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Local anesthetic techniques


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Local anesthetic techniques

  1. 1. LOCAL ANESTHETIC TECHNIQUE’S Presented by : Dr. Suman Mukherjee 1st Yr MDS V.S.D.C.H. Yr : 2017-18
  2. 2. Contents : • Introduction • Regional anesthesia  Field block  Nerve block  Local infiltration • Local Anesthesia Injection Technique  Supraperiosteal injections  Intraligamentary injections  Intraosseous injections  Intraseptal injections  Subperiosteal injections • Maxillary injection techniques  PSAN  ASAN  MSAN  Nasopalatine nerve block  Greater Palatine nerve block  Maxillary nerve block • Mandibular Injection Technique’s  IANB  Incisive nerve block  Gow–Gates nerve block  Vazirani–Akinosi nerve block • Regional anesthesia to soft tissue  Buccal nerve block  Mental nerve block • Conclusions • Reference.
  3. 3. Introduction Pain control in dentistry presents one of the greatest challenges. (Pain leads to increased stress, release of endogenous catecholamines and unexpected cardiovascular responses) Before anesthetization, dentists should evaluate the medical history of each patient and document data on the systemic and psychological status of the patients in order to determine whether the patient is able to tolerate the treatment with no risk from the systemic and psychological points of views.
  4. 4. Before the injection of the local anesthetic, the dentist should recognize the potential risks. However, most adverse reactions to local anesthetics are not related to the drug itself, but to the injection of the drug. The injection of the local anesthesia is the most reported cause for fear and discomfort of dental patients.
  5. 5. NEEDLE GAUGE • Gauge refers to the diameter of the lumen of the needle; the smaller the number, the greater the diameter of the lumen. • There is increased resistance to aspiration of blood through a thinner needle (eg,30-gauge) compared with a larger-diameter needle (eg,27- or 25-gauge). • Needle deflection along the axis of the bevel and breakage must also be examined. • The smaller the diameter of the needle, the more it deflects. • Thirty-gauge needles deflect significantly, whereas 25-gauge needles essentially do not deflect at all. Likewise,25-gauge needles very rarely, if ever, break during an intraoral injection, and 99% of the needles that do break are 30-gauge needles.
  6. 6. Regional anesthesia : • Regional anesthesia or “the nerve block” is a form of anesthesia in which only a part of the body is anesthetized (“made numb”). • Field block : In a field block, local anesthetic is infiltrated around the border of the surgical field, leaving the operative area undisturbed. • Field block also may be considered when operating on the ear or lips. Eg. Gow gates technique is a kind of field block. American Academy of Family Physicians:
  7. 7. • Nerve block : In a nerve block, anesthetic is injected directly adjacent to the nerve supplying the surgical field. Supraorbital, supratrochlear, infraorbital, and mental nerve blocks can provide adequate anesthesia in procedures on parts of the face. Nerve blocks are used for pain treatment and management. • Often a group of nerves, called a plexus or ganglion, that causes pain to a specific organ or body region can be blocked with the injection of medication into a specific area of the body. The injection of this nerve-numbing substance is called a nerve block. Eg. IANB, PNB American Academy of Family Physicians:
  8. 8. Local infiltration : Local infiltration is used when anesthesia is required in small areas (e.g., for repair of minor lacerations, skin biopsies). The anesthetic solution is infiltrated to the deep dermis, where the sensory plexus supplying the skin begins to branch. The amount of solution used depends on the area that needs to be infiltrated; however, extensive local infiltration is not recommended. American Academy of Family Physicians:
  9. 9. Local Anesthesia Injection Technique’s :
  10. 10. Supra periosteal injection : • Pulpal and Soft tissue anesthesia in maxillary anterior teeth. • A short 25 or 27 gauge needle is recommended for this technique. • Sometimes this injection technique is referred to as infiltration, but the solution is deposited near terminal branches of nerves so it is actually a type of field block. • It is inserted at the height of the mucobuccal fold near the apex of the tooth to be treated. The bevel of the needle should be toward the bone. • Pulp, root, buccal periosteum, connective tissue, and mucous membrane are the areas anesthetized
  11. 11. Intraligamentary injection/ PDL injection • Approximately 0.2mL of anesthetic solution is deposited over a minimum of 20 seconds forced under pressure into the gingival sulcus of maxillary and mandibular teeth. This injection may be uncomfortable if the rate of injection is too rapid or the tissues are inflamed. • The PDL injection method of anesthetizing an individual tooth is utilized to avoid the undesirable consequences of regional block anesthesia. • A 27-gauge short needle with the bevel toward the tooth is inserted through the gingival sulcus on the mesial of the tooth to be anesthetized and inserted as far apically as possible.
  12. 12. PDL injection
  13. 13. Intraosseous injections : Aim of intra-osseous anesthesia is to inject local anesthesia solution into cancellous bone adjacent to the apex of the tooth by piercing bucal gingiva and bone in relation to the tooth to be anesthetized. It can be used as a supplemental technique with mandibular nerve blocks to enhance deep pulpal anesthesia or as a primary technique so that patients do not experience numb lips or tongues postoperatively.
  14. 14. intraosseous
  15. 15. Intra Septal injections • used for hemostasis, soft tissue anesthesia, and osseous anesthesia. • Use a 27 gauge short needle and insert it into the papilla of the area to be anesthetized at an angle of 90º to the tissue. • Slowly deposit 0.2 ml of solution.
  16. 16. Intra pulpal injection • A 27-gauge short needle is inserted into the pulp chamber and wedged firmly into the root canal. • A small volume (0.2to0.3mL) of local anesthetic is injected. • While this technique may prove uncomfortable for the patient, it invariably works to provide effective pain control. • In most cases, the duration is adequate to permit extirpation of the pulpal tissues.
  17. 17. Maxillary injection technique:
  18. 18. PSAN (posterior superior alveolar nerve block) • Anesthetize the maxillary molars except for the mesio buccal aspect of the first molars. • Clinically, the PSA injection is given with the insertion point at the height of the buccal vestibule at a point just distal to the malar process.
  19. 19. Advance the needle slowly in an upward, inward and backward direction. • TECHNIQUES – • Landmarks – • MUCOBUCCAL FOLD • MAXILLARY TUBEROSITY • ZYGOMATIC PROCESS OF MAXILLA • Prepare the tissues and orient the bevel of the needle towards the bone. • Advance the needle slowly in an upward, inward and backward direction. • The needle is inserted distally and superiorly at approximately 45 degrees to the mesiodistal and buccolingual planes at the Height of mucobuccal fold above maxillary second molar is the area of insertion • The depth of insertion is approximately 15 mm, and following careful aspiration, 1.0 mL of solution is slowly deposited. • short 25 or 27 gauge needle is recommended to decrease the risk of a hematoma.
  20. 20. COMPLICATIONS: • HAEMATOMA – needle placed most posteriorly into pterygoid plexus of veins and chances of maxillary artery perforation. Short needle use is recommended. • Visible intraoral hematoma develops within several minutes in mandibular buccal region. Bleeding continues until the pressure of extravascular blood equals the intravascular blood. • MANDIBULAR ANESTHESIA – since mandibular division is located lateral to PSA nerves. • CONTRAINDICATION – risk of hemorrhage is great in hemophilics. (Supraperiosteal injection or PDL injection recommended)
  21. 21. MIDDLE SUPERIOR ALVEOLAR NERVE BLOCK • MSAN - present in only about 28% of the population. • The (MSA) injection will anesthetize the mesiobuccal aspect of the maxillary first molar, both premolars, PDL, buccal bone, and periosteum, along with the soft tissue lateral to this area.
  22. 22. • TECHNIQUES – 27 gauge short or long needle is used. 1 ml of anesthetic solution should slowly be introduced after careful aspiration. • AREA OF INSERTION – height of the mucobuccal fold above the maxillary second premolar. The needle tip should approximate the apex of the tooth, which usually requires a penetration of about 5 mm. • TARGET AREA – maxillary bone above the apex of the maxillary second premolar. • LANDMARK – mucobuccal fold above the maxillary second premolar.
  23. 23. ANTERIOR SUPERIOR ALVEOLAR NERVE BLOCK • Also called Infraorbital Nerve Block. • The ASA injection will anesthetize the PDL, alveolar bone, periosteum, buccal soft tissue, and teeth from the canine to the midline. • The penetration is over the maxillary canine • A 25 gauge long needle is recommended • The needle depth will be about 16 mm for an average sized adult with varying depths proportional to the size of the patient and the bony structure of the cheek.
  24. 24. • AREA OF INSERTION – height of the mucobuccal fold directly over the first premolar. • TARGET AREA – infraorbital foramen (below the infraorbital notch) • Landmarks • - mucobuccal fold • -Infraorbital notch • -Infraorbital foramen • ORIENTATION OF THE BEVEL – Toward bone
  25. 25. • To transform it into Anterior Superior alveolar nerve block – • Maintain firm pressure over injection site both during and after the injection for 1 min. • Withdraw the syringe slowly. • Maintain direct pressure after withdrawal for 2 minute to allow more diffusion of solution into the foramen. • Wait for 3 to 5 min before the start of dental procedure.  Maintain firm pressure over injection site both during and after the injection for 1 min.  Withdraw the syringe slowly.  Maintain direct pressure after withdrawal for 2 minute to allow more diffusion of solution into the foramen.  Wait for 3 to 5 min before the start of dental procedure.
  26. 26. Infraorbital nerve block
  27. 27. Failures of anesthesia – • When needle contacts bone of lower border of infraorbital foramen, anesthesia developes in the desired soft tissue area only. That is why a failed ASA is supraperiosteal injection over the first premolar. • Needle deviation medial or lateral to infraorbital foramen. • Complications – hematoma may develop across the lower eyelid around infraorbital foramen
  28. 28. Other techniques.. • There are two approaches to Infraorbital nerve block, the most commonly being bicuspid and central incisor approach. • BICUSPID APPROACH – needle is inserted into the mucosa and areolar tissue using the maxillary bicuspid as the guide and the needle should pass beneath and lateral to the external maxillary artery and the anterior facial vein. • CENTRAL INCISOR APPROACH – needle is inserted into the mucosa and areolar tissue using the central incisor as guide and it passes beneath the angular head of quadratus labii superioris muscle. It proceeds anteriorly to the origin of the caninus muscle and beneath the external maxillary artery and the anterior facial vein.
  29. 29. Extra-oral approach
  30. 30. NASOPALATINE NERVE BLOCK • Also called incisive and sphenopalatine nerve block. • The nasopalatine (NP)injection will anesthetize the tissues of the palatal aspect of the premaxilla. • Two approaches – • Single penetration • Multiple penetration • Two approaches –  One tissue penetration  Three needle punctures • Two approaches –  One tissue penetration  Three needle punctures
  31. 31. Single penetration technique… • A 25 or 27 gauge short or ultra-short needle may be used. • The area of insertion is the palatal mucosa just lateral to the incisive papilla (located in the midline behind the central incisors). • The path of insertion is approaching the incisive papilla at a 45 degree angle with the orientation of the bevel toward the palatal tissue.
  32. 32. Technique (multiple penetration) • A 25 or 27 gauge short or ultra-short needle is recommended. • There are 3 points of insertion: • The labial frenum between the maxillary central incisors. • The interdental papilla between the maxillary central incisors. • The palatal soft tissue lateral to the incisive papilla. • First injection: If labial anesthesia has not been achieved with labial local infiltration of the area, the following injection is performed. If the area is anesthetized, proceed to the second injection. • The path of insertion is into the labial frenum with the orientation of the bevel of the needle toward the bone. Retract the upper lip to improve visibility. • Insert the needle into the frenum and deposit 0.3ml anesthetic solution over 15 seconds. The tissue may balloon. Anesthesia of the tissue should develop immediately.
  33. 33. • Second injection: • Hold the needle at right angles to the papilla. The orientation of the bevel is not relevant. • Insert the needle into the papilla just above the crest of bone. • Direct it toward the incisive papilla on the palatal side of the interdental papilla while slowly injecting anesthetic solution. Do not penetrate through the palatal tissue. • When blanching is noted in the incisive papilla, aspirate. • If negative administer 0.3ml of anesthetic solution over 15 seconds.
  34. 34. • Third injection: • Proceed as above for the single penetration injection; however, application of topical anesthetic and pressure anesthesia is unnecessary.
  35. 35. Greater Palatine Nerve Block • TECHNIQUES – 27 gauge short needle is used • AREAS OF INSERTION – soft tissues slightly anterior to the greater palatine foramen. • TARGET AREA – greater palatine nerve passing anteriorly between soft tissues and bone of the hard palate. • LANDMARKS - • Greater palatine foramen • Junction of the maxillary alveolar process and palatine bone • PATH OF INSERTION – advance the syringe from the opposite side of the mouth at a right angle to the target area. • ORIENTATION OF THE BEVEL – towards palatal soft tissues.
  36. 36. • Anatomically, this is generally 5 mm anterior to the junction of the hard and soft palates. Penetration will occur through the epithelium, and the needle will appear to ‘‘fall into’’ a space of less resistance. The needle should be inserted until bone is contacted. The depth of penetration is variable, but usually less than 5 mm is sufficient. After aspiration, 0.5mL of anesthetic solution is very slowly deposited. • Areas anesthesized : Posterior portion of the hard palate and overlying soft tissues anteriorly as far as the first premolar and medially to the midline. • COMPLICATION – • Rare hematoma • Ischemia and necrosis of soft tissues
  37. 37. Greater palatine nerve block
  38. 38. Maxillary Nerve Block • It is an effective method of achieving profound anesthesia of a hemi-maxilla. • Useful in procedures involving quadrant dentistry and in extensive surgical procedures. • INDICATIONS – • Pain control before extensive oral surgical, periodontal or restorative procedures requiring anesthesia of entire maxillary division. • When tissue inflammation or infection exceeds the use of another regional nerve block. • Diagnostic or therapeutic procedures for neuralgias.
  39. 39. • TECHNIQUES – HIGH TUBEROSITY APPROACH • AREA OF INSERTION – height of the mucobuccal fold above the distal aspect of the maxillary second molar. • TARGET AREA – maxillary nerve as it passes through the pterygopalatine fossa. • LANDMARKS – • Mucobuccal fold at the distal aspect of the maxillary second molar. • Maxillary tuberosity. • Zygomatic process of the maxilla. • The long 25 gauge needle is recommended with the bevel of the needle facing the bone. The needle is guided into the foramen to 30 mm.
  40. 40. • Subjective signs – pressure behind the upper jaw on the side being injected; this subsides rapidly, progressing to tingling and numbness of the lower eyelid, side of the nose and upper lip. • Subjective symptoms – sensation of numbness in the teeth and buccal soft tissues on the side of injection. • complications – • Risk of hematoma. • Arbitrary approach, over insertion is possible because of absence of bony landmarks if proper technique not followed.
  41. 41. Maxillary nerve block
  42. 42. Recommended volumes of local anesthetic for maxillary techniques Technique VOLUME, ml Posterior superior alveolar 0.9-1.8 Middle superior alveolar 0.9-1.2 Anterior superior alveolar 0.9-1.2 Greater palatine 0.45-0.6 Nasopalatine 0.45 Maxillary nerve block 1.8
  43. 43. Mandibular Injection Technique’s
  44. 44. IANB (INFERIOR ALVEOLAR NERVE BLOCK) • Also called mandibular nerve block. • Second most frequently used after infiltration. • For quadrant dentistry. NERVES ANESTHETIZED – • Inferior alveolar nerve. • Incisive, Mental and Lingual nerves.
  45. 45. • TECHNIQUE – 25 gauge long needle is preferred • AREA OF THE INSERTION – • mucous membrane on the medial side of the ramus • Target area – inferior alveolar nerve as it passes downward before entering the mandibular foramen. • LANDMARKS – • Coronoid notch • Pterygomandibular raphe • Occlusal plane of mandibular teeth
  46. 46. Traditionally, the IA injection is described with an insertion point 1.0 cm above the mandibular occlusal plane. IANB
  47. 47. • SIGNS AND SYMPTOMS – • Tingling or numbness – • Of the lower lip indicates anesthesia of the mental nerve. • Of the tongue indicates anesthesia of the lingual nerve. • PRECAUTIONS – • Do not deposit anesthesia when no bone contact • Do not contact bone forcefully • COMPLICATIONS – • Hematoma • Trismus • Transient facial paralysis
  48. 48. Incisive nerve block: • TECHNIQUES – 27 gauge short needle • Area of insertion – mucobuccal fold at or just anterior to the mental foramen • Target area – mental foramen through which the mental nerve exits and inside of which incisive nerve is located. • Landmarks – mandibular premolars and mucobuccal fold. • FAILURES OF ANESTHESIA – • Inadequate volume of anesthetic solution • Failure to achieve anesthesia of second premolar • COMPLICATIONS – • Hematoma • Paresthesia of lip and chin
  49. 49. Gow-Gates Mandibular (Open-Mouth) Nerve Block • George A. E. Gow-Gates first published this technique in 1973. • Significant advantages of the Gow-Gates technique over the IA nerve block include its higher success rate, it slower incidence of positive aspiration, and the absence of problems with accessory sensory innervation to the mandibular teeth. • The Gow Gates injection anesthetizes the inferior alveolar, lingual, auriculotemporal, buccal (75% of the time), and mylohyoid nerves.The injection blocks the nerves at a point that is proximal to their division into inferior alveolar, buccal, and lingual nerves.
  50. 50. Bennett C.R, Trigeminal Nerve. In: Monheim’s Local anaesthesia and pain control in dental practise.7:CBS;2010:26-53
  51. 51. The needle endpoint is the lateral aspect of the anterior portion of the condyle, just inferior to the insertion of the lateral pterygoid muscle. A 25-gauge long needle is inserted slowly to a depth of 25 to 30mm; the end point is inferior and lateral to the condylar head.
  52. 52. Gow Gates Mandibular anesthesia technique
  53. 53. Vazirani-Akinosi (Closed-Mouth) Nerve Block • In 1977, Dr. Sunder J. Vazirani and Dr. Joseph Akinosi reported on a closed mouth approach to mandibular anesthesia. • It is an intraoral approach to provide both anesthesia and motor blockade in cases of severe unilateral trismus. This injection is useful for patients with trismus because it is performed while the jaw is in the physiologic rest position • Other common names – Tuberosity technique.
  54. 54. Malamed Stanley, Techniques of mandibular anesthesia. In: Hand Book of Local Anesthesia.6:ELSEVEIR;2014:225-252 • This form of injection, also known as the closed mouth mandibular block, anesthetizes the inferior alveolar, lingual, buccal, and mylohyoid nerves. • A 25-gauge long needle is inserted parallel to the maxillary occlusal plane at the height of the maxillary buccal vestibule. • AREAS OF INSERTION – soft tissue in the lingual border of the mandibular ramus directly adjacent to the maxillary tuberosity at the height of the mucogingival injection adjacent to the maxillary third molar.
  55. 55. • TARGET AREA – soft tissue of the medial border of the ramus where they run towards the mandibular foramen. • The depth of insertion will vary with the anteroposterior size of the patient’s ramus.TheVazirani-Akinosi injection is performed ‘‘blindly’’ because no bony endpoint exists. However, in adult patients, a rule of thumb is that the hub of the needle should be opposite the mesial aspect of the maxillary second molar. • COMPLICATION – hematoma, trismus, facial nerve paralysis
  56. 56. Regional Anesthesia to Soft Tissue Mental Nerve Block : • this injection technique can be useful when bilateral anesthesia is desired for procedures on premolars and anterior teeth. • A 25- or 27-gauge short needle is inserted at the mucobuccal fold at or just anterior to the mental foramen, which is typically located between the apices of the 2 premolars • The difference between the mental nerve block and the incisive nerve block is that the incisive nerve block requires pressure to direct local anesthetic solution into the mental foramen.
  57. 57. • INDICATIONS – • soft tissue biopsies and suturing of soft tissues. • COMPLICATIONS – • Hematoma. • Paresthesia of lip/chin.
  58. 58. Buccal Nerve Block : • Also called long buccal nerve block and buccinator nerve block. • The buccal injection will anesthetize the buccal soft tissue lateral to the mandibular molars. • The needle is inserted into the tissue in the distobuccal vestibule opposite the second or third mandibular molar just medial to the coronoid notch until bone is contacted (approximately1to 3 mm), and 0.25 mL of anesthetic is deposited. • A 25 gauge long needle is recommended (because the injection usually follows an inferior alveolar nerve block, so the same needle can be used after more anesthetic is loaded).
  59. 59. • TECHNIQUES – 25 Gauge Needle • AREAS OF INSERTION – mucous membrane distal and buccal to the most distal molar tooth in the arch. • TARGET AREA – buccal nerve as it passes over the anterior border of the ramus. • LANDMARKS – mandibular molars, mucobuccal fold
  60. 60. • Direct the syringe, facing downward towards bone and parallel to the occlusal plane. • Penetrate the mucous membrane at the injection site, distal and buccal to the last molar. • INDICATIONS – • Scaling and curettage. • Placement of a rubber dam clamp on soft tissues. • Removal of subgingival caries. • Subgingival tooth preparation. • Placement of gingival retraction cord. • Placement of matrix bands. • DISADVANTAGES – painful if contacts the periosteum • COMPLICATIONS – Hematoma.
  61. 61. Lingual nerve block • The lingual nerve block will anesthetize the lingual gingiva, floor of the mouth, and tongue from the third molar anteriorly to the midline. This nerve may be anesthetized directly, by inserting the needle as in the IA to approximately 10mm and injecting.
  62. 62. Recommended volumes of local anesthetic solution for mandibular injection technique TECHNIQUE VOLUME,ml Inferior alveolar 1.5ml Buccal 0.3ml Mental 0.6ml Incisive 0.6 - 0.9ml Gow – Gates 1.8 - 3.0ml Vazirani – Akinosi 1.5 – 1.8ml
  63. 63. COMPUTER-CONTROLLED LOCAL ANESTHETIC DELIVERY SYSTEMS [CCLAD] • In 1997, a new delivery system using computer technology to control the rate and flow of anesthetic solutions evolved, and are called as computer controlled local anesthetic delivery systems. The first of them is the Wand, followed by Wand Plus and CompuDent.
  64. 64. • Fukayama et al. conducted a controlled clinical study evaluating pain perception of a CCLAD device. • They concluded that “the new system provides comfortable anesthesia for patients and can be a good alternative for conventional manual syringe injection.” • There are three modes of flow rate available: slow, fast and turbo mode. In 2001, the Comfort Control Syringe (Dentsply International, N. York, USA) was marketed as an alternative to the Wand and has two components; base unit and syringe and there is no foot pedal. • The most important functions of this unit is injection and aspiration can be controlled directly from the syringe. • Five different basic injection rate settings for specific applications, block, infiltration, PDL, IO and Palatal regions.
  65. 65. Single-Tooth Anesthesia [STA] In 2006, the manufacturers of the original CCLAD, the Wand, introduced a new device, Single Tooth Anesthesia (STA™) which incorporates dynamic pressure-sensing (DPS) technology that provides a constant monitoring of the exit pressure of the local anesthetic solution in real time during all phases of the drug’s administration.
  66. 66. JET INJECTORS Jet injection technology is based on the principle of using a mechanical energy source to create a pressure sufficient to push a liquid medication through a very small orifice, that it can penetrate into the subcutaneous tissues without a needle. Advantages are painless injection, less tissue damage, faster injection and faster rate of drug absorption into the tissues. Drawbacks are: it cannot be used for nerve blocks, only infiltration and surface anesthesia are possible.
  67. 67. VIBROTACTILE DEVICES These devices work on the principle of ‘gate control’ theory thereby reduces pain. It acts based on the fact that the vibration message is carried to brain through insulated nerves and pain message through smaller uninsulated nerves. The insulated nerves overrule the smaller uninsulated nerves. The devices are: VibraJect, Dental Vibe, Accupal.
  68. 68. • VibraJect has a battery operated device which is attached to the standard anesthetic syringe, causing the syringe and needle apparatus to vibrate. Nanitsos et al and Blair have recommended the use of VibraJect for painless injection. • Accupal is a cordless device which applies both vibration and pressure at the injection site.
  69. 69. Dental vibe • Dental Vibe is a cordless hand held device which gently stimulates the sensory receptors at the injection site causing the neural pain gate to close. • Advantage is, the tissues are vibrated before the needle penetrates. • Disadvantage is, it is not directly attached to the syringe and a separate unit is required, so both hands are engaged. • Dentalvibe and syringe micro vibrator uses micro- vibration to the site where an injection is being administered.
  70. 70. SAFETY DENTAL SYRINGES • Aim of these devices is to prevent from the risk of accidental needle stick injury occurring with a contaminated needle after local anesthesia administration. • These syringes possess a sheath that locks over the needle when it is removed from the patient’s tissues preventing accidental needle stick injury. • Eg are 1. Ultra safe syringe, 2. Ultra safety plus XL syringe, 3.hyposafety syringe, wand 5. Rev Vac safety syringe.
  71. 71. DENTIPATCH [INTRAORAL LIGNOCAINE PATCH] • Dentipatch contains 10-20% lidocaine, which is placed on dried mucosa for 15 minutes. • Hersh et al (1996) studied the efficacy of this patch and recommended it for use in achieving topical anesthesia for injections in both maxilla and mandible. • It is not recommended in children. Disadvantages include central nervous system and cardiovascular system complications.
  72. 72. Comfort Control Syringe • This syringe (Dentsply) is an electronic pre programmed anesthesia delivery device that uses a 2-stage delivery rate. • The rate of injection varies based on the injection technique chosen. • It begins with as low rate; the flow the increases to a pre programmed technique-specific rate selected by the dentist. • The operation of this syringe (initiation and termination of the injection, controlled aspiration and flow rate) is controlled by a button on the handpiece. • A disposable cartridges heath is required for each patient, but a standard dental needle and anesthetic cartridge can be used with this device.
  73. 73. Intranasal Local Anesthesia The major problem that remains is the patient’s fear of the needle. Phase 3 clinical trials on the use of a nasal spray to provide pulpal anesthesia to maxillary teeth are on going . Cocaine and tetracaine have been commonly used intranasally to provide anesthesia (both drugs) or vasoconstriction (cocaine only) prior to surgical procedures in otolaryngology in the extremely vascular nasal cavity or prior to passage of a tube through the nares .
  74. 74. Increasing comfort during injection • Warming • Buffering • Slow injection • Bevel of the needle • Needle guage
  75. 75. LOCAL ANESTHEISA COMPLICATIONS • An anesthetic complication is defined as – any deviation from the normally expected pattern during or after the securing of regional analgesia. • Complications may be further divided into two groups – • Those attributed to the solutions used. • Those attributed to the insertion of the needle.
  76. 76. COMPLICATION CAUSED BY THE INSERTION OF THE NEEDLE • NEEDLE BREAKAGE – extremely rare. • long dental needles are more prone to break. • Retrieval of the fragment with a hemostat is easily accomplished. • Bent needles • Defective needles • MANAGEMENT – • Remain calm, don’t explore • Have the patient keep opening wide and remove it if visible • Locate the retained fragment through computed tomographic scanning.
  77. 77. FACIAL NERVE PARALYSIS • Caused by local administration of local anesthesia into the capsule of parotid gland and damage to peripheral branches of facial nerve. • Overinsertion during closed mouth technique or inferior alveolar nerve block • Unilateral paralysis of facial muscles • MANAGEMENT – reassure the patient, contact lenses removed, and follow up
  78. 78. TRISMUS – • Tetanic spasm of the jaw muscles by which the normal opening of the mouth is restricted. • Causes – trauma to muscles or blood vessels • excessive volumes of local anesthesia deposited into a restricted area produce distention of tissues. • Contaminated solutions • Infection • MANAGEMENT – • Prevention • Heat therapy, warm saline rinses, analgesics, muscle relaxants • Diazepam (muscle relaxant)10mg twice daily • Chewing gum (lateral movement of temporomandibular joint) • Referred to oral surgeons for evaluation.
  79. 79. HEMATOMA – • Effusion of blood into extravascular spaces caused by nicking of a blood vessel during administration of local anesthesia. • MANAGEMENT – • If hematoma is visible apply direct pressure if possible • Once bleeding has stopped – instruct the patients • Apply ice for first 6 hrs and heat the next day • Analgesics prescribed • Discoloration expected and if it persists – treat as trismus
  80. 80. BURNING ON INJECTION - • pH of the solution deposited in the soft tissues • Plain LA has pH of 6.5 but 3.5 when vasoconstrictors are added. • Rapid injection of LA in dense area • Prevention – buffered solution uesd • Slow deposit of the solution
  81. 81. Conclusion: Due to the advancement of technology, many newer delivery systems for local anesthesia have evolved and the dental practitioners must be well aware of their usage and applications. The required armamentarium may be chosen according to the patient’s needs. Dentists must be well aware of these newer delivery systems, their usage and must have an up-to-date knowledge, so as to provide the benefits of latest technology to their patients. The ability to deliver painless injections and a desirable level and duration of anesthesia results in reduced patient fear, reduced patient stress and therefore reduced stress for the clinician and can aid patient compliance with dental treatment.
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  83. 83. 6. Malamed SF and Trieger N Intraoral Maxillary Nerve Block: an Anatomical and Clinical Study Anesthesia Progress 30: 44- 48, 1983 7. Poore, TE and Carney F Maxillary Nerve Block: A Useful Technique Journal of Oral Surgery 31: 749-755, 1973 8. Gow-Gates, GAE Mandibular Conduction Anesthesia: a New Technique Using Extraoral Landmarks Oral Surgery 36: 321-328, 1973 9. Akinosi JO, A New Approach to the Mandibular Nerve Block British Journal of Oral and Maxillofacial Surgery 15: 83- 87, 1977 10. Vazirani, SJ, Closed Mouth Mandibular Nerve Block: A New Technique Dental Digest 66: 10-13, 1960 11. Local Anesthesia in Pediatric Dentistry Nasopalatine Nerve Block . Course Author(s): Steven Schwartz, DDS
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  85. 85. Thank you ..