Anestezie Endo

LOCAL ANESTHESIA IN
DENTISTRY
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INDIAN DENTAL
ACADEMY
Leader in continuing dental education
HISTORY
 500’s: Coca leaves were first used by Peruvians for
psychotropic properties.
 1850’s: German chemist Albert Niemann
successfully isolated the active principle of
coca leaf; he named it cocaine. Hypodermic needle
developed
 1884: Sigmund Freud studied the effects of cocaine.
 1884: Carl Koller introduced cocaine into medical
practice.
….History
 1884 : Local anesthesia used in dentistry by Halsted
and Hall
 1905 : Procaine synthesized by Einhorn
 1921: Cartridge syringe marketed by Cook
 1947: Aspirating syringe developed
 1948: Lidocaine marketed
 1959: Disposable needle introduced
DEFINITON.
“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”
-(Grune & Straton-1976)
 REGIONAL ANALGESIA: loss of pain sensation over
a portion of the anatomy without loss of
consciousness
 REGIONAL ANESTHESIA: it applies not only to loss

of pain sensation over a specific area of anatomy
without loss of consciousness but also to the
interruption of all other sensations, including
temperature, pressure and motor function.
CLASSIFICATION
BASED ON CHEMICAL STRUCTURE
 ESTERS:  AMIDES:
 Benzoic acid esters:  Articaine
 Benzocaine  Bupivacaine
 Cocaine  Etidocaine
 Para-amino benzoic  Lidocaine
esters:  Mepivacaine
 Tetracaine  Prilocaine
 Chlorprocaine  QUINOLINE:
 Procaine  Centbucridine
 Propoxycaine
STRUCTURES OF AMIDES
AND ESTERS
R3
Ester: R1 —COO—R2 —N
R4
R3
Amide: R 1 —NHCO—R2 —N
R4
R1 — Lipophilic aromatic residue.

R2 — Aliphatic intermediate connector.
R3 , R4 — Alkyl groups
Based on biological site and mode of action
Class AClass BClass CClass D
Based on the source
Natural Synthetic Others
Based on duration of action
Short Intermediate Long
 Short duration –
 eg: Lidocaine HCl 2%, Mepivacaine HCl 3%
 Intermediate duration –
 eg: Lidocaine HCl 2% + epinephrine 1:1,00,000
 Long duration–
 eg: Bupivacaine HCl 0.5% + epinephrine 1:2,00,000, Etidocaine
Based on mode of application
Topical Injectable
NEROPHYSIOLOGY
MODE OF ACTION OF LOCAL
ANESTHETIC…
 Local anesthetic agents interfere with excitation
process in a nerve membrane in one or more of the
following ways:
 Altering basic resting potential

 Altering the threshold potential
 Decreasing the rate of depolarization
 Prolonging the rate of repolarization
THEORIES OF MECHANISM
OF ACTION OF L.A…
 Ca2+ DISPLACEMENT THEORY (Goldman-1966)
 SURFACE CHARGE THEORY (Wei-1969)
 ACETYLCHOLINE THEORY (Dett barn-1967)
 MEMBRANE EXPANSION THEORY (Lee-1976)
 SPECIFIC RECEPTOR THEORY (Strichartz-1987)
ACETYL CHOLINE THEORY
MEMBRANE EXPANSION
THEORY
SPECIFIC RECEPTOR THEORY
CHEMICAL REACTON OF LA
RNHOH + HCl  RNHCl + H2O

Weak strong acid water
Base acid salt
RNHCl  RNH+ + CI-
EFFECT OF PH
Basic environment (higher pH)

RNH+ > RN + H+
Acidic environment (low pH)

RNH+ < RN + H+
RNH+ displaces calcium ions for the sodium channel receptor site.
↓ which causes
Binding of the local anesthetic molecules to this receptor site
↓ which produce
Blockade of sodium channel
↓ and
Decrease in sodium conduction
↓ which leads to
Depression of the rate of electrical depolarization
↓ and
Failure to achieve the threshold potential level

Lack of development of propagated action potentials
↓ called
Conduction blockade
HENDERSON – HASSELBALCH EQUATION
 Log Base = pH – pKa

Acid
INDIVIDUAL LOCAL ANESTHETIC
AGENTS…
Drug pka ph Conc Onset ½ life
used
Procaine 9.1 5-6.5 2-4% 6-10 min ½ hr
3.5-5.5
Propoxycaine - - 0.4% 2-3 min -
Lidocaine 7.9 6.5 2% 2-3 min 1.6 hr

5-5.5
Mepivacaine 7.6 4.5 3% 1.5-2 1.9 hr
3-3.5 2% min
Prilocaine 7.9 4.5 4% 2-4 min 1.6 hr
3-4
Articaine 7.8 4.4-5.2 4% 2-3 min 1.25

hrs
Bupivacaine 8.1 4.5-6 :3-4.5 0.5% 6-10 min 2.7 hr
Etidocaine 7.7 4.5 1.5% 1.5 3- 2.6 hr

3-3.5 min
PHARMACOKINETICS
UPTAKE
 Oral route :
 “Hepatic first pass effect”. 72% Lignocaine.
 Topical route:
 Tracheal mucosa. (lignocaine. Adrenaline, fumazenil).
 Pharyngeal mucosa.
 Esophageal or bladder mucosa.
 Skin or oral mucosal.
 Injection:
 Activity depends on:
 Vascularity of the tissue.
 Vasoactivity of the drug.
 IV caution. ( used in treatment of ventricular
dyrhythmias).
DISTRIBUTION.
 High conc seen in well purfused organs such as brain,
kidney, lungs, heart.
 Level of drug in blood depend on:
 Rate at which drug is absorbed into CVS.
 Rate at which drug is distribute from vasculature to tissue.
 Elimination of drug through excretion.
“Elimination half life.”
BITRANSFORMATION.
 Esters:
 Pseudocholinesterase.
 Succinylcholine.
 Atypical pseudo cholinesterase.
 PABA (cause allergic reactions).
 Amides:
 More complicated.
 Hepatic microsomal enzymes.
 Liver function and perfusion play an important role.
 Intermediate products cause complications.
 Prilocaine metabolite: orthotoluidine
- methhemoglobinemia.
 Lilocaine metabolites: monoethyl glycine xylidide & xylidide
- sedation
EXCRETION.
 Kidneys are the primary
excretory organs.
 Less % of parent molecules
of ester anesthetics.
 Large% of unchanged amide
parent molecules.
 Renal impairment causes
accumulation of drug and its
metabolites causing toxity.
SYSTEMIC ACTIONS.
 CNS.
 CVS.
 LOCAL TISSUE TOXICITY.
 RESPIRATORY SYSTEM.
 MISCELLANEOUS.
 Neuromuscular blockade.
 Drug interactions.
 Malignant hyperthermia.
CNS-Pathophysiology
Local anesthetics cross blood-brain barrier, producing CNS
depression as level rises
eg. LIDOCAINE
Blood Level Action Produced
< .5 ug/ml - no adverse CNS effects
0.5-4 ug/ml - anticonvulsant
4.5-7.5 ug/ml - agitation,irritability (pre - convulsant)
> 7.5 ug/ml - tonic-clonic seizures
Analgesia.
Mood elevation.
CVS-Pathophysiology
Local anesthetics exert a lesser effect on the
cardiovascular system
eg. LIDOCAINE
1.8-5 ug/ml - treat PVCs, tachycardia
5-10 ug/ml - cardiac depression
>10 ug/ml - severe depression,
bradycardia, vasodilatation, arrest
MINIMAL TO MODERATE
OVERDOSE.
SIGNS SYMPTOMS:
Talkativeness Light-headed and dizzy
Excitability Restless
Apprehension Nervous
Slurred speech Numbness
Stutter( Muscular twitching / tremors
) Nervousness
Euphoria Sensation of twitching (before
actual
Dysarthria
Nystagmus twitching is observed)
Sweating Metallic taste
Nausea/vomiting Visual disturbances
Failure to follow commands / reason Auditory disturbances
Elevated BP Drowsy and disoriented
Elevated heart rate Losing consciousness
Elevated resp rate
MODERATE TO HIGH OVER
DOSE.
Generalized tonic-clonic seizure activity
followed by
Generalized CNS depression
Depressed BP, heart rate
Depressed respiratory rate
 LOCAL TISSUE TOXICITY.
 RESPIRATORY SYSTEM.
 MISCELLANEOUS.
 Neuromuscular blockade.
 Drug interactions.
 Potentiates the action the action of CNS depressants.
 Prolongs the action of succinlycholine.
 Malignant hyperthermia.
 Thachycardia, tachypnea, cynosis, unstable BP,
 Respiratory and metabolic acidosis, fever.
 Muscle rigidity and death
FACTORS AFFECT THE REACTION OF
LOCAL ANESTHETICS
pKa:
 Local anesthetics have two forms, ionized and nonionized. The
nonionized form can cross the nerve membranes and block the
sodium channels.
 So, the more nonionized presented, the faster the onset action.
pH influence:
 Usually at range 7.6 – 8.9
 Decrease in pH shifts equilibrium toward the ionized form,
delaying the onset action.
Lipid solubility:
 All local anesthetics have weak bases. Increasing the lipid
solubility leads to faster nerve penetration, block sodium channels,
and speed up the onset of action.
Protein binding:
 The more tightly local anesthetics bind to the protein, the longer
the duration of onset action.
Vasodilation:
 Vasodilator activity of a local anesthetic leads to a faster
absorption and slower duration of action
 Vasoconstrictor is a substance used to keep the anesthetic
solution in place at a longer period and prolongs the action of the
drug
 vasoconstrictor delays the absorption which slows down the
absorption into the bloodstream
 Vasoconstrictor used the naturally hormone called epinephrine
(adrenaline). Epinephrine decreases vasodilator.
VASOCONSTRICTORS
 Decrease blood flow
 Lower anesthetic blood levels
 Decrease the risk of toxicity
 Increases duration of action
 Decrease bleeding
ADRENERGIC RECEPTORS
 Ahlquist in 1948
 Two types
 Alpha () – vasoconstriction
 1  excitatory – post synaptic
 2  inhibitory – post synaptic.
 Beta () - vasodilation and bronchodilation + cardiac
stimulation
 1 Found in heart & small intestines & responsible for cardiac
stimulation & lipolysis
 2  found in bronchi, vascular beds, & uterus & produces
bronchodilation and vasodilation
EPINEPHRINE
 Most potent and widely used vasoconstrictor in dentistry
 Source: 80% of medullary secretion, also available as a synthetic
 MOA- both  and , with  being predominate
 Systemic Effects of Epinephrine
 Myocardium - ↑ heart rate & cardiac output
 Pacemaker - ↑ risk of dysrhythmias
 Coronary Artery-Dilation of coronary artery
 B P- ↑ systolic pressure, effect on diastolic pressure is dose related
 Cardiovascular -Decrease cardiac efficiency
 Vasculature
 Vasoconstriction in skin, mucous membrane &
kidneys
 Vasodilation in skeletal muscle in small doses
 Respiratory - Bronchodilator
 CNS - Not a potent CNS stimulant
 Metabolism
 Increase oxygen consumption
 Glycogenolysis- ↑ blood sugar
 Termination of Epinephrine
 Reuptake
 COMT and MAO
 Excreted unchanged in urine (1%)
 Clinical Manifestations of Epinephrine Overdose

 CNS stimulation - fear, anxiety, tremor, pallor, dizziness
 Cardiac dysrhythmia
 Ventricular fibrillation
 Drastic increase in BP - can cause cerebral hemorrhage
 Angina in patientswww.indiandentalacademy.com
with coronary insufficiency
 Maximum Dose for Dental Appointment
 Normal healthy patient
0.2 mg. per appointment
 Significant cardiovascular impairment
0.04 mg per appointment
 Clinical Applications for Epinephrine

 Acute allergic reaction
 Bronchospasm
 Cardiac arrest
 Hemostasis
 Produce mydriasis
 Vasoconstrictor
 Norepinephrine www.indiandentalacademy.com
ARMAMENTARIUM
SYRINGE
NEEDLE
ANESTHETIC SOLUTION
TOPICAL ANESTHETIC
 Minimize sensation of needle penetrating the
soft tissue.
 Used in greater concentration than LA in
order to penetrate the mucous membrane.
TOPICAL ANESTHETIC AGENTS
Lidocaine Benzocaine
 5% ointment, gel, liquid  14-20% liquid, gel
 Onset 30 seconds
 10% metered spray  Longer duration than the

others
 Onset 3-5 minutes  Lower toxicity potential than
the others
 Best one for Pedo although
some children say it feels
“hot”
RECOMMENDATIONS
 For the administration of local dental anesthesia,
dentists should select aspirating syringes that meet
the standards of the ADA.
1. Short needles may be used for any injection in which the
thickness of soft tissue is less than 20 mm
2. Long needle for a deeper injection into soft tissue.
3. Any 23- through 30-gauge needle may be used for intraoral
injections since blood can be aspirated through all of them;
however, aspiration can be more difficult when smaller gauge
needles are used.
4. An extra-short, 30-gauge is appropriate for infiltration
injections.
5. Needles should not be bent or inserted to their hub for
injections to avoid needle breakage.
BASIC INJECTION
TECHNIQUE
 Use sterile sharp needle.
 Check the temperature of the local
anesthetic solution
 Check the flow of local anesthetic solution.
 Operator position.
 Position the patient.
Dry the tissue.
Apply topical antiseptic.
Apply topical anesthetic.
 Establish a firm hand rest.
 Make the tissue taut.
 Keep the syringe out of the patients line of sight.
 Orientation of the bevel.
 Insert the needle into the mucosa.
 Watch and communicate with the patient.
 Inject several drops of solution
 Slowly advance the needle to the target site.
 Aspirate.
 Slowly deposit the solution.
 Communicate with the patient.
 Slowly withdraw the syringe.
 Observe the patient after injection.
 Indications :
 Anesthesia of more than two teeth
 Supraperiosteal injections ineffective
 Inflammation/infection contraindicating local infiltration
 Contraindications :
 Discrete treatment areas (1-2 teeth only) Hemostasis
 Bleeding problems (eg. hemophelia, etc..)
 Advantages :
 Comparatively simple, safe technique
 Minimized volume of solution
 Minimized number of needle punctures
 Disadvantages:
 Vary according to the type of block.
 Failure: www.indiandentalacademy.com
TECHNIQUES
OF
LOCAL ANESTHESIA
TECHNIQUES
OF
MAXILLARY ANESTHESIA
LOCAL INFILTRATION
FIELD BLOCK
NERVE BLOCK
MAXILLARY INJECTION
TECHNIQUES
 Supraperiosteal
 Periodontal ligament
 Intraseptal injection
 Posterior superior alveolar nerve block
 Middle superior alveolar nerve block
 Anterior superior alveolar nerve block
 Maxillary (second division) nerve block
 Greater (anterior) palatine nerve block
 Nasopalatine nerve block
LOCAL INFILTRATION
LOCAL INFILTRATION
 Areas anesthetized:
 Entire area innervated by the large terminal nerve branches
 Tooth pulp and root area
 Buccal periosteum
 Mucous membrane and connective tissue
 Indications:
 Pulpal anesthesia of one or two maxillary teeth
 Soft tissue anesthesia when indicated
 Hemostasis
 Contraindications:
 Infection or acute inflammation in the area
 Dense bone covering apices of teeth
 Advantages:
 High success rate (>95%)
 Technically easy injection
 Usually entirely atraumatic
 Disadvantages:
 Not suitable for large areas
 Multiple needle insertions
 Large volumes of anesthetic solution
 Percent Positive Aspiration:
 Negligible, but possible (<1%)
 Alternatives:
 Periodontal ligament injection
 Regional nerve block
Technique
 Apply topical
 Landmarks:
 Mucobuccal fold.
 Long axis of tooth.
 Insert needle: At height of mucobuccal fold
 Target area: Apex of tooth
 Aspirate, deposit approx. 0.6-1 ml solution
 Signs and Symptoms:
 Numbness
 Absence of pain during dental therapy
 Safety Feature:
 Minimum opportunity for intravascular
 Administration
 Failures of Anesthesia:
 Needle tip below the apex of the tooth.
 Needle too far from bone.
POSTERIOR SUPERIOR
ALVEOLAR NERVE BLOCK
Nerve Anesthetized:
Posterior Superior Alveolar Nerve (PSA)
- for maxillary molars and buccal tissue
 Indications for PSA Block:
 First or second maxillary molar
 Supraperiosteal injection is contraindicated
 Contraindication:
 Risk of hemorrhage is too great
(eg. hemophilia, coumadin)
 Advantages:
 Atraumatic
 High success rate
 Less number of injections
 Minimize amount of local used
 Disadvantages:
 Risk of hematoma
 Does not anesthetize first molar completel
 No bony landmarks
 Positive Aspiration :Approximately 3.1%
Technique
 25 gauge, long needle
 Landmarks:
 Mucobuccal fold
 Maxillary tuberosity
 Zygomatic process of maxilla
 Area of Insertion :
 Mucobuccal fold above maxillary second molar
 Advance needle upward, inward and backward
 Aspirate, inject 1.8 ml of solution
 Needle too lateral
 Needle not deep enough
 Needle too far superior
 Complications :
 Hematoma
 Mandibular anesthesia
MIDDLE SUPERIOR ALVEOLAR
NERVE BLOCK
 Nerve Anesthetized:
 Middle Superior Alveolar Nerve
 Areas Anesthetized:
 Maxillary premolars and buccal tissues
 Indications :
 Anesthesia of maxillary premolars only
 Infraorbital nerve block failure
 Infection /inflammation in area of injection
 Advantage :
 Minimized number of injections
 Disadvantage :
 MSA nerve is only present 28% of the time
 Alternatives :
 Local infiltration (supraperiosteal)
 Periodontal ligament injection (PDL)
 Infraorbital nerve block
Technique - MSA
 Landmarks / Area of Insertion :
 Mucobuccal fold above second premolar
 Apex of second premolar
 Apply topical
 Position patient and identify landmarks
 Insert needle 5-10 mm
 Aspirate
 Inject 0.9 ml of solution, slowly
 Signs and Symptoms:
 Numb upper lip
 Pain free dental therapy
 Safety Features :
 Anatomically safe (no signifcant structures)
 Relatively avascular area
 Positive aspirations - negligible (< 3%)
 Complications are rare
 Needle inserted too high, or not high enough
 Deposition of solution too far laterally
INFRAORBITAL NERVE BLOCK
 Nerves Anesthetized:
 Anterior Superior Alveolar Nerve
 Middle Superior Alveolar Nerve
 Superior Labial Nerve
 Inferior Palpebral Nerve
 Lateral Nasal Nerve
 Areas Anesthetized:
 Pulpal anesthesia of maxillary anterior teeth
 Pulpal anesthesia of premolars and mesiobuccal root of first
molar
 Buccal soft tissue and bone of same teeth
 Lower eyelid, lateral nose, and upper lip
NERVES ANESTHETIZED
AREAS ANESTHETIZED
 Indications :
 Anesthesia of more than two maxillary teeth
 Supraperiosteal injections ineffective
 Inflammation/infection contraindicating local
infiltration
 Discrete treatment areas (1-2 teeth only)
Hemostasis
 Bleeding problems (eg. hemophelia, etc..)
 Advantages :
 Comparatively simple, safe technique
 Minimized number of needle punctures
 Disadvantages:
 Psychological
 Administrator- fear of eye involvement
 Patient- apprehension of extraoral approach
 Anatomical-Difficulty defining landmarks
 Alternatives:
 Supraperiosteal injection for each tooth
 Maxillary nerve block
Technique
 Apply topical
 Position patient and identify landmarks
 Landmarks :
 Mucobuccal fold above first premolar
 Infraorbital notch
 Infraorbital foramen
 Area of Insertion :
 Mucobuccal fold above first premolar
 Target area
 Infraorbital foramen
 Neurovascular bundle
 Insert needle to upper rim of infraorbital foramen
 Aspirate
 Signs and Symptoms :
 Tingling and numbness of lower eyelid, side of
nose, and upper lip
 Numbness in teeth and soft tissues
 No pain during dental therapy
 Safety Features :
 Needle contacting bone
 Finger over infraorbital foramen
Failures of Anesthesia
Bone contact below infraorbital foramen
Needle deviates laterally or medially

Complications :
Hematoma (rare)
Positive aspirations - 0.7 %
ANTERIOR MIDDLE SUPERIOR
ALVEOLAR NERVE BLOCK.
PALATAL ANESTHESIA
NERVES ANESTHETIZED.
GREATER PALATINE NERVE
BLOCK
 Anterior Palatine Nerve
 Areas anesthetized:
 Posterior portion of hard palate and overlying soft tissues
 Anteriorly to 1st premolar
 Medially to midline
 Indications
 Pain control in posterior palatal hard and/or soft tissues
 Contraindications
 Inflammation / infection at injection site
 Only small area necessary (eg. 1-2 teeth)
 Advantages
 Minimizes penetrations and discomfort
 Minimizes volume of solution (0.5 ml)
Greater Palatine Nerve Block
 Disadvantages
 Limited hemostasis
 Potentially traumatic
 Alternatives:
 Local infiltration in each area
 Maxillary Nerve Block
 Aspiration:
 < 1% positive
 Landmarks
 Greater palatine foramen
 Junction of alveolus and palatine bone
Greater Palatine Nerve Block
 Area of Insertion
 Soft tissue anterior to foramen, from opposite side
 Precautions
 Do not enter canal
 Signs & symptoms
 Numb posterior palate; painfree treatment
 Safety features
 Bone contacted; aspiration
 Technique
 Position - open wide, extend & turn head
 Cotton swab - identify landmarks, topical
 Approach - bevel to tissue, advance to bone
 Aspirate; inject 0.5 ml slowly
 Failure:
 Overlap of fibers from Nasopalatine nerve
 Injection too anterior
 Complications:
 Soft tissue ischemia / necrosis
 Post injection pain, hematoma
NASOPALATINE NERVE
BLOCK
Nasopalatine Nerve Block
 Indications:
 Pain control in anterior hard and/or soft tissues
 Contraindications:
 Inflammation / infection at injection site
 Only small area necessary (eg. 1-2 teeth)
 Advantages:
 Minimizes needle penetrations
 Minimizes volume of solution (0.4 ml)
 Disadvantages:
 Limited hemostasis
 Potentially traumatic
 Alternatives
 Local infiltration
 Maxillary Nerve Block
 Aspiration
 < 1% positive
 Precautions
 Do not inject directly into papilla/canal
 Inject slowly, with small volume
 Signs / symptoms
 Numb anterior palate; painfree treatment
 Safety features
 Bone contacted; aspiration
 Technique
 Position - open wide, extend head
 Landmarks - incisive papilla, central incisors
 Approach - lateral to incisive papilla, starting with cotton swab, topical
 Deposit approx. 0.4 ml / 30 sec
 Failure
 May be only unilateral
 May have overlap with Greater Palatine
 Complications
 Ischemia, tissue necrosis
 Others rare
TECHNIQUES
OF
MANDIBULAR ANESTHESIA
MANDIBULAR ANESTHESIA
 Lower success rate than Maxillary anesthesia
 Related to bone density
 Less access to nerve trunks.
 Success depends on depositing solution within 1 mm
of nerve trunk
MANDIBULAR NERVE BLOCKS
 INFERIOR ALVEOLAR
 BUCCAL
 LINGUAL
 MENTAL - INCISIVE
 GOW-GATES
 AKINOSI
INFERIOR ALVEOLAR NERVE
BLOCK
 Not a complete mandibular nerve block.
 Requires supplemental buccal nerve block
 May require infiltration of incisors or mesial root of first molar
 Nerves anesthetized
 Inferior Alveolar
 Mental
 Incisive
 Lingual
 Areas Anesthetized
 Mandibular teeth to midline
 Body of mandible, inferior ramus
 Buccal mucosa anterior to mental foramen
 Anterior 2/3 tongue & floor of mouth
 Lingual soft tissue and periosteum
Inferior Alveolar Nerve Block
 Indications
 Multiple mandibular teeth
 Buccal anterior soft tissue
 Lingual anesthesia.
 Infection/inflammation at injection site
 Patients at risk for self injury (eg. children)
10%-15% positive aspiration
 Alternatives
 Mental nerve block
 Incisive nerve block
 Anterior infiltration
 Periodontal ligament injection (PDL)
 Gow-Gates
 Akinosi
 Intraseptal
Technique
Apply topical
Area of insertion:
medial ramus, mid-coronoid notch,
level with occlusal plane (1 cm above),
3/4 posterior from coronoid notch to pterygomandibular raphe
advance to bone (20-25 mm)
Target Area
Inferior alveolar nerve, near mandibular foramen
Landmarks
Coronoid notch
Pterygomandibular raphe
Occlusal plane of mandibular posteriors
Precautions
Do not inject if bone not contacted
Avoid forceful bone contact
Failure of Anesthesia
Injection too low
Injection too anterior
Accessory innervation
-Mylohyoid nerve
-contralateral Incisive nerve innervation
Complications
Hematoma
Trismus
Facial paralysis
Long Buccal Nerve Block
 Anterior branch of Mandibular nerve (V3)
 Provides buccal soft tissue anesthesia adjacent to
mandibular molars
 Not required for most restorative procedures.
 Indications
 Anesthesia required - mucoperiosteum buccal to mandibular
molars
 Advantages
 Technically easy
 Disadvantages
Buccal Nerve Block
Alternatives
Buccal infiltration
Gow-Gates
PDL
Intraseptal
Buccal Nerve Block
 Technique
 Apply topical
 Insertion distil and buccal to last molar
 Target - Long Buccal nerve as it passes anterior border of ramus
 Insert approx. 2 mm, aspirate
 - 25-27 gauge needle
 Area of insertion:
 - Mucosa adjacent to most distal
 Landmarks
 Mandibular molars
 Mucobuccal fold
 Complications
 Hematoma (unusual)
 Positive aspiration
 0.7 %
Mental Nerve Block
 Terminal branch of IAN as it exits mental foramen
 Provides sensory innervation to buccal soft tissue
anterior to mental foramen, lip and chin
 Indication
 Need for anesthesia in innervated area
 Contraindication
 Advantages
 Easy, high success rate
 Usually atraumatic
 Disadvantage
 Hematoma
INFILTRATION
Incisive Nerve Block
Terminal branch of IAN
Originates in mental foramen and proceeds
anteriorly
Good for bilateral anterior anesthesia
Not effective for anterior lingual anesthesia
Incisive Nerve Block
 Nerves anesthetized
 Incisive
 Mental
 Areas Anesthetized
 Mandibular labial mucous membranes
 Lower lip / skin of chin
 Incisor, cuspid and bicuspid teeth
 Indication
 Anesthesia of pulp or tissue required anterior to mental foramen
 Contraindication
 Advantages
 Pulpal anesthesia w/o lingual anesthesia
 Disadvantages
 Lack of lingual or midline anesthesia
 Complications
 Hematoma
 Positive aspiration
 5.7 % www.indiandentalacademy.com
ALTERNATIVE INJECTION
TECHNIQUES.
INTRAPULPAL
INTRASEPTAL
INRA OSSEOUS
COMPLICATIONS
IN
ANESTHESIA
ADMINISTRATION
LOCAL COMPLICATIONS
IN
ANESTHESIA
ADMINISTRATION
Local Complications
 Needle breakage  Trismus
 Pain on injection  Hematoma
 Infection
 Burning on injection  Edema
 Persistent anesthesia  Sloughing of tissues
or paresthesia
 Lip chewing
 Facial nerve paralysis
 Post-anesthetic
intraoral lesions
NEEDLE BREAKAGE
 Causes
 Unexpected movement
 Small needle size
 Bent needles
 Defective needles
 Prevention
 Use large needles
 Use long needles for deep injection,>18mm
 Never insert to hub
 Redirect only when adequately withdrawn
 Management
 Remain calm
 Don't explore
 Have the patient keep opening wide
 If the needle is out remove it
 Refer to an Oral Surgeon
PAIN ON INJECTION
 Causes
 Careless technique
 Dull needles
 Rapid deposit of solution
 Needles with barbs
 Prevention
 Careful technique
 Sharp needles
 Topical anesthetic
 Slow injections
 Room temperature solutions
BURNING ON INJECTION
 Causes
 pH of solution
 Rapid injection
 Contamination
 Warmed solutions
PERSISTENT ANESTHESIA
OR PARESTHESIA
 Causes
 Trauma to nerve
 Hematoma
 Neurolytic agents (alcohol, phenol)
 Intraneural injection
 Prevention
 Careful injection technique
 Management
 Patient counseling and reassurance
 Documentation
 Follow-up
 Appropriate referral
TRISMUS
 Causes
 Trauma to muscles or blood vessels
 Contaminated anesthetic solutions
 Hemorrhage
 Infection
 Excessive anesthetic volume
 Prevention
 Sharp needles
 Proper care and handling of cartridges
 Aseptic technique and clean injection site
 Atraumatic insertion
 Minimal injections and volume
 Management
 Examination
 Conservative therapy
 passive ROM therapy
 analgesics
 heat
 muscle relaxants
HEMATOMA
 The effusion of blood into extravascular spaces
 Prevention
 Care with needle placement
 Minimize injections
 Don't probe with needle
 Modify technique
 short needles
 penetration depth
 Management with
 IAN block
 Infraorbital block
 Mental Nerve block
 Buccal block
 PSA block
INFECTION
 Causes
 Needle contamination
 Improper handling of armamentarium
 Infection at injection site
 Improper handling of tissue
 Prevention
 Disposable needles
 Proper care of equipment
 Aseptic technique
 Management
 Usual sign is trismus
 Trismus persists (1-3 day resolution )
 Antibiotics, if suspicious
EDEMA
 Causes
 Trauma during injection
 Infection
 Allergy
 Hemorrhage
 Irritating solutions
 Management
 Address cause and treat accordingly
SLOUGHING OF TISSUE
 Causes
 Topical anesthetic
 Prolonged ischemia
 Management
 Observation
 Documentation
LIP CHEWING
 Management
 Analgesics
 Antibiotics
 Saline rinses
 Lip lubricants
FACIAL NERVE PARALYSIS
 Cause: Anesthesia of peripheral Facial nerve branches
 Prevention
 Bone contact when injecting
 Avoid over penetration
 Avoid arbitrary injection
 Management
 Reassure patient
 Documentation
 Consider deferring dental care
POST ANESTHETIC
INTRAORAL LESIONS
Recurrent apthous
Herpes Simplex
SYSTEMIC
COMPLICATIONS
ADVERSE DRUG REACTIONS
 Direct extensions of usual effects
 Side effects
 Overdose
 Local toxic effects
 Altered recipient
 Disease process
 Emotional disturbances
 Genetic aberrations
 Idiosyncracy
 Allergic reaction
 Immediate - anaphylaxis
 Delayed - contact dermatitis
OVERDOSE
 Dose related
 Systemic distribution
 Extension of pharmacologic effects
 Selective CNS or CVS depression
ALLERGIC REACTIONS
 Not dose related
 May be systemic or localized
 Unrelated to pharmacological effects
 Exaggerated immune system response
IDIOSYNCRACY REACTION
 Unexplained by any known mechanism of the
drug’s action
 Neither overdose nor allergic reaction
 Unpredictable; treat symptoms
CAUSE OF OVERDOSE LEVELS
 Total dose is too large
 Absorption is too rapid
 Intravascular injection
 Biotransformed too slowly
 Eliminated too slowly
INTRAVASCULAR INJECTION
Occurrence varies with type of injection:
Nerve Block % positive aspirate

Inf. alveolar 11.7
Mental/Incisive 5.7
Post. sup. alv. 3.1
Ant. sup. alv./ Buccal <1
CLINICAL
MANIFESTATIONS
of
OVERDOSE
Minimal to Moderate
SIGNS SYMPTOMS:
Talkativeness Light-headed and dizzy
Excitability Restless
Apprehension Nervous
Slurred speech Numbness
Stutter( Muscular twitching / tremors
) Nervousness
Euphoria Sensation of twitching (before
actual
Dysarthria
Nystagmus twitching is observed)
Sweating Metallic taste
Nausea/vomiting Visual disturbances
Failure to follow commands / reason Auditory disturbances
Elevated BP Drowsy and disoriented
Elevated heart rate Losing consciousness
Elevated resp rate
Moderate to High
Generalized tonic-clonic seizure activity
followed by
Generalized CNS depression
Depressed BP, heart rate
Depressed respiratory rate
Pathophysiology
Local anesthetics cross blood-brain barrier, producing
CNS depression as level rises
eg. LIDOCAINE
< .5 ug/ml - no adverse CNS effects
0.5-4 ug/ml - anticonvulsant
4.5-7.5 ug/ml - agitation, irritability
> 7.5 ug/ml - tonic-clonic seizures
Pathophysiology
Local anesthetics exert a lesser effect on the
cardiovascular system
eg. LIDOCAINE
1.8-5 ug/ml - treat PVCs, tachycardia
5-10 ug/ml - cardiac depression
>10 ug/ml - severe depression,
bradycardia, vasodilatation, arrest
VASOCONSTRICTOR OVERDOSE
Clinical manifestations:
Fear, anxiety
Tenseness
Restlessness
Tremor
Weakness
Throbbing headache
Perspiration
Dizziness
Pallor
Respiratory difficulty
Palpitations
ALLERGIC REACTIONS
Type Mechanism Time Clinical Example
I Antigen induc. sec/min Angioedema,
Anaphylaxis
IV Cell mediated 48 hrs Contact

dermatitis
ALLERGENS IN LOCAL
 Esters - usually to the Para-amino-benzoic-
acid product
 Na bisulfite or metabisulfite - found in
anesthetics as perservative for
vasoconstrictors
 Methylparaben - no longer used as
perservative in dental cartridges
PREVENTION
of
SYSTEMIC
COMPLICATIONS
PRIOR TO TREATMENT
 Complete review of medical status
(including vital signs)
 Anxiety / Fear should be assessed and

managed before administering anesthetic
ADMINISTRATION OF ANESTHETIC
 Place pt. supine or semi-supine position

 Dry site, apply topical X 1 min
 Select appropriate drug for treatment (time)
 Vasoconstrictor unless contraindicated
 Weakest anesthetic in the minimum volume
(compatible with successful anesthesia)
 Inject slowly (minimum of 60 sec / 1.8 ml)
 Continually observe -
 Never leave patient alone after injection
 Use only aspirating syringe
 Aspirate in two planes, before injecting
 Use sharp, disposable needles of adequate diameter and length
LOCAL ANESTHESIA FOR
CHILDREN
Use with Sedative Drugs
With conscious sedation, especially narcotics,
decrease dosage of both local anesthetic
and the sedative drug to avoid toxicity
(additive depressant effect).
Recommended Dosage Levels
 2% lidocaine - 2 mg/lb
 2% lidocaine 1/100,000 epi - 2 mg/lb
 2% carbocaine 1/20,00 neocobefrin - 2 mg/lb
In general, 2 mg/lb WITH or WITHOUT

vasoconstrictor
Delivery Methods
Aspirating Syringe
 ALWAYS ASPIRATE!!!
 Loading the syringe
 Place carpule in syringe. Engage harpoon. Place
needle on syringe and puncture carpule.
Delivery Methods
Air Jet Syringe
 LA injected at pressure of ~2000 psi
Use of Topical
 Benzocaine is best.
Allow at least one minute for application
(onset in 30 seconds).
GENERAL TECHNIQUES
Use of Assistant
 Assistant should be ready at all times to
restrain hands.
 Assistant can help block view and keep patient
distracted.
General Techniques
Body Control
 Operator should be in
control of patient's
head - it may move
suddenly!!
 Hands - at side, in
pockets, sit on them,
hold belly button.
General Techniques
Syringe Management and Etiquette

 HIDE IT!!!
 Pass behind or over patient.
 Block patient's view with your retracting
hand.
 BE CONFIDENT.
SYRINGE MANAGEMENT
AND ETIQUETTE
EUPHEMISMS
 Tooth jelly
 Sleepy juice/medicine
 Bubble blower
 Mosquito bite, pinch
 Tooth will take a nap and feel fat & fuzzy.
DISTRACTION
 Verbal - chitter-chatter
(talk about anything)
 Overwhelm patient with
stimulus
 Pull on cheek, touch
face
 Keep things moving
 Pulling the tissue taut as
the needle enters makes
the procedure less
painful
DESENSITIZATION
ANATOMIC DIFFERENCES
ANATOMIC DIFFERENCES
Mandible
 Ramus is shorter vertically and
narrower anteroposteriorly.
 Mandibular foramen is lower than in adult
(may be below occlusal plane
in < 4yo).
SPECIFIC INJECTION SITES
FOR CHILDREN MANDIBLE
 Inferior alveolar block - Injection site is
lower and more posterior.
 Do not need to penetrate tissue as far as in
adult.
Anesthesia Technique
Occasionally the mylohyoid will

have accessory innervation to the
mandibular molar. Infiltrate on
the lingual.
SPECIFIC INJECTION SITES FOR CHILDREN
MANDIBLE
 BILATERAL INFERIOR ALVEOLAR BLOCKS
SHOULD NOT BE ADMINISTERED TO
CHILDREN.
Bilateral blocks greatly increase the chance

of post anesthesia trauma
Extractions
 Infiltration works in mandibular anterior
although block may be best for posterior
extractions (look at root length and
difficulty level).
Infiltration
 Used effectively for incisor and canine
restorations.
 BUCCAL NERVE BLOCK:
 SUBMUCOSAL INFILTRATION
 FIELD BLOCK
 MENTAL NERVE BLOCK :

 TARGET:
 Mesio buccal fold apical to prim 1 and 2 molar
 Inter-radicular area of 1 and 2 premolar
 NEEDLE PENETRATION: just anterior to mental foramen
 RULE OF 20: AGE OF CHILD X NO. OF TOOTH

4 X 4 = 16
FOR CHILDREN MAXILLA
 Apices of primary anterior teeth are at depth
of mucobuccal fold.
 Inject at depth of mucobuccal fold.
 Short or extra-short needle.
FOR CHILDREN MAXILLA
 Primary teeth and premolars - infiltrate
 Permanent molars - PSA, MSA
 FOR PRIMARY ANTERIOR TEETH:
 Inj made close to gingival margin
 Needle penetration: muco-buccal fold
 FOR PERMANENT INCISORS:

 Inj made close to muco-buccal fold
 Small amount of sol deposited at apex
of opposite side of incisor
 FOR FIRST PRIMARY MOLAR:

 Bone is thin – sol deposited at apices of root
 FOR SECOND PRIMARY MOLAR:
 Dense overlying bone – suprapeiosteal inj ineffective
 FOR ASA:
 LANDMARK: loose alv tissue superior to max canine
 FOR MSA:
 LANDMARK: loose alv tissue apical to first prim molar or first premolar
 For perm first molar and second prim molar – additional PSA block reqd
 FOR PSA:
 LANDMARK: red, loose alv tissue, apical to most post erupted molar tooth -
distal to zygomatic process
NASOPALATINE NERVE BLOCK:
 Penetration site: MM lateral to incisive papilla
 TWO WAYS:
 INTERDENTAL PAPILLARY APPROACH
 USE OF PRESSURE-TOPICAL ANESTHETIC
GREATER PALATINE NERVE
BLOCK
 IN A CHILD WITH PRIMARY DENTITION: inj

10mm post to distal surface of second primary molar
 ALTERNATIVES:
 BLANCHING TARGET AREA
 INTRAPAPILLARY INJECTION
 0.2-0.3 ml of sol is deposited
Specific Injection Sites for
Children Maxilla
 Primary molars (same as premolars) - Inject
over primary first molar.
 Primary second molar may have innervation
from posterior superior alveolar nerve.
Inject behind tuberosity.
Specific Injection Sites for
Children Maxilla
 Permanent molars - PSA injection - Inject behind tuberosity.
 Also inject over MB root of permanent first molar to
anesthetize MSA.
Specific Injection Sites for Children
Maxilla
 Interdental papilla - To achieve palatal
anesthesia. Inject as go through
papilla from facial to lingual. Should see
blanching as inject.
DO
 BE CONFIDENT
 Use good syringe etiquette
 Keep talking
 Maintain hand and head control
 Have assistant stay alert
 Shield and distract vision of the recipient and
neighbors.
DON’T:
 Openly display syringe
 “S(hot)”, “N(eedle)”, or “H(urt)” word
 Inject too fast
POST-ANESTHESIA
TRAUMA
 The number one postoperative complication of local
anesthesia in children.
POST-ANESTHESIA
TRAUMA
Minor to major. Always painful.

POST-ANESTHESIA
TRAUMA
Prevention:
 Remindboth parent and child that area will remain
numb after the appointment.
 Cautionthat child should not to chew, bite or pick
at area. Extremely important for young children
and "first timers".
 Sometimes placing a cotton roll between the teeth
will help remind patient not to chew.
CALCULATION OF MG. OF LOCAL
ANESTHETIC PER CARTRIDGE
 2% solution = 20 mg/ml
 Volume of cartridge = 1.8 ml
 So for a 2% solution:
20mg/ml x 1.8 ml/ cartridge = 36.0 mg/ cartridge
CALCULATION OF MG. OF LOCAL
ANESTHETIC PER CARTRIDGE
CALCULATION OF MG. OF
VASOCONSTRICTOR PER CARTRIDGE
 1:20,000 concentration = 0.05 mg/ml
 Volume of cartridge = 1.8 ml
 So for a 1:20,000 concentration:
0.05mg/ml x 1.8 ml/ cartridge = 0.09 mg/ cartridge
Mg/Ml VALUES OF CALCULATION OF MG. of
VASOCONSTRICTORS VASOCONSTRICTOR
PER CARTRIDGE
CONCENTRATION Mg/Ml VOLUME OF Mg PER

CARTRIDGE CARTRIDGE
1:1,000 1.0 1.8 1.8

1:2,500 0.4 1.8 .72
1:10,000 0.1 1.8 .18
1:20,000 0.05 1.8 .09
1:30,000 0.033 1.8 .06
1:50,000 0.02 1.8 .036
1:100,000 0.01 1.8 .018
1:200,000 0.005 1.8 .009
Other Post-Anesthesia
Conditions
Blanching due
to
vasoconstrictor
Other Post-Anesthesia
Conditions
Hematoma due to local anesthesia

RECENT ADVANCES AND
FUTURE TRENDS IN PAIN
CONTROL…
CENTBUCRIDINE
 Quinalone derivative
 Five to eight times the potency of lidocaine
 It does not effect CNS & CVS significantly
 Vacharajini et al
pH ALTERATIONS
 Alkalinization - ↑ RN:
 Sodium bicarbonate.
 Rapid onset of action.
 Carbonation :
 Helps in the rapid diffusion of local anesthetic through
the nerve membranes.
 Decreases intracellular pH traps RNH+ in the cell.
 Anesthetic drug must be administered immediately after
preparing the syringe.
HYALURONIDASE
 Breaks down intercellular cement.
 Added to the anesthetic cartridge just before administering
the LA.
 Causes rapid onset of anesthesia.
 Allergic reactions have been reported.
ULTRA –LONG ACTING LOCAL
ANESTHETICS
 Biotoxins:
 Tetradotoxin -puffer fish
 saxitoxin -dinoflagelates.
 Block Na channels of nerve membrane.
 250,000 as potent as procaine.
TENS
 Cardiac pacemakers
 Neurological disorders
 Pregnancy
 Immaturity (in ability to understand) the concept of patient control of pain)
 Very young pediatric patient
 Older patients with senile dementia
 Language communication difficulties
 Advantages
 No needle
 No injection of drug
 Patient is in control of the anesthesia
 No residual anesthetic effect at the end of procedure
 Residual analgesic effect remain for several hours
 Disadvantages
 Cost of the unit
 Training
 Intra oral electrodes – weak link in the entire system.
Computer Controlled Local Anesthetic
Delivery System (CCLADS)
JET INJECTORS
Eutectic Mixture of Local Anesthetic
(EMLA)
………………………conclusion
REFERENCES.
 Hand book of local anesthesia ………………………….5th ed Stanley F. Malamed.
 Monheim’s Local anesthesia and pain control in dental practice….. 7 th ed.

 Clinical Guideline on Appropriate Use of Local Anesthesia for Pediatric
Dental Patients ……………………………..……………. AAPD Reference manual 2005
 Pediatric dentistry infancy through adolescence………….…. 4 th ed Pinkham.
 Dentistry for child and adolescent……………………………….… 8 th ed McDonald.
 Pediatric dentistry total patient care …………….……………Stephen H. Y. Wei.
THANK YOU

Anestezie Endo

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LOCAL ANESTHESIA IN

-(Grune & Straton-1976)

 REGIONAL ANESTHESIA: it applies not only to loss

R1 — Lipophilic aromatic residue.

Class AClass BClass CClass D

Natural Synthetic Others

 Altering basic resting potential

 SURFACE CHARGE THEORY (Wei-1969)

 ACETYLCHOLINE THEORY (Dett barn-1967)

 MEMBRANE EXPANSION THEORY (Lee-1976)

 SPECIFIC RECEPTOR THEORY (Strichartz-1987)

RNHOH + HCl  RNHCl + H2O

RNHCl  RNH+ + CI-

Basic environment (higher pH)

Acidic environment (low pH)

 Log Base = pH – pKa

Propoxycaine - - 0.4% 2-3 min -

Lidocaine 7.9 6.5 2% 2-3 min 1.6 hr

Articaine 7.8 4.4-5.2 4% 2-3 min 1.25

Etidocaine 7.7 4.5 1.5% 1.5 3- 2.6 hr

“Elimination half life.”

 Lower anesthetic blood levels

 Decrease the risk of toxicity

 Increases duration of action

 Clinical Manifestations of Epinephrine Overdose

 Clinical Applications for Epinephrine

 10% metered spray  Longer duration than the

Posterior Superior Alveolar Nerve (PSA)

- for maxillary molars and buccal tissue

Needle deviates laterally or medially

Nerve Block % positive aspirate

IV Cell mediated 48 hrs Contact

 Anxiety / Fear should be assessed and

 Place pt. supine or semi-supine position

In general, 2 mg/lb WITH or WITHOUT

Syringe Management and Etiquette

Occasionally the mylohyoid will

Bilateral blocks greatly increase the chance

 MENTAL NERVE BLOCK :

 NEEDLE PENETRATION: just anterior to mental foramen

 RULE OF 20: AGE OF CHILD X NO. OF TOOTH

 FOR PERMANENT INCISORS:

of opposite side of incisor

 FOR FIRST PRIMARY MOLAR:

 Penetration site: MM lateral to incisive papilla

 IN A CHILD WITH PRIMARY DENTITION: inj

 0.2-0.3 ml of sol is deposited

Minor to major. Always painful.

CONCENTRATION Mg/Ml VOLUME OF Mg PER

1:1,000 1.0 1.8 1.8

Hematoma due to local anesthesia

 Monheim’s Local anesthesia and pain control in dental practice….. 7 th ed.

 Pediatric dentistry infancy through adolescence………….…. 4 th ed Pinkham.

 Dentistry for child and adolescent……………………………….… 8 th ed McDonald.

 Pediatric dentistry total patient care …………….……………Stephen H. Y. Wei.

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