Local Anaesthesia

Local AnesthesiaLocal Anesthesia

Topical, Patch, Infiltration, Topical, Patch, Infiltration, BlockBlock

PAIN CONTROL FACTORSPAIN CONTROL FACTORS

High pain ThresholdHigh pain Threshold• Hypo-reactiveHypo-reactive

» Low reaction to painLow reaction to pain

Low Pain ThresholdLow Pain Threshold• Hyper-reactiveHyper-reactive

» High reaction to painHigh reaction to pain

Pain Reaction Depends Pain Reaction Depends On:On:

Emotional StateEmotional State Degree of fatigueDegree of fatigue ApprehensionApprehension GenderGender Fear Fear AgeAge

Local AnesthesiaLocal Anesthesia

A drug which upon contact with A drug which upon contact with nervous nervous

tissue renders that tissue incapable of tissue renders that tissue incapable of

transmitting an impulse on transmitting an impulse on stimulation.stimulation.

How Nerve Fibers How Nerve Fibers Transmit Transmit Painful Painful StimuliStimuli

NF extension of NF extension of single cell, nucleus is single cell, nucleus is brainbrain

NF is in periphery of NF is in periphery of body & responsible body & responsible for receiving initial for receiving initial painpain

Pain stimulus irritates Pain stimulus irritates nerve endingnerve ending

Creates series Creates series changeschanges

Stimulus reproduces Stimulus reproduces itselfitself

Stimulus called Stimulus called impulse at this pointimpulse at this point

Impulse proceeds Impulse proceeds along nervealong nerve

Continuation of Continuation of impulse called impulse called conductionconduction

Brain recognizes painBrain recognizes pain

How Local Anesthetics How Local Anesthetics WorkWork

Theory : Transmission of impulse Theory : Transmission of impulse along nerve caused by alteration in along nerve caused by alteration in nerve membrane and LA agents nerve membrane and LA agents alter integrity factoralter integrity factor

Raises threshold for excitation of Raises threshold for excitation of nervenerve

Anesthetic must come in direct Anesthetic must come in direct contact with nerve tissuescontact with nerve tissues


Motor nerves require higher Motor nerves require higher concentration of anesthetic to concentration of anesthetic to cause blockade than do sensory cause blockade than do sensory nerves.nerves.

Small fibers blocked earlier than Small fibers blocked earlier than large fibers.large fibers.


Pain fibers Pain fibers anesthetized anesthetized before those for before those for temperature temperature and touch. and touch.

The return of The return of function function

in these fibers in in these fibers in in in

reverse order.reverse order.

Chemical CompositionChemical Composition

Esters of Esters of aminobenzoic acidaminobenzoic acid• NovocaineNovocaine

• MonocaineMonocaine

• PontocainePontocaine

• Primacaine Primacaine

Non-ester typesNon-ester types

• XylocaineXylocaine

• DynacaineDynacaine

• CarbocaineCarbocaine

• Citanest ForteCitanest Forte

Chemical CompositionChemical Composition

Clinical significance is not the Clinical significance is not the difference difference

in chemical compositionin chemical composition

butbut

in allergic potential.in allergic potential.

Purpose of Purpose of VasoconstrictorsVasoconstrictors

Reduces blood flow through injected area Reduces blood flow through injected area so that rate of disappearance of local so that rate of disappearance of local anesthetic from tissues is reduced.anesthetic from tissues is reduced.

This results in prolonged anesthesia and This results in prolonged anesthesia and lesser amount or concentration of LA to lesser amount or concentration of LA to produce desired results.produce desired results.

Decrease incidence of toxicity of drug. Decrease incidence of toxicity of drug. Toxicity depends amount in bloodstream.Toxicity depends amount in bloodstream.

VasoconstrictorsVasoconstrictors

Commonly used in dentistry isCommonly used in dentistry is Epinephrine--1 : 50,000 to 1 : 200,000Epinephrine--1 : 50,000 to 1 : 200,000

Norepinephrine--1:30,000Norepinephrine--1:30,000

Neo-Synephrine--1:2,500Neo-Synephrine--1:2,500

Neo-Cobefrin--1:20,000 Neo-Cobefrin--1:20,000

Two Basic Types of Two Basic Types of InjectionInjection

Nerve Block: Nerve Block: Place LA Place LA adjacent to main adjacent to main nerve bundle so it nerve bundle so it will produce will produce anesthetized area anesthetized area covered by covered by distribution of the distribution of the affected nerveaffected nerve

Infiltration: Infiltration: Main nerve bundle Main nerve bundle not accessible OR not accessible OR reason to reason to anesthetize entire anesthetize entire area--agent can be area--agent can be deposited in area deposited in area where pain where pain emanates-only emanates-only nerve in local area nerve in local area affectedaffected

Block Anesthesia Block Anesthesia

Bone of mandible Bone of mandible densedense

Deposit solution Deposit solution near nervenear nerve

Nerve close to Nerve close to artery and veinartery and vein

Injecting into vessel Injecting into vessel can complicate can complicate procedureprocedure

Blood in anesthetic Blood in anesthetic carpule indicates carpule indicates vessel punctured vessel punctured by needleby needle

DDS must aspirate DDS must aspirate before injectionbefore injection

May take 20 May take 20 minutes for full minutes for full effect effect

Block Anesthesia EffectsBlock Anesthesia Effects

Produces numbness Produces numbness and tingling of lipand tingling of lip

Lip feels large and Lip feels large and swollenswollen

Tip and side of Tip and side of tongue will tingle tongue will tingle and become numband become numb

Numbs only one Numbs only one side of tongue side of tongue

Areas of Anesthesia & Areas of Anesthesia & TechniqueTechnique

Mandibular ( Inferior Alveolar ) Mandibular ( Inferior Alveolar ) Nerve BlockNerve Block supplies mandibular supplies mandibular teeth is the inferior alveolar-- can be teeth is the inferior alveolar-- can be blocked at entrance to mandible at blocked at entrance to mandible at inferior alveolar forameninferior alveolar foramen

Numbness & tingling of lip, anesth of Numbness & tingling of lip, anesth of teeth,buccal gingiva from midline to teeth,buccal gingiva from midline to 1st PM,possible anesth of tongue same 1st PM,possible anesth of tongue same sideside


Lingual Nerve BlockLingual Nerve Block- Branch of - Branch of mandibular nerve which lies mandibular nerve which lies medial to inferior alveolar nerve in medial to inferior alveolar nerve in area of inferior alveolar foramenarea of inferior alveolar foramen

Produces numbness of lateral Produces numbness of lateral border of tongue on same side, border of tongue on same side, anterior two thirds tongue, floor of anterior two thirds tongue, floor of mouth same sidemouth same side


Long Buccal Nerve InjectionLong Buccal Nerve Injection- nerve - nerve lies within gingiva of 2nd & 3rd molars lies within gingiva of 2nd & 3rd molars on buccal side of mandibleon buccal side of mandible

Performed by few drops placed in tissuePerformed by few drops placed in tissue

Will anesth buccal gingiva from 1st Will anesth buccal gingiva from 1st premolar to distal of 3rd molar areapremolar to distal of 3rd molar area


Mental Nerve BlockMental Nerve Block- object of - object of block is to interfere with nerve block is to interfere with nerve conduction along mental nerve by conduction along mental nerve by placing anesth in mental foramen placing anesth in mental foramen -- seldom used-- seldom used

Produces numbness of central and Produces numbness of central and lateral incisors, canine, and 1st lateral incisors, canine, and 1st premolar and gingiva, lip, chin areapremolar and gingiva, lip, chin area


Posterior Superior Alveolar Posterior Superior Alveolar InjectionInjection- PSA- PSA

Supplies innervation to maxillary sinus Supplies innervation to maxillary sinus and molar teeth, with exception of and molar teeth, with exception of mesial buccal root of first molar second mesial buccal root of first molar second buccal gingiva around molar teethbuccal gingiva around molar teeth

Site is height of mucobuccal fold apex Site is height of mucobuccal fold apex of max 2nd molar,distal to zygomatic of max 2nd molar,distal to zygomatic process of maxillaprocess of maxilla


Middle Superior Alveolar Injection Middle Superior Alveolar Injection - -

MSA blockMSA block

Nerve supplies premolar teeth and the Nerve supplies premolar teeth and the mesial buccal root of the first molarmesial buccal root of the first molar

Site over apex of 1st premolarSite over apex of 1st premolar


Anterior Superior Alveolar Anterior Superior Alveolar Injection - Injection -

Nerve supplies the incisors and Nerve supplies the incisors and caninescanines

Given slightly mesial to apex of canine Given slightly mesial to apex of canine - bilateral to anesth six anterior teeth- bilateral to anesth six anterior teeth


Middle Superior Alveolar Middle Superior Alveolar InjectionInjection: :

Nerve supplies premolar teeth and Nerve supplies premolar teeth and mesial buccal root of 1st molarmesial buccal root of 1st molar

Site over apex of 1st premolarSite over apex of 1st premolar


Anterior Superior Alveolar Anterior Superior Alveolar InjectionInjection: :

Nerve supplies incisors and caninesNerve supplies incisors and canines

Site slightly mesial to apex of Site slightly mesial to apex of canine-bilateral six anterior teeth canine-bilateral six anterior teeth


Greater Palatine (Anterior) InjectionGreater Palatine (Anterior) Injection: : Nerve supplies mucosa of hard palate Nerve supplies mucosa of hard palate opposite molar and premolar teethopposite molar and premolar teeth

Site opposite 2nd molar about 1 cm toward Site opposite 2nd molar about 1 cm toward midline of palate-greater palatine nervemidline of palate-greater palatine nerve

Usually used forsurgical procedures Usually used forsurgical procedures because palatal gingiva attaches to teeth-because palatal gingiva attaches to teeth-will numb palatal area opposite M & PM will numb palatal area opposite M & PM

Anesthesia & TechniquesAnesthesia & Techniques

Nasopalatine Nerve InjectionNasopalatine Nerve Injection: : Nerve emerges from nasopalatine Nerve emerges from nasopalatine (incisive) canal to supply mucosa of (incisive) canal to supply mucosa of palate opposite incisors and caninespalate opposite incisors and canines

Site is nasopalatine foramen- few Site is nasopalatine foramen- few drops onlydrops only

Anesthetizes palatal mucosa Anesthetizes palatal mucosa opposite six anterior teeth opposite six anterior teeth

Reactions to Local Reactions to Local AnesthesiaAnesthesia

SyncopySyncopy

ToxicToxic

Loss of blood flow-Loss of blood flow-fainting-psycho-fainting-psycho-Trendelburg positionTrendelburg position

High level of drug in High level of drug in circulation-agitation-circulation-agitation-restless-HR& BP up-restless-HR& BP up-then CNS then CNS depression-nonester depression-nonester have depression onlyhave depression only

Reactions to Local Reactions to Local AnesthesiaAnesthesia

AllergicAllergic Immediate- target Immediate- target lungs and circulatorylungs and circulatory

Delayed-minor type-Delayed-minor type-hours to days after - hours to days after - IM or IV or oral IM or IV or oral antihistamines- antihistamines- Benadryl 50 mg Benadryl 50 mg eitherIM or POeitherIM or PO

Document patient Document patient chartchart

Complications of InjectionsComplications of Injections

Injury to nerveInjury to nerve• Inferior alveolar blockInferior alveolar block• Burning sensation lipBurning sensation lip

Injury to blood vesselsInjury to blood vessels• Torn vessel-hematomaTorn vessel-hematoma• warm rinse/warm warm rinse/warm

compress reduce compress reduce swellingswelling

Blanching of skinBlanching of skin• spasm, time healsspasm, time heals

Broken needleBroken needle• Infrequent,removalInfrequent,removal

InfectionsInfections• previously used previously used

needleneedle• passage of needle passage of needle

thru infected area thru infected area IdiosyncrasyIdiosyncrasy

• unknown reactionunknown reaction

Anesthetics Used In CCSU Anesthetics Used In CCSU ClinicClinic

Carbocaine 2% with Neo-CobefrinCarbocaine 2% with Neo-Cobefrin

• mepivacaine hydrochloride and mepivacaine hydrochloride and levonordefrinlevonordefrin

• 1:20,0001:20,000• No epinephrineNo epinephrine• Use for hypertensive patients Use for hypertensive patients

Anesthetics Used In CCSU Anesthetics Used In CCSU ClinicClinic

Octocaine 100Octocaine 100• Lidocaine HCI 2% and Epinephrine Lidocaine HCI 2% and Epinephrine

1:100,0001:100,000

2% Xylocaine2% Xylocaine• Lidocaine HCI and epinephrine Lidocaine HCI and epinephrine

1:100,0001:100,000

Indications for UseIndications for Use

Dental HygieneDental Hygiene• Scaling and root planing in deep Scaling and root planing in deep

periodontal pocketsperiodontal pockets• Gingival curettageGingival curettage• Extreme cases of soft tissue Extreme cases of soft tissue

inflammation and discomfortinflammation and discomfort• Instrumentation of extremely Instrumentation of extremely

hypersensitive teethhypersensitive teeth

Correct DocumentationCorrect Documentation

ALWAYS enter on procedures any ALWAYS enter on procedures any anesthesia used on patientanesthesia used on patient

• 2% lidocaine1:100,000 epi 2 cc (Dr. 2% lidocaine1:100,000 epi 2 cc (Dr. Lemons) RSP URLemons) RSP UR

Preparation for Local Preparation for Local AnesthesiaAnesthesia

Sterile 2X2 gauzeSterile 2X2 gauze cotton tip cotton tip

applicatorapplicator topical anesthetictopical anesthetic aspirating syringeaspirating syringe needleneedle stick shieldstick shield anesthetic anesthetic

carpulescarpules

Long: mandible Long: mandible blockblock

Short: maxilla & Short: maxilla & mandible infiltrationmandible infiltration

Gauge: larger Gauge: larger number means number means smaller diameter of smaller diameter of needleneedle• eg. 27, 30eg. 27, 30

Procedure for Local Procedure for Local AnesthesiaAnesthesia

See CCSU Clinic See CCSU Clinic ManualManual

Section 5.12Section 5.12

Transoral Delivery Transoral Delivery AnesthesiaAnesthesia

DentipatchDentipatch 2 cm patch contains Lidocaine2 cm patch contains Lidocaine Acts on INTACT mucosa to produce Acts on INTACT mucosa to produce

local anesthesialocal anesthesia Anesthesia occurs within 2.5 minutes Anesthesia occurs within 2.5 minutes

of application and can last up to -of application and can last up to -present for 15 minute application present for 15 minute application period and 30 minutes after removalperiod and 30 minutes after removal

Transoral Delivery Transoral Delivery AnesthesiaAnesthesia

Has one fifth level of intravenous doseHas one fifth level of intravenous dose Not for pregnant Not for pregnant

individual/nursing/childindividual/nursing/child Reactions: rare, mild, taste Reactions: rare, mild, taste

perversion,stomatitis,erythema,mucosaperversion,stomatitis,erythema,mucosal reactionsl reactions

Gently dry area-remove clear Gently dry area-remove clear protective liner- allow patch to remain protective liner- allow patch to remain in place-no longer than 15 minutesin place-no longer than 15 minutes

Topical AnesthesiaTopical Anesthesia

20% Benzocaine in a water soluble base20% Benzocaine in a water soluble base Can be liquid or gelCan be liquid or gel Fast actionFast action Short durationShort duration Virtually no systemic absorptionVirtually no systemic absorption Apply to small area to be anesthetizedApply to small area to be anesthetized Anesthesia accomplished 15 to 30 Anesthesia accomplished 15 to 30

secondsseconds

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Local Anaesthesia