17-4-18

LOCAL ANESTHESIA
IN DENTISTRY

Dr Suneel Kumar, FCPS

LIAQUAT UNIVERSITY OF MEDICAL &
HEALTH SCIENCES, JAMSHORO

2nd International LUMHS Dental Conference, 28th Oct; 2016

LOCAL ANAESTHESIA
 Anaesthesia is the loss of consciousness
and all form of sensation.

 Local Anaesthesia is the local loss of pain,

temperature, touch

 In dentistry, Only loss of pain sensation is

desirable. Local Analgesia.
LOCAL ANAESTHETIC AGENTS:
 Are drugs that block nerve conduction when
applied locally to nerve tissues in appropriate
concentrations,
 Acts on any part of the nervous system,
peripheral or central
 Any type of nerve fibres, sensory or motor.
LOCAL ANAESTHESIA
 Methods:
 Reducing temperature.
 Is used only to produce surface anaesthesia e.g. ethyl
chloride spray.

 Physicaldamage to nerve trunk e.g. nerve

sectioning.
 Unsafe for therapeutic uses, only in Trigeminal Neuralgia.

 Chemical damage to nerve trunk e.g. neurolytic

agents.
 Silver nitrate, Phenol - Unsafe for therapeutic use.
LOCAL ANAESTHESIA
 Methods: Cont
 Anoxia or hypoxia resulting in lack of oxygen to
nerve.
 Unsafe as well.
 Stimulationof large nerve fibres, blocking the
perception of smaller diameter fibres.
 includes Acupuncture and TENS (Transcutaneous
Electronic Nerve Stimulation)
 Drugsthat block transmission at sensory nerve
endings or along nerve fibres.
 There action is fully reversible and without permanent
damage to the tissues.
DENTAL USES OF LOCAL
ANESTHESIA
 Elimination Of The Pain During Treatment

 Diagnostic Purpose

 To Reduce Haemorrhage

 In Conjunction With Sedation Technique

ADVANTAGES OF LOCAL ANESTHESIA
OVER GENERAL ANESTHESIA
 Safety
 Ease Of Administration
 Cooperation of the patient
 Unlimited operating time
 Reduce bleeding during surgical treatment
 When the patient is unfit for general anesthesia.
 The Ideal Local Anesthetic

 Water soluble/stable in solution

 Non-irritating to nerve
 Low systemic toxicity
 Short induction period
 Adequate duration of action
 No post anesthetic side effects
 Vasoconstriction effect
 Not be habit forming
ARMAMENTARIUM
ARMAMENTARIUM
1-The Syringe

2- The Needle

3-The Cartridge
 1-The Syringe
 SYRINGE COMPONENTS
1.) Needle adapter

2.) Piston with harpoon

3.) Syringe barrel

4.) Finger grip

5.) Thumb ring

SYRINGE COMPONENTS
SYRINGE
American Dental Association ceriteria for
syringe
 1-must be durable and able to withstand
repeated sterlization without damage
 2-capable of wide variety of cartiages,
needles and permit reapted use
 3-inexpensive, self contained ,light weight
and simpler to use with one hand
 4-Provide effective aspiration
TYPES OF SYRINGES
1) Non-disposable syringes
a. Breech-loading, metallic, cartridge-type,
aspirating
b. Breech-loading, plastic, cartridge-type,
aspirating
c. Breech-loading, plastic, cartridge- type,
self-aspirating
d. Pressure syringe for periodontal ligament
injection
e. Jet injector (Needleless syringe)
TYPES OF SYRINGES
2) Disposable syringe

3) Safety syringe

4) Computer controlled local anesthetic

delivery systems
BREECH-LOADING, METALLIC,
CARTRIDGE-TYPE, ASPIRATING
BREECH-LOADING, PLASTIC, CARTRIDGE-
TYPE, SELF-ASPIRATING
BREECH-LOADING, PLASTIC,
CARTRIDGE- TYPE, SELF-ASPIRATING
 PRESSURE SYRINGE FOR
PERIODONTAL LIGAMENT INJECTION
SAFETY SYRINGE
Disposable syringe
CARE & HANDLING OF SYRINGE
 1-After use syringe throughly cleaned &
washed and autoclaved
 2-After every 5 autoclaving syringe should
be demalted and clean and make oiling
 3-The harpoon should be cleaned with bursh
after every use
 4-Replacement if the harpoon is not working
PROBLEMS
1-Leakage during injection:
When syringe is reloaded with second cartridge
problem can occur
2- Broken cartridge:
Piston problem, bent needle problem
3-Bent harpoon :
4-disengagement of the harpoon from plunger
during aspiration
5-surface deposition:
 2- The Needle
THE NEEDLE
 Stainless steel
 Platinum
 Iridium-platinum
 Ruthenium-platinum

 Always used disposable needle

PARTS OF THE NEEDLE
1.) Bevel

2.) Shank (shaft)

3.) Hub

4.) Syringe adapter

5.) Syringe
penetrating end
1.) BEVEL

long

medium

short
 BEVEL:
 Defined as point or tip of needle

 Types: Long, Medium, Short

 SHAFT:
 Long piece of tubular metal running from tip
to hub

 Two factors important:

 Diameter of lumen (Needle Guage)

 Length
GAUGE:
 Refer to the Diameter of the lumen of the
needle

 Smaller the number greater the diameter

 In aspiration greater gauge is required

(Vascular Area ((SANB,MNB,IDNB))

 27 gauge can be used for all (aspiration,

Pentration)
GAUGE
 RED 25 gauge
 Yellow 27 gauge
 Blue 30 gauge
Advantages of Greater gauge needle over
smaller gauge needles:
 1-Less deflection
 2-Greater accurarcy
 3-less chances needle breakage
 4-easier aspiration

 5-no difference in pts discomfort

LENGTH
Two length:
 Long
 Short
 Ultrashort

 Average length of short length 20 mm upto

32mm for long needle
THE NEEDLE
 Length
 Short 2-2.5cm
 Long 3.2cm

 Gauge
 27 gauge
 30 gauge
 RECOMMENDED SIZES OF THE
LOCAL ANESTHETIC NEEDLES:
 Intraligamentary
Anesthesia: 30 G, 12 mm

 Infiltration Anesthesia:
27 G Or 30 G 2.5cm

 Regional Block: 27 G 3.2

cm
CARE & HANDLING
 1-Single use needle
 2-Needles should be changed after 3 to 4
pricks in one patient
 3-Needle should be protected with sheath
cover
 4-Attention should be paid on position of
uncover needle
 5-Needle must be properly disposed after use
PROBLEMS
 1-Pain on insertion:

 Use of dull needle can happen this

 Always use topical anesthesia before
insertion needle
 Needle should be changed after 3 to 4 pricks
in same patient
PROBLEMS
 2-Breakage:

 Bending weakens
the needle

 Not be bent if
inserted more
than 5mm
PROBLEMS
 3-Pain on withdrawal:

 Fishhook form on the tip of needle avoid

rubbing on the hard object
 Manufacturing fault
PROBLEMS
 4-Injury to patient or adminstrator:
RECAPPING THE NEEDLE
− Always use the scoop technique

− This is the time you are most likely to get

stuck by the needle.

Never do this
RECAPPING THE NEEDLE
Never Do This Scoop Technique
ANY QUESTION?
3-THE DENTAL CARTRIDGE
THE CARTRIDGE
1.) Cylindrical glass tube

2.) Stopper

3.) Aluminum cap

4.) Diaphragm
THE CARTRIDGE
CARTRIDGE
-1.8 mL (United States)
-2.2 mL (UK and Australia)
-Should not be autoclaved
-Stored at room temperature (21°C to
22°C (70°F to 72°F)
-Should not soak in alcohol
-Should not be exposed to direct
sunlight
L/A COMPOSITION
 1-Lidocaine L/A  Blockade of nerve
durg conduction
 2-Sodium cholride  Isotoncity of sol:
 3-Sterile water  Volume
 4-Thymol  Anti Fungal
 5-Vasoconstrictor  Increase depth,
 Inc Durtion
 Dec absorption
L/A COMPOSITION
 5-Sodium meta  Antioxidant
bisulfate
 6-Methyl paraben  Bacteriostatic
CARE & HANDLING
 Glass cartridge Should not be autoclaved

 Plastic cartridge Should not be autoclaved

 Always read instruction which are given by

manufacutres / warnings
PROBLEMS
1. Bubble in cartridge
2. Extruded stopper
3. Burning on injection
4. Sticky stopper
5. Corroded cap
6. Rust on cap
7. Leakage during injection
8. Broken cartridge
RECOMMENDATION
 1-Single use Dental cartridges

 2-Cartridge must be stored at room temperature

 3-Not necessary to warm the cartridges before

use
 4-Always check expiry date

 5-Should be checked carefully for cracks, chips

and integrity of the stopper and cap before use
OTHER ARMAMENTARIUM
 OTHER ARMAMENTARIUM

1) Topical antiseptic
(optional)
2) Topical Anesthetic
(strongly recommended)
3) Applicator sticks
4) Cotton gauze (2” x 2”)
5) Hemostat
TOPICAL ANTISEPTIC
 Transient decrease in bacterail poplation

 For 15 to 30 seconds with applicator

 Betadine (Povidine-iodine)
 Merthiolate (thimerosal)
 Avoid alchol containing antiseptic because
causes tissue irritation
 If antiseptic not available than use sterile
gauze wipe
TOPICAL ANESTHETIC
 Applied with applicator for 1 to 2 mintues
 Ester L/A Benzocaine (Gel)
 Allergic reaction greater than Amide group
 Benzocaine is not absorb systemically so less
effects
 In Amides only lidocaine possess topical
anestheic properties
 Lidocaine (Spray, Gel, Pastes, Ontiment)
 Unmetered /Metered
 Dispoasable Applicator nozzles
APPLICATOR STICKS
 Wooden small rods at anterior head small
piece of cotton warp
COTTON GAUZE/ HEMOSTAT
 Wiping the area before injection
 Retraction of lips, checks for improve access

 Removal of needle from soft tissue

 CLASSIFICATION OF LOCAL
ANAESTHETICS
 Amide  Ester
 Lignocaine  Procaine
 Mepivacaine  Cocaine
 Prilocaine  Benzocaine
 Articaine  Tetracaine
 Bupivacaine
 Etidocaine
 Mechanism Of Action

Local Anesthetic
Agent Sodium Channels

No Action Potential Blockade of sodium

channel

No Impulse Conduction
 ACTION OF LOCAL
ANESTHESIA
Action On Cardiovascular System

 Direct depression of myocardium

 Bradycardia
 Decrease cardiac out put
 Peripheral vasodilation
 Ventricular fibrillation
 ACTION OF LOCAL
ANESTHESIA
On Central Nervous System
 Anxiety
 Restlessness

 Slurred speech

 Talkativeness

 Tremors

 Generalized convulsion

 Disorganized respiration

 CNS depression
 BIOTRANSFORMATION AND
ELIMINATION
 Esters are metabolized in the plasma by pseudo-
cholinesterase.

 Amides are primarily metabolized in the liver.

 Clinical Consideration
 Avoid large doses in patient affected with
impaired liver and renal function.

 For patients with hepatic disease, the usual

dose per site is still required, but the total dose
needs to be reduced.

 For patients with hepatic disease, treat one

quadrant per appointment if possible.
 LIGNOCAINE
 Is most effective and most commonly used drug.

 Twice as affective as procaine

 Rapid onset

 Produce more profound anesthesia of longer

duration.
LIGNOCAINE
Available Formulations
 As Infiltration Or Block
2% of solution in ampoule or
cartridge

 As Topical Anesthetic Agent

2% viscous gel
5% ointment
5% in mouth wash
LIGNOCAINE
 Duration Of Anesthesia
 Pulpal anesthesia after infiltration in maxilla -60
mints
 For inferior alveolar nerve block -90 mints
 Soft tissue anesth: 3-4 hours

 Recommended Maximum Doses

 5mg/kg of body weight
 350mg with vasoconstrictor = 10 cartridges
 200mg without vasoconstrictor
LIGNOCAINE
Clinical Consideration
 Unlike other anesthetic agent it tends to
produce signs of CNS depression

 It does not exhibit cross sensitivity with esters.

VASOCONSTRICTORS
 ADVANTAGES OF
VASOCONSTRICTORS
 It reduces the toxic effects

 Increases the depth and duration of anesthesia

 Provides bloodless field for surgical procedure

 Provides homeostasis
 MOST COMMON
VASOCONSTRICTORS
 Epinephrine

 Felypressin

 Levonordefrin
 CONCENTRATION OF
VASOCONSTRICTORS IN LA
Epinephrine
Gram per milliliter
 1:50,000 = .020mg/ml
 1:80,000 = .012mg/ml
 1:100,000 = .010mg/ml
 1:200,000 = .005mg/ml
 Max Dose Of Vasoconstrictors

• Healthy patient approximately 0.2mg

• Patient with significant cardiovascular

history: 0.04mg
 Adrenaline
Clinical Consideration
 Be careful to use in patient suffering from
thyrotoxicosis. (Thyroid Strom)

 Pt: receiving tricyclic antidepressant or

monoamine oxidase inhibitor.

 Avoid to use in conjunction with G.A

(halothane, cyclopropane)
FELYPRESSIN (OCTAPRESSIN)

 1:2000 000 = .03 i.u/ml

(Citanest or Prilocaine )
Maximum Dose

 13ml for healthy individual


8.8 ml in pt with CV disease
 Felypressin
Clinical Consideration

Best alternative in ……

 Thyrotoxicosis

 Pt: receiving monoamine oxidase inhibitor or

tricyclic antidepressant.

 Pt: with ischemic heart disease

 FELYPRESSIN
IS CONTRAINDICATED IN
PREGNANCY OWING OXYTOXIC
EFFECT
INNERVATION OF THE
JAWS
 INNERVATION OF THE JAWS
Mandible
 Inferior Alveolar Nerve
 all teeth and buccal soft tissues
of premolars, canine, and
incisors.

 Lingual nerve
 Lingual soft tissues of all the
teeth

 Long buccal nerve

 Buccal
 INNERVATION OF THE JAWS
Maxilla
 Anterior superior alveolar
nerve
 Incisors and canine tooth and
adjoining labial soft tissues.
 Middle superior alveolar nerve
 Premolars and MB root of Ist molar
tooth and adjoining buccal soft
tissues.
 Posterior superior alveolar
nerve
 Buccal, palatal root of Ist molar and
rest of the molars and adjoining soft
tissues.
 INNERVATION OF THE JAWS
Maxilla
 Anterior palatine
nerve
 Palatal
soft tissues of
molars and premolars.

 Nasopalatine nerve
 Palatalsoft tissues of
incisors and canine.
BASIC INJECTION
TECHNIQUE
STEPS FOR INJECTION
1. Use sterilized sharp needle (fishhook)
2. Check the flow of local anesthetic solution
3. Position the patient (supine)
4. Dry the tissue
5. Apply topical anesthetic
STEPS FOR INJECTION (CONT)
6. Communicate with the patient (pain,
discomfort)
7. Establish a firm hand rest
8. Make the tissue taut (stretching)
9. Keep the syringe out of the patient’s
line of sight
10. Insert the needle into the mucosa
level
STEPS FOR INJECTION (CONT)
11. Slowly advance the needle toward the
target (few drops while advancing needle)
12. Aspirate (negative pressure, self aspirating
syringe)
13. Slowly deposit the local anesthetic solution
(1 mL/min, 1.8 mL /min practical)
14. Slowly withdraw the syringe (recapping,
scoope technique)
15. Observe the patient
TECHNIQUES OF LOCAL
ANESTHESIA
 Surface Anesthesia

 Infiltration Anesthesia

 Regional Anesthesia
SURFACE ANESTHESIA
METHODS OF APPLICATION
 Mouthwash
 Lozenges
 Pastes and solutions
 Spray
 Jet injectors
 Refrigeration
USES OF SURFACE ANESTHESIA
 Prior to injection
 For minor surgical procedure
 Incision of an abscess
 Deep scaling
 Prior making impression
 To reduce the pain in stomatitis
MINIMIZING NEEDLE DEFLECTION:
ROTATIONAL INSERTION TECHINQUE:
 BRIT(Bi-Rotational Insertion technique)

the operator rotates the needle in a back-

and-forth rotational movement while
advancing the needle through the tissues;
traditional hand-held syringes cannot be
rotated in this manner, however, The Wand
can be rotated in this fashion results in less
deflection, less force is needed for needle
penetration