Local Anesthesia in dentistry

Dr. Nardos Tsegay

2021
 Outline
- Objective
- Introduction
- Action of L.A.
- Desirable property of L.A
- Classification of L.A
- Technique of administering L.A
- Complication
- Contraindication

2
 Objective

• By the end of this lecture you should be able

to:
 Explain what Local anesthesia is and how it
acts.
 Recognize basic property of L.A.
 Identify L.A. technique of administration in
dentistry.
 know the complication of L.A. and when its
contraindicated.
3
 Introduction
• Local anesthesia has been defined as loss of
sensation in a circumscribed area of the body
caused by depression of excitation in nerve
endings or inhibition of the conduction
process in peripheral nerves.

• it produces this loss of sensation without loss

of consciousness

4
 Action of local anesthetics
• When propagation of a nerve impulse is
prevented, then there can be no sensation
/Impulse reaching the CNS/ brain

• LA are eliciting their conduction-blocking

effects by reversibly blocking the movement of
sodium in and out of the nerve axon required
for action potentials.

5
Cont…

6
 Cont…
• Local anesthetic renders the membrane
impermeant to sodium ion, hence inexcitable
by local action currents.
• With out sodium there can be no nerve
depolarization hence no action potential
propagate
• Lack of action potentials impulses implies loss
of sensation which includes the absence of
painful sensations

7
 Desirable Property of L.A.
1. It should not be irritating to the tissue
2. It should not cause any permanent alteration
of nerve structure.
3. Its systemic toxicity should be low.
4. It must be effective (injected or applied locally)
5. The time of onset of anesthesia should be as
short as possible.
6. The duration of action must be long enough
yet not so long.
8
 Classification of L.A
- The local anesthetics used in dentistry are
classified into two functional groups based on
their chemical properties:
1, Ester group: is composed of;
- An aromatic lipophilic group
- An intermediate chain containing an ester
linkage
- A hydrophilic secondary or tertiary amino
group
9
 Cont…

2, Amide group: is composed of the following

- An aromatic, lipophilic group
- An intermediate chain containing amide
linkage
- A hydrophilic secondary or tertiary amino
group

10
Cont…

11
 Cont…

Esters:
- Procaine [Novacaine]
- Benzocaine [topical 20 %]
- Cocaine [rarely employed these days]
- Amethocaine [skin topical]

12
 Cont…
Amides:
- Lignocaine/lidocaine
- Bupivacaine
- Prilocaine
- Articaine
- Mepivicaine

13
 Ester Vs Amides

• Ester’s and amides follow different pathways

for metabolism.
• Esters are easily broken down by
pseudocholinesterase in the plasma therefore
they have a much shorter duration of action.
• Amides are stable in plasma and they are only
broken down in the liver.

14
 Cont…
• Also the metabolism of most esters results in
the production of para-aminobenzoate (PABA)
which is associated with allergic reaction.

• Amides, in contrast, very rarely causes allergic

phenomena. For these reasons amides are
now more commonly used than esters.

15
 Cont…
• The ester linkage is more easily broken so the
ester drugs are less stable in solution and
cannot be stored for as long as amides.

• Amide anaesthetics are also heat-stable. 

16
 Content of L.A
• Local anesthetic drug
• Vasoconstrictor
• Antioxidant : 0.5 mg Sodium meta bisulphite;
it increases shelf life
• Preservatives : methylparaben -0.1% (1 mg)
• Fungicide: thymol
• Isotonic solution: 6 mg sodium chloride; to
minimizes discomfort during injection

17
 Lidocaine
• Most common and Golden standard that has been
used for over 50 years in dentistry
- Lignospan/xylocaine (2%)
- Adrenaline 1:80,000 as a vasoconstrictor
- Maximum dose: 4.4mg/kg and 7mg/kg if used
with Adrenaline
- Pulpal anaesthesia: 45 minutes
- Soft tissues : 2-3 hours.
- Half life:90 minutes
- Topical preparations exist
18
 Action of Vasoconstrictors
• Constrict vessels and decrease blood flow to
the site of injection.
• Absorption of LA in to bloodstream is slowed,
producing lower levels in the blood.
• Lower blood levels lead to decreased risk of
overdose (toxic) reaction
• Higher LA concentration remains around the
nerve increasing the LA duration of action

19
 Cont…
• Never the less, vasoconstrictor can induce
tachycardia resulting fainting.
• Adrenaline is contraindicated
- in patients with unstable hypertension and
unstable angina.
- in patients taking Monoamine Oxidase
Inhibitors-MAOIS

20
 Technique of administering L.A
- Ways of administration depends on: the tooth that
needs to be anaesthetized.
• Maxillary [Infiltration].
• Mandibular [Nerve Block].
: the type of treatment you are going to carry out.
• Extractions: All nerves in the area needs to be
anaesthetized. Main supply plus accessory nerves!
• Restorative/perio: Usually sufficient to block main
nerve supply.

21
 1. Local Infiltration
- Act locally to provide good LA.
- Effective on local soft tissues.
- Act on teeth where bone is reasonably thin.
- Used for upper teeth mainly and lower
anterior teeth.
- Anesthetic diffuses through alveolar bone to
root apex.
- Not as effective on posterior mandibular teeth
due to the thick cortical bone.

22
Cont…

23
 2. Field block
- L.A is deposited near the larger terminal nerve
branches
- anesthetized area will be circumscribed,
preventing the passage of impulses
- Incision (or treatment) is then made into an area
away from the site of injection of the anesthetic
- Refers to maxillary injections administered
above the apex of the tooth to be treated
- although common usage identifies them as
infiltration or supraperiosteal.
24
Field block Vs local infiltration

25
 3. Nerve block
- Anesthetic delivered to major nerve.
- Blocks all sensation downstream of the injection site.
- The more proximal the block, the greater the area
affected.
- Commonly used nerve blocks in dentistry:
• Greater palatine nerve block.
• Nasopalatine nerve block.
• Inferior alveolar nerve block.
• Mental nerve block.
• Lingual nerve block.
• Long buccal nerve block.
26
 Greater palatine nerve block

 Nerves affected
• Greater palatine nerve
 Injection site
• Greater palatine foramen (can be palpated)
 Tissues anaesthetised
• All hard palatal mucosa and gingiva posterior
to maxillary canine
• Ipsilateral to injection side.

27
Cont…

28
 Nasopalatine nerve block

 Nerves affected
• Nasopalatine nerve
 Injection site
• Mouth of incisive foramen (posterior to
incisive papilla)
 Tissues anaesthetized
• Palatal mucosa and gingiva anterior to
maxillary canines
• bilateral
29
Cont…

30
 Inferior alveolar nerve block
 Nerves affected
• Inferior alveolar nerve.
• Mental nerve and incisive nerve
 Target area
• Mandibular foramen within the pterygoid space
 Tissues anaesthetized
• All mandibular teeth, skin of chin, labial mucosa
and lower lip. Left or right depending on side of
injection

31
Cont…

32
 Mental nerve block
 Nerves affected
• Mental nerve and incisive nerve
 Injection site
• Mental foramen
 Tissues anaesthetised
• Mandibular incisors and canine, labial gingiva,
skin of chin

33
Cont…

34
 Lingual nerve block
 Nerve affected
• Lingual nerve
 Injection site
• Anterior to inferior alveolar site . Similar
technique
 Tissues anaesthetised
• Mucosa of anterior 2/3 of tongue
• Lingual alveolar mucosa and lingual gingivae
of all teeth ipsilateral to the injection side

35
Cont…

36
 Long buccal nerve block
 Nerves affected
• Long buccal nerve
 Injection site
• Retromolar fossa
 Tissues anaesthetised
• Skin and mucus membrane of cheek
• Buccal alveolar mucosa
• Gingivae of molars
• Ipsilateral to injection side
37
Cont…

38
Alternative methods of Administering L.A.
I. Intraosseous injection: directly into the
cancellous bone.
II. Intrapulpal injection: When pulp chamber has
been exposed.
III. Intraligamentary injection: A technique for
anesthesing a single tooth.
IV. Topical Anesthetic agents: prior to administration
of LA and for some procedures like scaling or
removal of a very loose primary tooth. ( gel,
spray, cream)
39
Cont…

40
 Complication of L.A
• Shock and collapse
• Breaking the needle
• Post operative pain
• Hematoma
• Trismus
• Infections
• Facial paralysis
• Prolonged anesthesia
• Procaine dermatitis
41
 Contraindication of L.A
• Acute suppurative infections
• Young children
• Uncooperative patients
• Patients jaw can not be opened
• Idiosyncrasy for procaine
• Cardiovascular disease

42
Thank you

43
 Refrences
1, Hand Book of local Anesthesia; Stanley F.
Malamed; sixth edition.
2, Clinical Dentistry; Rowe/ Alexander / Jones;
fourth edition
- Some pictures were taken from different
websites as well.

44