not for anterior

Failure : due to backflow specialy in X-TIp technique which make

the success rate of stabidant more than x-tip /reperforating
Or because of constricted cancellous bone which limit the
distrbution

Perforating breakage : metal perforator separates from the plastic

shank during use , metal wire is easily removed with a hemostat.

Optimal Location for Injection Site : distal to the tooth cause

disturpution occure mesialy , exception for this is upper & lower
molar due to highly plexus & unaccessable , thich cortical plate
with oplique ridge ,
affect two adjacent tooth then its not a selective anesthesia

Onset of anesthsia : immeditLy

Site selection : both user to locate the perforator on attached

gingiva through thick cortical bone & easy to find the perforator
with stabident system also to avoid insertion in area of roots &
cause perforation

X-tip system can use apicaly in alveolar mucosa because the

guide sleeve remaine in place , many causes like bone loss or
perio involvment need alveolar mucosa perforation “unattached
gingiva”

Insertion discomfort : as primary more pain than secoundry

 Timing : immediatly after lip numbness feeling

Amount : the whole carpule not 1/4 or 1/2

Duration : up to one hour , 3% mepvicaine shorter duration than

2% lidocaine with epinephrine

Repeating the IO injection : repeat after 30min of first injection will

increase duration 10 to 15min , 1.4ml of 2%lidocaine , 1:100,00 epi

Bupvicaine : no effect & should not be use as IO injection

Systemic effect : transient tachcardia , no elevation in BP , and this

is decrease with slow rate of injection , using 3%mupvicaine
without vasoconstructor for medical compromise pt will not cause
any systmic affect
M.C : antidepressent , non selective beta blocker , cocaine

Plasma level : same with infiltration

Postoperative discomfort : mild to no pain , but have a

postoperative problem : swelling , exudate , felling high occlusion

OI injection : allow adminstration of anesthesia directly

to canellous bone adjacent to tooth showed a quicker
onset with short duration

X-tip consiste of separated two parts , the drill & guide

sleeve which remin in hallow & accept 27gauge for anesthsia

Stabident OI : slow speed handpiece perforator & a solid 27

gauge wire with beveld end to deliverd the solution

Intraflow : motor rotating pin perforator & still in hallow to

delivery ansthesia

Comfirt ?!!
Pulpal injection :
Mand posterior with irreversaple pulpitis
supplemental IO or IL injection do not
produce profound anesthsia , this is
indication for IP
‫ النه‬duration ‫انو واحد احسن واخد فيهم‬
‫ لحد تلت‬IL ‫ بقعد ل حد ساعه وال‬iO ‫ال‬
‫ لخد ربع ساعه او تلت ساعه‬iP ‫ساعه وال‬
short ‫ انها‬IO ‫لكن مكتوب عن ال‬
duration

Major drawback is needle directly into vital & very sensitive

pulp is often sever to modurate pain
-duration 15-20min
-pulp must be abviously exposed to allow direct injection

Major advantage is back-pressure , immediate onset , no

equipment needed

Solution passively into champer is insufficient because

the solution dose not diffuse throughout the pulp

Its a pressure not a solution technqiue , do not open wide

access

Irreversable pulpitis : iO , IP , IL

Doctors who have equipemnt have routine supplemntral injection

Done for this chapter