Assistant Professor of Oral and Maxillofacial Surgery ...gtds.sbmu.ac.ir/uploads/local anesthesia.pdf · History of Local Anesthetics •Cocaine isolated 1856 •1884 cocaine used

Arash Khojasteh, DMD, MSAssistant Professor of Oral and Maxillofacial Surgery

Shahid Beheshti University of Medical Sciences

Hyppocarates Stated:

• Divine is work to

subdue pain

26 October 2012

Local Anesthetics

Important points

• History• Some differences• How they work• Test dose• Onset

I. The Drugs

II. The Armamentarium

III. Techniques of Regional Anesthesia in Dentistry

IV. Complications, Questions and Future Trends

What are local anesthetics?

• Local anesthetic: produce loss of sensation to

pain in a specific area of the body without the

loss of consciousness

What are local anesthetics?

• A local anesthetic is an agent that interrupts

pain impulses in a specific region of the body

without a loss of patient consciousness.

Normally, the process is completely reversible-

-the agent does not produce any residual

effect on the nerve fiber.

History of Local Anesthetics

• Cocaine isolated 1856

• 1884 cocaine used in occular surgery

• 1880’s Regional anesthesia plexus

• 1898 cocaine used in spinal anesthesia

• 1905 1st synthetic LA (procaine) introduced

• 1943 lidocaine synthesized

• Mepivacaine (1957), Bupiv (’63), Ropiv (’96)

History

Indian Hemp (glycosides) Poppy (Opium)

History

• Coca leaves from the genus Erythroxylum• Erythroxylum contains high concentration of alkaloid up to

0.7-1.8%• Alkaloid has natural nitrogen bases found in the coca leaves,

also known as cocaine• In 1571, Pedro Pizarro, a conquistador of Inca, observed

nobles and high rank officials of the Inca empire consumed the coca plant

• Earliest cultivation and use of the coca leaf went back to about 700 BC in Bolivia and Andes regions

• New discoveries showed humans used coca more than 5,000 years ago in Ecuador

• In 1860, German chemist Albert Niemann successfully isolate the active principle of coca leaf; he named it cocaine

Cocaine Addiction

• More physicians began to do research of cocaine in the clinic

trials.

• The physician Sigmund Freud used the stimulant effect of

cocaine to treat the morphine addiction in patients

• An ophthalmologist Carl Koller realized the importance of the

alkaloid’s anesthetic effect on mucous membranes

• In 1884, he used the first local anesthetic on a patient with

glaucoma

• Freud, Halsted, and Koller became addicted to the drug

through self-experimentation

Neurophysiology

The Neuron

Biological Membrane

Hydrophil

Hydrophobe

Gate and Receptor

Neurophysiology

Nerve bundle anatomy

Core

bundles

Mantle

bundlesEpineural sheath

Epineurium

Perineurium

Covers fasciculi

Nerve fiber= single nerve cell

Endoneurium= cover each neuron

Fasciculi= bundles of 500 to 1000 nerve fibers

Nerve morphology

Classification and characteristic of peripheral nerve fibers

characteristic A A A A ----alphaalphaalphaalpha AAAA----betabetabetabeta AAAA----gammagammagammagamma AAAA----deltadeltadeltadelta BBBB CCCC

MyelinMyelinMyelinMyelin ++++++++++++ ++++++++ ++++++++ ++++++++ ++++ ----

DiameterDiameterDiameterDiameter (um)(um)(um)(um) 12 12 12 12 to to to to 20202020 5 5 5 5 totototo12121212 5 5 5 5 totototo12121212 1 1 1 1 to to to to 4444 1 1 1 1 to to to to 3333 0.5 0.5 0.5 0.5 to to to to 1111

Conduction Conduction Conduction Conduction velocity velocity velocity velocity (m/sec)(m/sec)(m/sec)(m/sec)

70 70 70 70 to to to to 120120120120 30 30 30 30 to to to to 70707070 30 30 30 30 to to to to 70707070 12 12 12 12 to to to to 30303030 14.814.814.814.8 1.21.21.21.2

Onset timeOnset timeOnset timeOnset time 6666 5555 4444 3333 1111 2222

functionfunctionfunctionfunctionMotor ,muscle,

proprioception

Touch,

pressure

proprioceptionTouch, motor

proprioception

Pain , temperature

Pressure

proprioception

Preganglionic

autonomic

(sympathetic)

activity

Pain , Itch, temperature,

Pressure

Postganglionic

Sympathetic activity

Electrophysiology of Nerve conduction (Action potential)

In resting state the nerve

membrane is :

- Slightly permeable to Na+

- Freely permeable to K+

- Freely permeable to Cl -

15 mv

Intra/extracellular Ionic concentration

IonIonIonIon IntracellularIntracellularIntracellularIntracellular

((((mEqmEqmEqmEq/L)/L)/L)/L)

ExtracellularExtracellularExtracellularExtracellular

((((mEqmEqmEqmEq/L)/L)/L)/L)

Ratio Ratio Ratio Ratio

(approximate(approximate(approximate(approximate

))))

PotassiumPotassiumPotassiumPotassium

(K+)(K+)(K+)(K+)

110 110 110 110 to to to to 170170170170 3 3 3 3 to to to to 5555 27 27 27 27 ::::1111

Sodium Sodium Sodium Sodium

(Na+)(Na+)(Na+)(Na+)

5 5 5 5 to to to to 10101010 140140140140 1111::::14141414

ChlorideChlorideChlorideChloride

(Cl(Cl(Cl(Cl----))))

5 5 5 5 to to to to 10101010 110110110110 1111::::14141414

Sodium channel transition stages

Membrane channels (depolarization)Rest Depolarization

Impulse SpreadNonmyelinated

Myelinated

Prevention Generation and

Conduction of nerve impulse

Possible Mode and Site of Action of LA

1. Altering the basic resting potential

2. Altering the threshold potential( Firing level)

3. Decreasing the rate of depolarization

4. Prolonging the rate of repolarization

Primary effect of local

Anesthesia occur during

the depolarization phase

of the action potential

Mechanism of action of L.A (Theories)

• Acetylcholine theory

• Calcium displacement theory

• Surface charge theory

• Membrane expansion theory

• Specific receptor theory

Membrane Expansion Theory

Specific receptor

Classification of Local Anesthetic substance According to Site and Mode of Acton

classification Site of Action Chemical substance

Class AReceptor site on External surface of nerve membrane

Biotoxins (e.g. ,tetritoxin and saxitoxin)

Class BReceptor site on internal surface of nerve membrane

Quaternary ammonium analogues of Lidocaine

Scorpion Venom

Class CReceptor - independent physiochemical mechanism

Benzocaine

Class DCombination of Receptor and Receptor - independent physiochemical mechanism

Most clinically useful local anesthetic agent (e.g. articaine

,Lidocaine , Mepivacaine,Prilocaine)

Tetrododoxin

• Toxin from puffer fish

• Blocks the Na channel

– Used in research

– Blocks from the outer side of cell

Membrane channels

125

61

104

Procaine replaced Novocaine

cocaine Problems

• In 1898, Professor Heinrich Braun

introduced procaine as the first

derivative of cocaine, also known

as the first synthetic local

anesthetic drug

• Trade name is Novocaine®

• Took too long to set (i.e. to produce the

desired anesthetic result)

• Wore off too quickly, not nearly as

potent as cocaine

• Classified as an ester; esters have high

potential to cause allergic reactions

• Caused high conc. of adrenaline resulted

in increasing heart rate, make people

feel nervous

Most dentists preferred not to used any

local anesthetic at all that time; they

used nitrous oxide gas.

Today, procaine is not even available for

dental procedures.

Types of Local Anesthetics

Local anesthetic Molecules

Ester type

Amide type

Henderson Hasselbalch equation

RNH RN + H+ +

RNH > RN + H+ +

RNH < RN + H+ +

PH- pKa = LogBase

Acid

Effect of pH, and pKa

• The pKa of amides ranges from 7.6 to 8.1. At physiologic pH (7.4), most of the local anaesthetic is in the ionized state (a charged base). For example, lidocaine has a pKa of 7.9. The above formulat determines that at physiologic pH, lidocaineexists in a ratio of 3:1 ionized to non-ionized:

• 7.9 - 7.4=log [ionized/non-ionized]

• 0.5 =log [ionized/non-ionized]

• 10^ 0.5=ionized/non-ionized

• 3ionized~

1non-ionized

Anesthetic pKa 7.9 ; pH 7.4

pH 7.4

Extracellular

pH 7.4

Nerve sheath

Intracellular

RNH+

750

RN

250

RN

70

RNH+

180

RN RNH

250

Drug : Neurophysiology (Effect of PH )

RNH+

7.5

pH 6

Extracellular

RNH+

990

RN

10

pH 7.4 Intracellular

RN

2.5

RN RNH+

10

Pharmacology of Local anesthesia

• Uptake

• Distribution

• Metabolism (biotransformation)

– Amides : LIVER , ... ... ...

– Esters : hydrolyzed in PLASMA by psudocholinesterase

• Excretion : kidney

Anesthetic pKa Onset Duration (with Epinephrine) in minutes

Max Dose (with Epinephrine)

Procaine 9.1 Slow 45 - 90 8mg/kg –10mg/kg

Lidocaine 7.9 Rapid 120 - 240 4.5mg/kg –7mg/kg

Bupivacaine 8.1 Slow 4 hours – 8 hours

2.5mg/kg –3mg/kg

Prilocaine 7.9 Medium 90 - 360 5mg/kg –7.5mg/kg

Articaine 7.8 Rapid 140 - 270 4.0mg/kg –7mg/kg

Benzocaine : Pka =3.5


• Uptake

– All local anesthetics have vasodilation activity

– Procaine probably most potent vasodilator

– Cocaine the only local anesthetic producing vasoconstriction

– “Vasodilation” increase absorption into blood and decrease

the duration and quality of local anesthetic

Lipid solubility Drug Lipid solubility

Articaine 40

Mepivacaine 42

Prilocaine 55

Lidocaine 110

Bupivacaine 560

Lipid solubility is an

important

characteristic.

Potency is related to

lipid solubility,

because 90% of the

nerve cell membrane

is composed of lipid.

This improve transit

into the cell

membrane

Vasodilating activity

Drug Vasodilating activkity

Articane 1

Bupivacaine 2.5

Etidocaine 2.5

Lidocaine 1

Mepivacaine 0.8

Perilocaine 0.5

Protein binding

• Protein binding is related to the duration of action. The site of action (the Na channel) is primarily protein in a lipid environment. Binding affinity will thus affect duration of action.

• Protein binding also plays a part in the availability of the drug as LA binds to lipoproteins in the blood stream.

• And transfer to fetuses

Vasoconstrictors

• The addition of vasoconstrictors, such asepinephrine or phenylephrine can prolongduration of action of local anesthetics,decrease their absorption (and the peakplasma level) and enhance the blockade.

Factors affecting Local Anesthesia

action

FactorAction

affectedDescription

pKa OnsetLower pKa =

more rapid onset of action

Lipid solubility Anesthetic potencyIncreased lipid solubility =

Increased potency

Protein binding DurationIncreased protein binding=

Increasing Duration

Nonnervous Tissue

diffusibilityOnset

Increased diffusibility =

Decreased time of onset

Vasodilator activityAnesthetic potency

and onset

Greater vasodilatory activity=

Decreased potency /duration

Properties of Local AnestheticAgents

PROPERTIES AMINOESTERS AMINOAMIDES

Metabolism rapid by plasma cholinesterase slow, hepatic

Systemic toxicity less likely more likely

Allergic reaction possible - PABA derivatives form very rare

Stability in solution

breaks down in ampules (heat,sun)

very stable chemically

Onset of action slow as a general rule moderate to fast

pKa's higher than PH = 7.4 (8.5-8.9)close to PH = 7.4 (7.6-

8.1)

Oral Route

• Tocainide is a modification of lidocaine which

is used as an antidisrhytmic agent

Topical Anesthesia

• Benzocaine

• Solarcaine= Lidoocaine+ Benzocaine

• EMLA= Lidocaine + Prilocaine

Systemic Action of local Anesthesia

55


• Systemic action of local anesthesia

– CNS (excitation – depression ... )

– Cardiovascular system (depression ,antiarrythmic effects ...)

– Respiratory system (direct relaxation , depression and arrest)

– Miscellaneous actions

• Neuromuscular blockade

• Drug interaction

• Malignant hyperthermia

56

Systemic action of Local Anesthesia (CNS)

Preconvulsive Sign and symptoms of CNS Toxicity

• Slurred speech

• Shivering

• Muscular twitching

• Tremor of face muscles and

extremities

• Generalized light headness

• Dizziness

• Visual disturbances

• Auditory disturbances

• Drowsiness

• Disorientation

• Numbness of the tongue and

circumoral region

• Warm ,flushed feeling of skin

• Pleasant dreamlike state

SIGNS SYPMTOMS


• Systemic action of local anesthesia

– CNS (excitation – depression ... )

– Cardiovascular system (depression ,antiarrythmic effects ...)

– Respiratory system (direct relaxation , depression and arrest)

– Miscellaneous actions

• Neuromuscular blockade

• Drug interaction


59

The Drugs

• Pharmacology of Vasoconstrictors

– Increasing potency and duration of local anesthetic

– Decreasing systemic unfavorable effects of local

anesthetic

– Decreasing hemorrhage in the operation site

60

Sterile abscess

61

Effect of vasoconstrictor (epinephrine 1/200000 )

on peak local anesthetic level in blood

Local Local Local Local

anestheticanestheticanestheticanesthetic

DoseDoseDoseDose

(mg)(mg)(mg)(mg)

without without without without

vasoconstrictorvasoconstrictorvasoconstrictorvasoconstrictor

((((ugugugug/ml)/ml)/ml)/ml)

with with with with

vasoconstrictorvasoconstrictorvasoconstrictorvasoconstrictor

((((ugugugug/ml)/ml)/ml)/ml)

MepivacaineMepivacaineMepivacaineMepivacaine 500500500500 4.74.74.74.7 3333

LidocaineLidocaineLidocaineLidocaine 400400400400 4.34.34.34.3 3333

PrilocainePrilocainePrilocainePrilocaine 400400400400 2.82.82.82.8 2.62.62.62.6

EtidocaineEtidocaineEtidocaineEtidocaine 300300300300 1.41.41.41.4 1.31.31.31.3

Vasoconstrictors

• Catecholamine

– Epinephrine

– Norepinephrine

– Levonordefrine

– Isopretrenol

– Dopamine

• Non Catecholamine

– Amphetamine

– Methamphetamine

– Ephedrine

– Mephentramine

– Hydroxyphetamine

– Metaraminol

– Methoxamone

– phenylephrine

Vasoconstrictors

Direct acting Indirect acting Mixed - acting

Epinephrine Tyramine Metaraminol

Noreepinephrine Amphetamine Ephedrine

Levonordefrine Methamphetamine

Isopretrenol hydroxyamphetamine

Dopamine

Methoxamine

Phenylephrine

Adrenergic receptor Activity of Vasoconstrictors

DrugDrugDrugDrug αααα1111 αααα2222 ßßßß1111 ßßßß2222

EpinephrineEpinephrineEpinephrineEpinephrine ++++++++++++ ++++++++++++ ++++++++++++ ++++++++++++

NorepinephrineNorepinephrineNorepinephrineNorepinephrine ++++++++ ++++++++ ++++++++ ++++

LevonordefrineLevonordefrineLevonordefrineLevonordefrine ++++ ++++++++ ++++++++ ++++

Beta 1 Beta 2 Alpha1 Alpha2

Heart Bronchi Presynaptic

excitory

Post synaptic

inhibitory

Intestine Vascular Bed

Cardiac

stimulation

Uterous

lipolysis Vasodilation

bronchdilation

66

67

68

Prilocaine

• Greater Vasodilatory than Mepivacaine but less than Lidocaine

• Flypressin as a Vasoconstrictor

• Lung, Kidney, Liver

• Orthotoluidine

• Relatively contraindicated in SCC,

Acetaminophen user, Anemia

69

Articaine

• Thiophene Group

• Plasma esterase

• More penetration

• Pulpal and lingjual

anesthesia through

infiltration

• Risk of paresthesia

• Risk of Meth in IV

administration

70

• Significant Vasodialtion

• Long acting drug

• Management of Post op

Pain

• Pka=8.1 onset of

action

• Not recommended in

children

71

Benzocaine

72

The

Armamentarium

The Armamentarium

• The Syringe

• The Needle

• The Cartridge

• Additional Armamentarium

• Preparation of the armamentarium

75

The Armamentarium

• The Syringe

76

Original design of pressure syringe

(PDL)

77

Pressure syringe!

78

Second generation syringe (PDL)

79

SyriJet needleless injector

80

UltraSafety Plus XL syringe

81

Computer –controlled local anesthetic delivery system

the Wand

82

Anaeject Computer –controlled local anesthetic

delivery system

83

Problems

• Leakage during injection

• Broken cartridge

• Bent Harpoon

• Disengagement of the Harpoon from the Plunger during Aspiration

• Surface deposits

84

The Armamentarium

• The Needle

– Types

– Parts

– Gauge

– Length

85

The Needle (deflection effect)

BRIT Technique

86

Conventional / Nondeflecting needles

87

The Needle

• Care and handling

• Problems

– Breakage

– Pain on injection

– Injury to the patient or administrator

• Recommendations

88

The Armamentarium• The Cartridge

– Components

• Cylindrical glass tube

• Stopper

• Aluminum cap

• Diaphragm

Cylindrical glass

tube

Rubber

Diaphragm

Aluminum

cap

Silicon

rubber

Plunger

(Stopper)

89

Cartridge (Carpule)

• Ingredient

1. Local anesthetic drug (lidocaine 2% , prilocaine 3%)

2. Vasoconstrictor drug (epinephrine 1/80,000 )

3. Preservative for vasoconstrictor (Sodium bisulfate)

4. Sodium chloride

5. Distilled water

90

Cartridge Problems

1. Bubble in the cartridge

2. Extruded stopper

3. Burning upon injection1. Response to pH

2. Cartridge containing sterilization solution

3. Overheated cartridges

4. Use of a cartridges with vasoconstrictor

4. Sticky stopper

5. Corroded cap

6. “Rust” on the cap

7. Leakage during injection

8. Broken cartridge

91

Additional Armamentarium

1. Topical Antiseptic

2. Topical anesthetic

3. Applicator sticks

4. Cotton gauze

5. Hemostat

92

The Armamentarium


93

Preparation of the armamentarium

94

Safety syringe

95

Safety syringe

96

Ultra Safety Plus XL (Septodont, Inc.)

97


98


99

Preparation of the armamentarium

• Recapping of Needle

100

The Armamentarium

• The Syringe

• The Needle

• The Cartridge

• Additional Armamentarium


Techniques of Regional Anesthesia in Dentistry

Physical and psychological evaluation

102


• Medical History Questionnaire– Questions and Comments ... ... ... ...

• Dialogue History

• Physical Examination– Visual Inspection

– Vital signs

– Determination of medical risk

• Drug-Drug interactions


• Atypical Plasma Cholinesterase

• Methemoglobinemia

103

Physical and psychological evaluationA. Identification data

B. History

i. Chief complaint

ii. History of present illness

iii. Past medical history

iv. Family history

v. Past dental history

vi. Psychosocial history

vii. Review of systems

C. Physical examination

i. Extra / Intra oral exam

ii. Dental exam

iii. … … … …

D. Para clinical investigation

E. Clinical investigation

F. Diagnosis

G. Treatment plan

H. Follow up/ Rehabilitation

104


• Medical History Questionnaire– Questions and Comments ... ... ... (refer to reference !!)

• Dialogue History

• Physical Examination– Visual Inspection

– Vital signs 1. Blood Pressure

2. Heart rate /rhythm

3. Respiratory rate

4. Temperature

5. Height

6. weight

– Determination of medical risk

105


• Drug-Drug interactions

• Malignant hyperthermia– One of most intense life threatening(1/150,000 adult)

– Autosomal dominant ; male> female ;

– Tachycardia ,fever ,tackypnea, cardiac dysrythmias, muscle rigidity ,cyanosis and death

– Most probable with succynilcholine(77%),halothane (60%) ...

– Dantrolene,...

• Atypical Plasma Cholinesterase

• Methemoglobinemia

106

American Society of Anesthesiology

physical status classification

I. Normal healthy individual

II. Patient with mild to moderate systemic disease

III. Patient with severe systemic disease that limit

activity but not incapacitating

IV. Patient with severe systemic disease that limit

activity and is a constant threat to life

V. Moribund patient not expected to survive 24

hours with or without an operation

Drud-Drug Interaction

Interaction With local anesthetic

1. Local anesthetic• Ester

• Amide

2. Vasoconstrictors

Ester Local Anesthetics With

Sulfonamide Antibiotics

• Procaine with sulfamethoxazole

– Procaine is used infrequently; the procaine

metabolite p-amino benzoic acid may transiently

reduce sulfonamide antibiotic efficacy.

Lidocaine with bupivacaine

• Local anesthetic toxicity is additive

Amide Local Anesthetics With

Inhibitors of Metabolism

• Lidocaine with Cimetidine

• lidocaine with Propranolol

• Mepivacaine with Meperidine

• Lidocaine and Erythromycin

– Inhibition of local anesthetic metabolism will have

little effect on peak plasma levels of anesthetic

when given as a single injection.

Vasoconstrictor Interaction

113

Pharmacology of Vasoconstrictors

• Maximum recommended dose of Epinephrine

– Normal healthy patient 0.2 mg (200 ug)/ visit

• ( nine 1.8 cc cartridges with 1/80000 epinephrine)

– Patient with significant cardiovascular impairment (ASA

III ,IV)

0.04 mg (40 ug) /visit

• ( two 1.8 cc cartridges with 1/80000 epinephrine)

Antidepressants

Classification Generic name Trade name

MAOIIsocarboxazid Marplan

TCAsAmitriptyline,

Protriptyline

Imipramie

Amitril

Sinequan

Adapin

SSRIsFluoxetine Prozac

MAO +High Level TyramineFood & Beverages

( Cheese , Fish ,Beer,Red wine,Liver.. )Hypertensive Crisis,Intracranial bleeding

Excessive Fever , death

MAOIs

TCAs

TRICYCLIC ANTIDEPRESSANTS

(imipramine, amitriptyline, doxepin)

• Absolute Contraindication

– Levonordephrine

– Norepinephrine

• Relative contraindication

– Epinephrine (0.04mg)

Vasoconstrictor with nonselective

β-adrenoceptor antagonist

• Epinephrine with Propranolol

– BP

– PR

Vasoconstrictor with antipsychotic or

other α-adrenoceptor blocker

• Epinephrine with Chlorpromazine, Prazocin,

Risperidone

– BP

– Susceptible to orthostatic hypotension

Vasoconstrictor with adrenergic neuronal

blocker

• levonordefrin with guanithidine

– Sympathomimetic effects may be enhanced.

Vasoconstrictor should be used cautiously.

• Absolute contraindication

Vasoconstrictor with thyroid hormone

• Epinephrine with Thyroxine

– Summation of effects possible when thyroid

hormones are used in excess. Vasoconstrictor

should be used cautiously if signs of

hyperthyroidism are present

▪ Relative contraindication

Techniques of Regional Anesthesia in

Dentistry

Basic injection technique

122


1. Use sterilized sharp needle

2. Check the flow of anesthetic solution

3. Determine the temperature of syringe /cartridge

4. Position the patient

5. Dry tissue

123

Hand position during injection


6. Apply topical

antiseptic (optional)

7A. Apply topical

anesthetic (optional)

7B. Communicate with the

patient

124

125


8. Establish a firm hand rest

126


9. Make tissue taut

10. Keep the syringe out

of patient’s line of sight

127


11A. Insert the needle into the mucosa

11B . Watch and communicate

with the patient

128


12. Inject several drops of local anesthetic solution

(optional)

13. Slowly advance the needle toward the target

14. Inject several drops before touching the

periosteum

15. Aspirate

129


16 A. Slowly deposit the local anesthetic solution

16 B. Communicate with the patient

17. Slowly withdraw the syringe

18. Observe the patient

19. Record the injection on patient’s chart




Anatomical consideration

131

Anatomical consideration Trigeminal Nerve

132

Cranial NervesNumber Name Type

I Olfactory Sensory

II Optic Sensory

III Occulomotor Motor

IV Trochlear Motor

V Trigeminal Mixed

VI Abducense Motor

VII Facial Motor

VIII Auditory Sensory

IX Glossopharyngeal Mixed

X Vagus Mixed

XI Accessory Motor

XII Hypoglossal Motor

133

Cranial Nerve

134

Cranial Nerve

135

Trigeminal Nerve

• Sensory

– Ophthalmic (V1)

– Maxillary (V2)

– Mandibular (V3)

136

Trigeminal Nerve

• Motor (Mandibular (V3) division only)

– Muscles of Mastication

• Masseter

• Temporalis

• Ptrygoideus medialis

• Ptrygoideus lateralis

– Mylohyoid

– Digastric (anterior belly)

– Tensor tympani

– Tensor Veli palatini

137

Ophthalmic (V1)

– Nasociliary

– Frontal

– Lacrimal

Maxillary (V2)

• Alveolar

– Posterior superior alveolar

(PSA)

– Middle superior alveolar (MSA)

– Anterior superior alveolar (ASA)

• Palate

– Nasopalatine

– Greater palatine

– Lesser palatine

138

139

Maxillary (V2)

140

Maxillary (V2)

141

Maxillary (V2)

142

Maxillary (V2)

143

Maxillary (V2)

144

Maxillary (V2)

145

Anterior Superior Alveolar nerve

146

Mandibular (V3)

• Inferior alveolar

– Mental branch

– Incisive branch

• Buccal

• Lingual

• Mylohyoid

• Auriculotemporal

147

Inferior alveolar nerve (IAN)

148


149


Jafarian Local Anesthesia 150





Techniques of maxillary anesthesia

152

Typical information in each technique

� ... Injection

� Other common Names

� Nerves Anesthetized

� Areas Anesthetized

� Indications

� Contraindications

� Advantages

� Disadvantages

� Positive Aspiration

� Alternatives

� Techniques

� Signs and Symptoms

� Safety Features

� Precautions

� Failures of Anesthesia

� Complication


• Techniques of maxillary

anesthesia

– Local infiltration

– Field Block

– Nerve Block

153

154

Maxillary injection techniques

1. Supraperisteal (infiltration)

2. Periodontal Ligament (PDL)

3. Intraseptal

4. Intracrestal

5. Intraosseous

6. Posterior superior alveolar (PSA) nerve block

7. Middle superior alveolar (MSA) nerve block

8. Anterior Superior alveolar nerve block (ASA)

155

Supraperiosteal injection

156

Posterior Superior Alveolar Nerve

Block

157


Block

• Depth of penetration (half of a long 40mm

needle)

Long dental needleShort dental needleLess risk of Hematoma

158


Block

• The story of Mesiobuccal root of first Molar !!

• Significant difference in skull size


needle)

• Risk of Hematoma ; positive aspiration ~ 3.1%

159


Block

• The story of Mesiobuccal root of first Molar !!

• Significant difference in skull size


needle)

• Risk of Hematoma ; positive aspiration ~ 3.1%

160

Middle Superior Alveolar Nerve Block

161

Middle Superior Alveolar Nerve Block

• Present in only 28% of population

• Positive aspiration negligible <3%

162

Anterior Superior Alveolar Nerve Block

163


164


• Although not accurate, the other name :

infraorbital Nerve Block

• Disadvantages is more Psychological both for

Administrator and patient ; injury to EYE !!

165

Palatal Anesthesia

• Necessary for any Dental Procedure involving soft/hard tissue of palate

• Steps !!1. Adequate topical anesthesia

2. Pressure anesthesia at the site both before and during needle insertion and the deposition of solution.

3. Maintain control over the needle

4. Deposit the anesthetic solution slowly

5. Trust yourself ... ... You can complete the procedure atraumtically !!

166

Palatal Anesthesia

167

Greater palatine Nerve Block

168


169


170


171


172


173


174

Prepuncture technique

an excellent technique !!

175

Nasopalatine Nerve block

176

Nasopalatine Nerve block

177

Multiple Needle Penetration

178

Local infiltration of the Palate

179

Anterior Middle Superior Alveolar Nerve Block

180

Palatal approach Anterior superior Alveolar Nerve

181

Maxillary Nerve Block

( High – tuberosity approach)

182

Maxillary Nerve Block

(Greater Palatine canal approach)





Techniques of maxillary anesthesia

Techniques of mandibular anesthesia

184


185

Inferior Alveolar Nerve block

186

Inferior Alveolar Nerve block (variation)

Too far anteriorly

187

Inferior Alveolar Nerve block (variation)

Too far posteriorly

188

Inferior Alveolar Nerve block

Mylohyoid nerve block

189

Buccal Nerve block

190

Mandibular Nerve Block Gow - Gate

191

Mandibular Nerve Block Gow - Gate

192

Mandibular Nerve Block

Extraoral through sigmoid notch

193

Mandibular Nerve Block

Vazirani –Akinosy closed mouth

194

Mental Nerve Block

195

Mental Nerve Block

Lingual side

196

Incisive Nerve Block

197

Intraosseous Anesthesia

• Periodontal Ligament Injection

• Intraseptal injection

• Intraosseous injection


• Periodontal Ligament

Injection (PDL)

198

199




200




• Intraosseous injection

201

Intrapulpal Anesthesia

202

Complications, Questions and Future Trends

• Local complication

• Systemic complication

• Question

• Future trends in pain control

Complication

Local complication

204

Local complication

1. Needle breakage

2. Persistent paresthesia or

anesthesia

3. Facial nerve paralysis

4. Trismus

5. Soft tissue injury

6. Hematoma

7. Pain on injection

8. Burning on injection

9. Infection

10. Edema

11. Sloughing of tissues

12. Postanesthetic intraoral

lesions

205

Local complication

1. Needle breakage

– Causes

– Problem

– Prevention

– Management

206

Local complication

2. Persistent Anesthesia or Paresthesia

– Causes (Mechanical /chemical trauma ...)

– Problem

– Prevention

– Management

207

Local complication


– Cause

– Problem

– Prevention

– Management

208

Local complication

4. Trismus

– Cause

– Problem

– Prevention

– Management

209

Local complication


– Cause

– Problem

– Prevention

– Management

210

Local complication

6. Hematoma

– Cause

– Problem

– Prevention

– Management

211

Local complication


– Cause

– Problem

– Prevention

– Management

212

Local complication


– Cause

– Problem

– Prevention

– Management

213

Local complication

9. Infection

– Cause

– Problem

– Prevention

– Management

214

Local complication

10. Edema

– Cause

– Problem

– Prevention

– Management

215

Local complication


– Cause

– Problem

– Prevention

– Management

216

Local complication

12. Postanesthetic Intraoral Lesions

– Cause

– Problem

– Prevention

– Management

217

Local complication

1. Needle breakage

2. Persistent paresthesia or

anesthesia


4. Trismus


6. Hematoma



9. Infection

10. Edema


12. Postanesthetic intraoral

lesions

Complications, Questions and Future Trends

Local Complication

Systemic Complication

219


• Principle 1 : No drug ever exerts a single action

• Principle 2 : No clinically useful drug is entirely

devoid of toxicity

• Principle 3 : the potential of a drug rests in

the hands hand of operator

220

Causes of Adverse Drug Reactions

• Toxicity caused by Direct Extension of the usual pharmacological effects of the drug

1. Side effects

2. Overdose Reactions

3. Local toxic effects

• Toxicity caused by Alteration in the Recipient of the drug

1. A disease process ( hepatic dysfunction , CHF , Renal dysfunction )

2. Emotional disturbances

3. Genetic aberrations ( Atypical plasma cholinesterase , malignant hyperthermia )

4. Idiosyncrasy

• Toxicity caused by Allergic responses to the drug

221

Comparison of Allergy and Overdose

Allergy Overdose

Dose Non-dose related Dose related

S & S Similar ,regardless of allergen Relate to pharmacology of the drug

Management Similar (epinephrine ,histamine blockers) Different :specific for the drug


Local anesthetic overdose

223

Local anesthetic overdose (Predisposing factors)

• Patient Factors

– Age

– Weight

– Other drugs

– Sex

– Presence of disease

– Genetics

– Mental attitude and

environment

• Drug Factors

– Vasoactivity

– Concentration

– Dose

– Rout of administration

– Rate of injection

– Vascularity of the injection

site

– Presence of vasoconstrictors

224

Overdose • Causes

1. Biotransformation of the drug is unusually slow.

2. The unbiotransformed drug is too slowly eliminated from

the body through the kidneys.

3. Too large a total dose is administered.

4. Absorption from the injection site is unusually rapid.

5. Inadvertent intravascular administered occurs.

225

Overdose

• Reverse Carotid blood flow

226

Overdose

• False Negative Aspiration

227

Overdose

• Local Anesthetic blood levels and action

228

Overdose • Causes

• Prevention

• Sign and Symptoms (Box !8 -4 p.313)

• Management

– P; ABCD emergency

– Definite treatment



Vasoconstrictor Overdose


• Precipitating factors and

prevention

• Clinical manifestations

(Box 18-6 p.318)

• Management

230

Signs Symptoms

Sharp elevation of

BP

Fear , Anxiety

Elevated HR Tenseness

Possible

dysrhythmia

Restlessness

Throbbing headache

Tremor

Perspiration

Weakness

Dizziness

Pallor

Respiratory difficulty




Allergy

232

Allergy

• Predisposing Factors

• Prevention

• Dental management

• Clinical manifestations

• Management

233

Palatal Anesthesia

234

Palatal Anesthesia

235

Palatal Anesthesia

236

Palatal Anesthesia

237

Palatal Anesthesia

238

Palatal Anesthesia

239

Palatal Anesthesia

240

Maxillary

Assistant Professor of Oral and Maxillofacial Surgery ...gtds.sbmu.ac.ir/uploads/local anesthesia.pdf · History of Local Anesthetics •Cocaine isolated 1856 •1884 cocaine used

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