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Clinical tips in dental local anesthesia

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clinical tips in dental local anesthesia

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Clinical tips in dental local anesthesia

  1. 1. Dr.Elhawary Clinical Tips In Dental Local Anesthesia • Hesham El-Hawary • 1998 • Assoc Prof. OMFS – Cairo University – MSA University – Umm AL-Qura University • Email: hesham@elhawarydentalclinic.com Hesham.elhawary@dentistry.cu.edu.eg • Slide share: – www.slideshare.nethesham_elhawary • Website : – www.elhawarydentalclinic.com
  2. 2. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Clinical Tips Dental Local Anesthesia
  3. 3. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Pre-anesthetic evaluation of the patient 1. Case History 2. Local Examination 3. Patient Grouping and sensitivity test 4. Discussing with the patient the Treatment Plan
  4. 4. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Classification of the patients according to their physical condition According to the American Society of Anesthesiologists (ASA) Type I : Normal patient Type II : Mild to moderate systemic disease Type III: Sever systemic disease limiting patient activity Type IV: Sever systemic disease threatening life Type V : Morbid patient
  5. 5. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Treatment options 1. Office treatment • ASA type I • ASA type II 2. Hospitalization • ASA type III 3. Hospitalization and emergency treatment only • ASA type IV 4. Hospitalization and palliative treatment • ASA type V
  6. 6. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Sensitivity Test • Intranasal sensitivity test • Skin sensitivity test
  7. 7. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Skin Sensitivity Test
  8. 8. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Skin Sensitivity Test
  9. 9. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Pre-anesthetic evaluation of the patient 1. Case History 2. Local Examination 3. Patient Grouping and sensitivity test 4. Discussing with the patient the Treatment Plan
  10. 10. Dr.Elhawary Clinical Tips In Dental Local Anesthesia • Explain your treatment plan in a simple way • No – Scary – Scientific words • Never deny a procedure • Never lie to a child patient
  11. 11. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Armamentarium and Preparation for basic injection
  12. 12. Dr.Elhawary Clinical Tips In Dental Local Anesthesia
  13. 13. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Dental Syringe
  14. 14. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Pressure Syringe
  15. 15. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Jet injector Needle-less syringe
  16. 16. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Preparation of the site of injection and Needle insertion
  17. 17. Dr.Elhawary Clinical Tips In Dental Local Anesthesia 1. Use suitable Syringes and Needles 2. Hands of the operator: cleaned and disinfected 3. Anesthetic carpules: warmed, clean and disinfected 4. Patient's mouth: cleaned, rinsed 5. Site of injection: dried and disinfected 6. Insertion of the needle: 1. The patient should be aware that he is going to have the injection but not exactly when 2. Mucosa Stretched as possible to facilitate insertion of the needle 3. The syringe is held in a pen grasp 4. The needle should not be bent to change its direction inside the tissues 5. The needle should always follow the simplest way inside the tissues 6. After insertion of the needle, aspirate a little to be sure that the needle is not within a blood vessel 7. The anesthetic solution is then deposited at a rate of not more than 2 ml/min 8. meanwhile the patient should be watched carefully for any adverse reaction
  18. 18. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Innervation
  19. 19. Dr.Elhawary Clinical Tips In Dental Local Anesthesia The maxillary nerve
  20. 20. Dr.Elhawary Clinical Tips In Dental Local Anesthesia
  21. 21. Dr.Elhawary Clinical Tips In Dental Local Anesthesia
  22. 22. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Pulp , Investing structures & Labial (buccal) mucoperiosteum Anterior superior alveolar nerve Anterior teeth (1,2,3) Middle superior alveolar nerve Premolars (4,5) & MB root of 1st molar(6) Posterior superior alveolar nerve Molars except MB root of 1st molar(6) Nerve supply of Maxillary teeth
  23. 23. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Palatal mucoperiosteum Nasopalatine nerve Anterior teeth (1,2,3) Greater ( Anterior) palatine nerve Premolars (4,5) & Molars (678) Nerve supply of Maxillary teeth
  24. 24. Dr.Elhawary Clinical Tips In Dental Local Anesthesia The accessory innervations of the teeth • The buccal mucoperiosteum, the pulp and investing structures of upper anterior teeth cross innervation may take place i.e. branch from the anterior superior nerve of the other side • The palatal mucoperiosteum of the upper canine is supplied by interlacing fibers between the greater palatine nerve and the nasopalatine nerve
  25. 25. Dr.Elhawary Clinical Tips In Dental Local Anesthesia
  26. 26. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Nerve supply to the mandibular teeth Pulp , Investing structures Incisive nerve Anterior teeth (1,2,3) Inferior alveolar nerve Premolars (4,5) & Molars (678)
  27. 27. Dr.Elhawary Clinical Tips In Dental Local Anesthesia
  28. 28. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Nerve supply to the mandibular teeth Labial (buccal) mucoperiosteum Mental nerve Cutaneous coli nerve ( branch of cervical plexus C2 & c3 ) gives additional sensory supply for premolars ( 4 , 5 ) in about 20 % of the pt. Anterior teeth (1,2,3) & Premolars (45) Long buccal nerveMolars (678)
  29. 29. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Nerve supply to the mandibular teeth Lingual mucoperiosteum Lingual nerve Anterior teeth (1,2,3) Premolars (4,5) & Molars (678)
  30. 30. Dr.Elhawary Clinical Tips In Dental Local Anesthesia 1 2 3 4 5 6 7 8 L MB Lingual Nerve P Is Incisive Nerve IAN B MB Mental Nerve Long Buccal Nerve
  31. 31. Dr.Elhawary Clinical Tips In Dental Local Anesthesia The accessory innervations of the teeth • The pulp and investing structures of the lower anterior teeth cross innervation may take place i.e. branch from the incisive nerve of the other side • The buccal mucoperiosteum of the lower premolar may receive additional nerve supply from the cutaneous coli nerve (branch from the cervical plexus of nerves) • The pulp and investing structures of the lower molars may receive additional nerve supply from the nerve to mylohyoid
  32. 32. Dr.Elhawary Clinical Tips In Dental Local Anesthesia PHARMACOLOGY OF LOCAL ANESTHESIA
  33. 33. Dr.Elhawary Clinical Tips In Dental Local Anesthesia ANESTHETIC CARPULE Pharmacology of Local Anesthesia
  34. 34. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Anesthesia with V.C. 1. Local anesthetic agent ( L.A.) 2. Vasoconstrictor agent ( V.C.) 3. Preservative for V.C. agent (anti- oxidant) 4. Vehicle to make solution isotonic ( 0.9%NaCl) Plain Anesthesia (without V.C.) 1. Local anesthetic agent ( L.A.) 2. Vehicle to make solution isotonic ( 0.9%NaCl)
  35. 35. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Keep in mind • The main agent in the carpule is the L.A. agent • The other ingredients of the local anesthetic carpule are added : 1. To potentiate the action of the L.A. agent 2. To prevent deterioration of the contents
  36. 36. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Anesthetic Techniques
  37. 37. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Local Anesthesia 1. Topical anesthesia 2. Local infiltration 3. Nerve block
  38. 38. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Local Anesthesia 1. Topical anesthesia 2. Local infiltration 3. Nerve block  Ointments, gels, sprays and pastes  Applied on mucous membrane or skin  Allows for easy and painless insertion of needle  Affects free nerve endings
  39. 39. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Local Anesthesia 1. Topical anesthesia 2. Local infiltration 3. Nerve block  Flooding of the terminal nerve endings with local anesthetic solution  Infiltiration above a tooth apex is an example of a field block
  40. 40. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Local Anesthesia 1. Topical anesthesia 2. Local infiltration 3. Nerve block  The anesthetic solution is deposited close to a main nerve trunk  Usually at a distance from the operative site before the nerve divided into terminal branches
  41. 41. Dr.Elhawary Clinical Tips In Dental Local Anesthesia
  42. 42. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Factors affecting selection of the technique to be used 1. Area to be anesthetized 2. Extent of surgical procedure 3. Duration and profoundness of anesthesia 4. Age of the patient 5. Homeostasis 6. Presence of infection 7. Skills of the operator 8. Presence of the suitable equipment
  43. 43. Dr.Elhawary Clinical Tips In Dental Local Anesthesia
  44. 44. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Types of maxillary injections Maxillary anethesia Infiltration anesthesia Buccal inf Palatal inf Nerve block anesthesia Infraorbital NB Incisive NB Greater Palatine NB Posterior Superior Alv NB Maxillary NB
  45. 45. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Points • Chair position • Dentist position • Syringe • Needle • Areas/Nerves to be anesthetized - Landmarks • Point of insertion • Direction of injection • Checking the anesthesia
  46. 46. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Checking the anesthesia Subjective findings Objective findings
  47. 47. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Points • Chair position • Dentist position • Syringe • Needle • Areas/Nerves to be anesthetized - Landmarks • Point of insertion • Direction of injection • Checking the anesthesia
  48. 48. Dr.Elhawary Clinical Tips In Dental Local Anesthesia MAXILLARY BUCCAL INFILTRATION ANESTHESIA Maxillary Anesthetic Techniques
  49. 49. Dr.Elhawary Clinical Tips In Dental Local Anesthesia
  50. 50. Dr.Elhawary Clinical Tips In Dental Local Anesthesia
  51. 51. Dr.Elhawary Clinical Tips In Dental Local Anesthesia
  52. 52. Dr.Elhawary Clinical Tips In Dental Local Anesthesia
  53. 53. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Confirming the Anesthesia • Subjective findings – No subjective findings • Objective findings – Probing does not lead to pain
  54. 54. Dr.Elhawary Clinical Tips In Dental Local Anesthesia MAXILLARY PALATAL INFILTRATION ANESTHESIA Maxillary Anesthetic Techniques
  55. 55. Dr.Elhawary Clinical Tips In Dental Local Anesthesia
  56. 56. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Palatal Infiltration Technique The point of needle insertion
  57. 57. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Palatal Infiltration Technique Direction of needle insertion
  58. 58. Dr.Elhawary Clinical Tips In Dental Local Anesthesia
  59. 59. Dr.Elhawary Clinical Tips In Dental Local Anesthesia
  60. 60. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Confirming the Anesthesia • Subjective findings – No subjective findings • Objective findings – Probing does not lead to pain
  61. 61. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Variations in these techniques Buccal anesthesia  Injection for the maxillary third molar  Upper centrals Palatal anesthesia • Injection for maxillary third molar • Upper centrals and laterals
  62. 62. Dr.Elhawary Clinical Tips In Dental Local Anesthesia NERVE BLOCK TECHNIQUES IN THE MAXILLA
  63. 63. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Local Anesthesia • Nerve Block – The anesthetic solution is deposited close to a main nerve trunk – Usually at a distance from the operative site before the nerve divided into terminal branches
  64. 64. Dr.Elhawary Clinical Tips In Dental Local Anesthesia
  65. 65. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Mandibular Anesthetic techniques
  66. 66. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Types of mandibular injections Mandibular anethesia Infiltration anesthesia Anterior labial infl anesth Anterior lingual inf anesth Long buccal inf anesth Nerve block anesthesia IA and L NB Mental NB Long Buccal NB
  67. 67. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Infiltration Anesthesia
  68. 68. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Anteriors’ labial Infiltration Anesthesia The point of needle insertion
  69. 69. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Anteriors’ Labial Infiltration Anesthesia Direction of needle insertion
  70. 70. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Confirming the Anesthesia • Subjective findings – Numbness of the lower lip • Objective findings – Probing does not lead to pain
  71. 71. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Infiltration Anesthesia Anteriors’ lingual Infiltration Anesthesia
  72. 72. Dr.Elhawary Clinical Tips In Dental Local Anesthesia
  73. 73. Dr.Elhawary Clinical Tips In Dental Local Anesthesia
  74. 74. Dr.Elhawary Clinical Tips In Dental Local Anesthesia
  75. 75. Dr.Elhawary Clinical Tips In Dental Local Anesthesia
  76. 76. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Indirect technique of lingual infiltration of right anteriror teeth
  77. 77. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Infiltration Anesthesia
  78. 78. Dr.Elhawary Clinical Tips In Dental Local Anesthesia
  79. 79. Dr.Elhawary Clinical Tips In Dental Local Anesthesia MANDIBULAR ANESTHETIC TECHNIQUES IA & L NERVE BLOCK ANESTHESIA
  80. 80. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Techniques • Standard technique • Gaw-Gates Technique • Akinozi Technique
  81. 81. Dr.Elhawary Clinical Tips In Dental Local Anesthesia STANDARD TECHNIQUE
  82. 82. Dr.Elhawary Clinical Tips In Dental Local Anesthesia
  83. 83. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Patient position • Head , neck and trunk on the same straight line • The back of the chair is tilted so that it make a 45 degree angle with the floor • So that when the patient open his mouth the occlusal plane of the mandibular teeth becomes parallel to the floor • The occlusal plan of mandibular teeth near to the operator’s elbow Dentist position • Right side: – From infront and to the right • Left side: – From infront and to the right using • Cross hand technique • Using left hand – From right rear position using • From behind technique
  84. 84. Dr.Elhawary Clinical Tips In Dental Local Anesthesia
  85. 85. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Ocland DVD of Head and Neck Anatomy
  86. 86. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Points • Chair position • Dentist position • Syringe • Needle • Nerves to be anesthetized – Incisive Nerve – Mental nerve – Inferior alveolar nerve – Lingual nerve • Areas to be anesthetized • landmarks • Point of insertion • Direction of injection • Checking the anesthesia
  87. 87. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Points • Chair position • Dentist position • Syringe • Needle • Nerves to be anesthetized • Areas to be anesthetized – All the pulp and investing structures of lower posterior teeth in the side of anesthesia – Buccal mucoperiosteum of the anterior teeth and premolars – The lingual mucoperiosteum of the same side – Floor of the mouth of the same side – Half the tongue of the same side • landmarks • Point of insertion • Direction of injection • Checking the anesthesia
  88. 88. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Points • Chair position • Dentist position • Syringe • Needle • Nerves to be anesthetized • Areas to be anesthetized • landmarks • Point of insertion • Direction of injection • Checking the anesthesia
  89. 89. Dr.Elhawary Clinical Tips In Dental Local Anesthesia landmarks • Soft tissue landmarks • Bony landmarks
  90. 90. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Points • Chair position • Dentist position • Syringe • Needle • Nerves to be anesthetized • Areas to be anesthetized • landmarks • Point of insertion • Direction of injection • Checking the anesthesia
  91. 91. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Steps for right mandibular injection • Right handed operator • The operator is positioned from infront and to the right
  92. 92. Dr.Elhawary Clinical Tips In Dental Local Anesthesia
  93. 93. Dr.Elhawary Clinical Tips In Dental Local Anesthesia
  94. 94. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Deposited into the constrictor muscle of pharynx : disphagya
  95. 95. Dr.Elhawary Clinical Tips In Dental Local Anesthesia
  96. 96. Dr.Elhawary Clinical Tips In Dental Local Anesthesia
  97. 97. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Narrow angle of flare
  98. 98. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Narrow angle of flare
  99. 99. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Wide angle of flare
  100. 100. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Wide angle of flare
  101. 101. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Points • Chair position • Dentist position • Syringe • Needle • Nerves to be anesthetized • Areas to be anesthetized • landmarks • Point of insertion • Direction of injection • Checking the anesthesia – Subjective findings • Numbness of the lower lip – Objective findings • Probing does not lead to pain
  102. 102. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Steps for left mandibular injection • Right handed operator The operator is positioned on the right front of the patient – From infront and to the right • Cross hand technique • Left hand technique – Right rear position • From behind technique
  103. 103. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Cross Hand Technique
  104. 104. Dr.Elhawary Clinical Tips In Dental Local Anesthesia From Behind Technique
  105. 105. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Left Hand Technique
  106. 106. Dr.Elhawary Clinical Tips In Dental Local Anesthesia
  107. 107. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Errors during injection • Too high injection • Too low injection • Too deep injection • Too medial injection – Anesthesia of the auriclotemporal nerve : Numbness of the ear – Injection into lateral pterygoid muscle : Soreness and trismus
  108. 108. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Errors during injection • Too high injection • Too low injection • Too deep injection • Too medial injection • Failure of anesthesia
  109. 109. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Errors during injection • Too high injection • Too low injection • Too deep injection • Too medial injection – Deposited in parotid gland – Temporary facial nerve paralysis – Parotitis – Deposited into the posterior facial vein : – Toxicity – Deposited into medial pterygoid muscle – Pain – Trismus
  110. 110. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Errors during injection • Too high injection • Too low injection • Too deep injection • Too medial injection – Deposited into the constrictor muscle of pharynx : disphagya
  111. 111. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Complications Of Local Anesthesia
  112. 112. Dr.Elhawary Clinical Tips In Dental Local Anesthesia • A: Airway » Clear » Adequate Respiration • B: Bleeding » Stopped » Achieve inlet to vessels • C: Circulation » Fluids if needed • D: Drugs to treat the present condition
  113. 113. Dr.Elhawary Clinical Tips In Dental Local Anesthesia • Call medical emergency service • The patient position – Placed in horizontal position on his back – Tilt the patient in a slightly head down position or – elevate the legs to help increase cerebral circulation • Adequate oxygenation • Check the patient's cardiac and cardiovascular status • Start I.V. fluids (e.g. 5% dextrose in H2O) • Drugs according to the condition • If complete circulatory standstill – IV injection of atropine – Stimulation of the heart by introducing a needle directly into it – Intracardiac injection of epinephrine 0.1 ml of 1.1000 solution
  114. 114. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Complications from local Anesthesia I. Complications associated to the absorption of the solution used II. Complications associated with needle insertion
  115. 115. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Complications associated with absorption of the anesthetic solution 1. Systemic drug reactions due to the local anesthetic agent: 1. Toxicity 2. Allergy 3. Anaphylactic reactions 4. Idiosyncrasy 2. Local reactions: 1. Infections due to contaminated solutions 2. Local tissue irritation
  116. 116. Dr.Elhawary Clinical Tips In Dental Local Anesthesia Complications associated with needle insertion • Fainting and syncope • Needle breakage • Prolonged anesthesia • Pain • Edema • Trismus • Hematoma • Sloughing and ulceration • Infection • Bizarre neurological symptoms
  117. 117. Dr.Elhawary Clinical Tips In Dental Local Anesthesia

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