The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
00919248678078
2. INDIAN DENTAL ACADEMY
Leader in continuing dental education
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3. HISTORY
500’s: Coca leaves were first used by Peruvians for
psychotropic properties.
1850’s: German chemist Albert Niemann
successfully isolated the active principle of
coca leaf; he named it cocaine. Hypodermic
needle developed
1884: Sigmund Freud studied the effects of
cocaine.
1884: Carl Koller introduced cocaine into medical
practice.
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4. ….History
1884 : Local anesthesia used in dentistry by Halsted
and Hall
1905 : Procaine synthesized by Einhorn
1921: Cartridge syringe marketed by Cook
1947: Aspirating syringe developed
1948: Lidocaine marketed
1959: Disposable needle introduced
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5. DEFINITON.
“Loss of sensation in a circumscribed area of
the body caused by a depression of
excitation in nerve endings or an inhibition
of the conduction process in peripheral
nerves”
-(Grune & Straton-1976)
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6.
REGIONAL ANALGESIA: loss of pain sensation over
a portion of the anatomy without loss of
consciousness
REGIONAL ANESTHESIA: it applies not only to loss
of pain sensation over a specific area of anatomy
without loss of consciousness but also to the
interruption of all other sensations, including
temperature, pressure and motor function.
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20. MODE OF ACTION OF LOCAL
ANESTHETIC…
Local anesthetic agents interfere with excitation
process in a nerve membrane in one or more of the
following ways:
Altering basic resting potential
Altering the threshold potential
Decreasing the rate of depolarization
Prolonging the rate of repolarization
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21. THEORIES OF MECHANISM
OF ACTION OF L.A…
Ca2+ DISPLACEMENT THEORY
SURFACE CHARGE THEORY
(Wei-1969)
ACETYLCHOLINE THEORY
(Dett barn-1967)
MEMBRANE EXPANSION THEORY
SPECIFIC RECEPTOR THEORY
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(Goldman-1966)
(Lee-1976)
(Strichartz-1987)
28. RNH+ displaces calcium ions for the sodium channel receptor site.
↓ which causes
Binding of the local anesthetic molecules to this receptor site
↓ which produce
Blockade of sodium channel
↓ and
Decrease in sodium conduction
↓ which leads to
Depression of the rate of electrical depolarization
↓ and
Failure to achieve the threshold potential level
↓
Lack of development of propagated action potentials
↓ called
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Conduction blockade
34. UPTAKE
Oral route :
“Hepatic
first pass effect”. 72% Lignocaine.
Topical route:
Tracheal
mucosa. (lignocaine. Adrenaline, fumazenil).
Pharyngeal mucosa.
Esophageal or bladder mucosa.
Skin or oral mucosal.
Injection:
Activity
depends on:
Vascularity of the tissue.
Vasoactivity of the drug.
IV
caution. ( used in treatment of ventricular
dyrhythmias).
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35. DISTRIBUTION.
High conc seen in well purfused organs such as brain,
kidney, lungs, heart.
Level of drug in blood depend on:
Rate at which drug is absorbed into CVS.
Rate at which drug is distribute from vasculature to tissue.
Elimination of drug through excretion.
“Elimination half life.”
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37. EXCRETION.
Kidneys are the primary
excretory organs.
Less % of parent molecules
of ester anesthetics.
Large% of unchanged amide
parent molecules.
Renal impairment causes
accumulation of drug and its
metabolites causing toxity.
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40. CVS-Pathophysiology
Local anesthetics exert a lesser effect on the
cardiovascular system
eg. LIDOCAINE
Blood Level
Action Produced
1.8-5 ug/ml
- treat PVCs, tachycardia
5-10 ug/ml
- cardiac depression
>10 ug/ml
- severe depression,
bradycardia, vasodilatation, arrest
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41. MINIMAL TO MODERATE
OVERDOSE.
SIGNS
Talkativeness
Excitability
Apprehension
Slurred speech
Stutter( Muscular twitching /
tremors )
Euphoria
Dysarthria
Nystagmus
Sweating
Nausea/vomiting
Failure to follow commands / reason
Elevated BP
Elevated heart rate
Elevated resp rate
SYMPTOMS:
Light-headed and dizzy
Restless
Nervous
Numbness
Nervousness
Sensation of twitching (before
actual
twitching is observed)
Metallic taste
Visual disturbances
Auditory disturbances
Drowsy and disoriented
Losing consciousness
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42. MODERATE TO HIGH OVER
DOSE.
Generalized tonic-clonic seizure activity
followed by
Generalized CNS depression
Depressed BP, heart rate
Depressed respiratory rate
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43. LOCAL TISSUE TOXICITY.
RESPIRATORY SYSTEM.
MISCELLANEOUS.
Neuromuscular blockade.
Drug interactions.
Potentiates
the action the action of CNS depressants.
Prolongs the action of succinlycholine.
Malignant hyperthermia.
Thachycardia,
tachypnea, cynosis, unstable BP,
Respiratory and metabolic acidosis, fever.
Muscle rigidity and death
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44. FACTORS AFFECT THE REACTION OF
LOCAL ANESTHETICS
pKa:
Local anesthetics have two forms, ionized and nonionized. The
nonionized form can cross the nerve membranes and block the
sodium channels.
So, the more nonionized presented, the faster the onset action.
pH influence:
Usually at range 7.6 – 8.9
Decrease in pH shifts equilibrium toward the ionized form,
delaying the onset action.
Lipid solubility:
All local anesthetics have weak bases. Increasing the lipid
solubility leads to faster nerve penetration, block sodium channels,
and speed up the onset of action.
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45. Protein binding:
The more tightly local anesthetics bind to the protein, the longer
the duration of onset action.
Vasodilation:
Vasodilator activity of a local anesthetic leads to a faster
absorption and slower duration of action
Vasoconstrictor is a substance used to keep the anesthetic
solution in place at a longer period and prolongs the action of the
drug
vasoconstrictor delays the absorption which slows down the
absorption into the bloodstream
Vasoconstrictor used the naturally hormone called epinephrine
(adrenaline). Epinephrine decreases vasodilator.
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47. ADRENERGIC RECEPTORS
Ahlquist in 1948
Two types
Alpha (α) – vasoconstriction
α1 excitatory – post synaptic
α2 inhibitory – post synaptic.
Beta (β) - vasodilation and bronchodilation + cardiac
stimulation
β1 Found in heart & small intestines & responsible for cardiac
stimulation & lipolysis
β2 found in bronchi, vascular beds, & uterus & produces
bronchodilation and vasodilation
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48. EPINEPHRINE
Most potent and widely used vasoconstrictor in dentistry
Source: 80% of medullary secretion, also available as a synthetic
MOA- both α and β, with β being predominate
Systemic Effects of Epinephrine
Myocardium - ↑ heart rate & cardiac output
Pacemaker - ↑ risk of dysrhythmias
Coronary Artery-Dilation of coronary artery
B P- ↑ systolic pressure, effect on diastolic pressure is dose
related
Cardiovascular -Decrease cardiac efficiency
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49.
Vasculature
Vasoconstriction
in skin, mucous membrane &
kidneys
Vasodilation
in skeletal muscle in small doses
Respiratory - Bronchodilator
CNS - Not a potent CNS stimulant
Metabolism
Increase
oxygen consumption
Glycogenolysis-
↑ blood sugar
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50.
Termination of Epinephrine
COMT and MAO
Reuptake
Excreted unchanged in urine (1%)
Clinical Manifestations of Epinephrine Overdose
CNS stimulation - fear, anxiety, tremor, pallor, dizziness
Cardiac dysrhythmia
Ventricular fibrillation
Drastic increase in BP - can cause cerebral hemorrhage
Angina in patientswww.indiandentalacademy.com
with coronary insufficiency
51.
Maximum Dose for Dental Appointment
Normal healthy patient
0.2 mg. per appointment
Significant cardiovascular impairment
0.04 mg per appointment
Clinical Applications for Epinephrine
Acute allergic reaction
Bronchospasm
Cardiac arrest
Hemostasis
Produce mydriasis
Vasoconstrictor
Norepinephrine
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56. TOPICAL ANESTHETIC
Minimize sensation of needle penetrating the
soft tissue.
Used in greater concentration than LA in
order to penetrate the mucous membrane.
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57. TOPICAL ANESTHETIC AGENTS
Lidocaine
Benzocaine
14-20% liquid, gel
Onset 30 seconds
5% ointment, gel, liquid
Longer duration than the
others
Lower toxicity potential than
the others
Best one for Pedo although
some children say it feels
“hot”
10% metered spray
Onset 3-5 minutes
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59. RECOMMENDATIONS
For the administration of local dental anesthesia,
dentists should select aspirating syringes that meet
the standards of the ADA.
1.
2.
3.
4.
5.
Short needles may be used for any injection in which the
thickness of soft tissue is less than 20 mm
Long needle for a deeper injection into soft tissue.
Any 23- through 30-gauge needle may be used for intraoral
injections since blood can be aspirated through all of them;
however, aspiration can be more difficult when smaller gauge
needles are used.
An extra-short, 30-gauge is appropriate for infiltration
injections.
Needles should not be bent or inserted to their hub for
injections to avoid needle breakage.
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61.
Use sterile sharp needle.
Check the temperature of the local
anesthetic solution
Check the flow of local anesthetic solution.
Operator position.
Position the patient.
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63.
Establish a firm hand rest.
Make the tissue taut.
Keep the syringe out of the patients line of sight.
Orientation of the bevel.
Insert the needle into the mucosa.
Watch and communicate with the patient.
Inject several drops of solution
Slowly advance the needle to the target site.
Aspirate.
Slowly deposit the solution.
Communicate with the patient.
Slowly withdraw the syringe.
Observe the patient after injection.
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64.
Indications :
Contraindications :
Comparatively simple, safe technique
Minimized volume of solution
Minimized number of needle punctures
Disadvantages:
Discrete treatment areas (1-2 teeth only) Hemostasis
Bleeding problems (eg. hemophelia, etc..)
Advantages :
Anesthesia of more than two teeth
Supraperiosteal injections ineffective
Inflammation/infection contraindicating local infiltration
Vary according to the type of block.
Failure:
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74. LOCAL INFILTRATION
Areas anesthetized:
Indications:
Entire area innervated by the large terminal nerve branches
Tooth pulp and root area
Buccal periosteum
Mucous membrane and connective tissue
Pulpal anesthesia of one or two maxillary teeth
Soft tissue anesthesia when indicated
Hemostasis
Contraindications:
Infection or acute inflammation in the area
Dense bone covering apices of teeth
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75.
Advantages:
Disadvantages:
Not suitable for large areas
Multiple needle insertions
Large volumes of anesthetic solution
Percent Positive Aspiration:
High success rate (>95%)
Technically easy injection
Usually entirely atraumatic
Negligible, but possible (<1%)
Alternatives:
Periodontal ligament injection
Regional nerve block
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77.
Signs and Symptoms:
Safety Feature:
Numbness
Absence of pain during dental therapy
Minimum opportunity for intravascular
Administration
Failures of Anesthesia:
Needle tip below the apex of the tooth.
Needle too far from bone.
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78. POSTERIOR SUPERIOR
ALVEOLAR NERVE BLOCK
Nerve Anesthetized:
Posterior Superior Alveolar Nerve (PSA)
- for maxillary molars and buccal tissue
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81.
Indications for PSA Block:
Contraindication:
Atraumatic
High success rate
Less number of injections
Minimize amount of local used
Disadvantages:
Risk of hemorrhage is too great
(eg. hemophilia, coumadin)
Advantages:
First or second maxillary molar
Supraperiosteal injection is contraindicated
Risk of hematoma
Does not anesthetize first molar completel
No bony landmarks
Positive Aspiration :Approximately 3.1%
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82. Technique
25 gauge, long needle
Landmarks:
Maxillary tuberosity
Mucobuccal fold
Zygomatic process of maxilla
Area of Insertion :
Mucobuccal fold above maxillary second molar
Advance needle upward, inward and backward
Aspirate, inject 1.8 ml of solution
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83.
Failures of Anesthesia:
Needle not deep enough
Needle too lateral
Needle too far superior
Complications :
Hematoma
Mandibular anesthesia
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84. MIDDLE SUPERIOR ALVEOLAR
NERVE BLOCK
Nerve Anesthetized:
Middle Superior Alveolar Nerve
Areas Anesthetized:
Maxillary premolars and buccal tissues
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87.
Indications :
Contraindications :
Minimized number of injections
Minimized volume of solution
Disadvantage :
Infection /inflammation in area of injection
Advantage :
Anesthesia of maxillary premolars only
Infraorbital nerve block failure
MSA nerve is only present 28% of the time
Alternatives :
Local infiltration (supraperiosteal)
Periodontal ligament injection (PDL)
Infraorbital nerve block
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88. Technique - MSA
Landmarks / Area of Insertion :
Apply topical
Position patient and identify landmarks
Insert needle 5-10 mm
Aspirate
Inject 0.9 ml of solution, slowly
Signs and Symptoms:
Mucobuccal fold above second premolar
Apex of second premolar
Numb upper lip
Pain free dental therapy
Safety Features :
Anatomically safe (no signifcant structures)
Relatively avascular area
Positive aspirations - negligible (< 3%)
Complications are rare
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89.
Failures of Anesthesia:
Needle inserted too high, or not high enough
Deposition of solution too far laterally
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90. INFRAORBITAL NERVE BLOCK
Nerves Anesthetized:
Anterior Superior Alveolar Nerve
Middle Superior Alveolar Nerve
Superior Labial Nerve
Inferior Palpebral Nerve
Lateral Nasal Nerve
Areas Anesthetized:
Pulpal anesthesia of maxillary anterior teeth
Pulpal anesthesia of premolars and mesiobuccal root of first
molar
Buccal soft tissue and bone of same teeth
Lower eyelid, lateral nose, and upper lip
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95.
Indications :
Supraperiosteal injections ineffective
Anesthesia of more than two maxillary teeth
Inflammation/infection contraindicating local
infiltration
Contraindications :
Discrete treatment areas (1-2 teeth only)
Hemostasis
Bleeding problems (eg. hemophelia, etc..)
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96.
Advantages :
Disadvantages:
Comparatively simple, safe technique
Minimized volume of solution
Minimized number of needle punctures
Psychological
Administrator- fear of eye involvement
Patient- apprehension of extraoral approach
Anatomical-Difficulty defining landmarks
Alternatives:
Supraperiosteal injection for each tooth
Maxillary nerve block
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97. Technique
Apply topical
Position patient and identify landmarks
Landmarks :
Mucobuccal fold above first premolar
Infraorbital notch
Infraorbital foramen
Area of Insertion :
Mucobuccal fold above first premolar
Target area
Infraorbital foramen
Neurovascular bundle
Insert needle to upper rim of infraorbital foramen
Aspirate
Inject 0.9 ml of solution, slowly
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98.
Signs and Symptoms :
Numbness in teeth and soft tissues
Tingling and numbness of lower eyelid, side of
nose, and upper lip
No pain during dental therapy
Safety Features :
Needle contacting bone
Finger over infraorbital foramen
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99. Failures of Anesthesia
Bone contact below infraorbital foramen
Needle deviates laterally or medially
Complications :
Hematoma (rare)
Positive aspirations - 0.7 %
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105. GREATER PALATINE NERVE
BLOCK
Anterior Palatine Nerve
Areas anesthetized:
Indications
Pain control in posterior palatal hard and/or soft tissues
Contraindications
Posterior portion of hard palate and overlying soft tissues
Anteriorly to 1st premolar
Medially to midline
Inflammation / infection at injection site
Only small area necessary (eg. 1-2 teeth)
Advantages
Minimizes penetrations and discomfort
Minimizes volume of solution (0.5 ml)
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106. Greater Palatine Nerve Block
Disadvantages
Alternatives:
Local infiltration in each area
Maxillary Nerve Block
Aspiration:
Limited hemostasis
Potentially traumatic
< 1% positive
Landmarks
Greater palatine foramen
Junction of alveolus and palatine bone
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107. Greater Palatine Nerve Block
Area of Insertion
Precautions
Position - open wide, extend & turn head
Cotton swab - identify landmarks, topical
Approach - bevel to tissue, advance to bone
Aspirate; inject 0.5 ml slowly
Failure:
Bone contacted; aspiration
Technique
Numb posterior palate; painfree treatment
Safety features
Do not enter canal
Signs & symptoms
Soft tissue anterior to foramen, from opposite side
Overlap of fibers from Nasopalatine nerve
Injection too anterior
Complications:
Soft tissue ischemia / necrosis
Post injection pain, hematoma
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111. Nasopalatine Nerve Block
Indications:
Pain control in anterior hard and/or soft tissues
Contraindications:
Inflammation / infection at injection site
Only small area necessary (eg. 1-2 teeth)
Advantages:
Minimizes needle penetrations
Minimizes volume of solution (0.4 ml)
Disadvantages:
Limited hemostasis
Potentially traumatic
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112. Nasopalatine Nerve Block
Alternatives
Local infiltration
Maxillary Nerve Block
Aspiration
< 1% positive
Precautions
Do not inject directly into papilla/canal
Inject slowly, with small volume
Signs / symptoms
Numb anterior palate; painfree treatment
Safety features
Bone contacted; aspiration
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113. Nasopalatine Nerve Block
Technique
Landmarks - incisive papilla, central incisors
Approach - lateral to incisive papilla, starting with cotton swab, topical
Position - open wide, extend head
Deposit approx. 0.4 ml / 30 sec
Failure
May be only unilateral
May have overlap with Greater Palatine
Complications
Ischemia, tissue necrosis
Others rare
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115. MANDIBULAR ANESTHESIA
Lower success rate than Maxillary anesthesia
Related to bone density
Less access to nerve trunks.
Success depends on depositing solution within 1 mm
of nerve trunk
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120. Inferior Alveolar Nerve Block
Technique
Apply topical
Area of insertion:
medial ramus, mid-coronoid notch,
level with occlusal plane (1 cm above),
3/4 posterior from coronoid notch to pterygomandibular raphe
advance to bone (20-25 mm)
Target Area
Inferior alveolar nerve, near mandibular foramen
Landmarks
Coronoid notch
Pterygomandibular raphe
Occlusal plane of mandibular posteriors
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121. Inferior Alveolar Nerve Block
Precautions
Do not inject if bone not contacted
Avoid forceful bone contact
Failure of Anesthesia
Injection too low
Injection too anterior
Accessory innervation
-Mylohyoid nerve
-contralateral Incisive nerve innervation
Complications
Hematoma
Trismus
Facial paralysis
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132. Mental Nerve Block
Terminal branch of IAN as it exits mental foramen
Provides sensory innervation to buccal soft tissue
anterior to mental foramen, lip and chin
Indication
Contraindication
Infection/inflammation at injection site
Advantages
Need for anesthesia in innervated area
Easy, high success rate
Usually atraumatic
Disadvantage
Hematoma
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136. Incisive Nerve Block
Terminal branch of IAN
Originates in mental foramen and proceeds
anteriorly
Good for bilateral anterior anesthesia
Not effective for anterior lingual anesthesia
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137. Incisive Nerve Block
Nerves anesthetized
Areas Anesthetized
Lack of lingual or midline anesthesia
Complications
High success rate
Pulpal anesthesia w/o lingual anesthesia
Disadvantages
Infection/inflammation at injection site
Advantages
Anesthesia of pulp or tissue required anterior to mental foramen
Contraindication
Mandibular labial mucous membranes
Lower lip / skin of chin
Incisor, cuspid and bicuspid teeth
Indication
Incisive
Mental
Hematoma
Positive aspiration
5.7 %
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144. Local Complications
Needle breakage
Trismus
Pain on injection
Hematoma
Burning on injection
Infection
Persistent anesthesia
or paresthesia
Edema
Sloughing of tissues
Lip chewing
Facial nerve paralysis
Post-anesthetic
intraoral lesions
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145. NEEDLE BREAKAGE
Causes
Prevention
Unexpected movement
Small needle size
Bent needles
Defective needles
Use large needles
Use long needles for deep injection,>18mm
Never insert to hub
Redirect only when adequately withdrawn
Management
Remain calm
Don't explore
Have the patient keep opening wide
If the needle is out remove it
Refer to an Oral Surgeon
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161. ALLERGIC REACTIONS
Not dose related
May be systemic or localized
Unrelated to pharmacological effects
Exaggerated immune system response
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162. IDIOSYNCRACY REACTION
Unexplained by any known mechanism of the
drug’s action
Neither overdose nor allergic reaction
Unpredictable; treat symptoms
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163. CAUSE OF OVERDOSE LEVELS
Total dose is too large
Absorption is too rapid
Intravascular injection
Biotransformed too slowly
Eliminated too slowly
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164. INTRAVASCULAR INJECTION
Occurrence varies with type of injection:
Nerve Block
% positive aspirate
Inf. alveolar
11.7
Mental/Incisive
5.7
Post. sup. alv.
3.1
Ant. sup. alv./ Buccal
<1
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171. ALLERGIC REACTIONS
Type Mechanism
Time Clinical Example
I Antigen induc. sec/min Angioedema,
Anaphylaxis
IV Cell mediated
48 hrs
Contact
dermatitis
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172. ALLERGENS IN LOCAL
Esters - usually to the Para-amino-benzoicacid product
Na bisulfite or metabisulfite - found in
anesthetics as perservative for
vasoconstrictors
Methylparaben - no longer used as
perservative in dental cartridges
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174. PRIOR TO TREATMENT
Complete review of medical status
(including vital signs)
Anxiety / Fear should be assessed and
managed before administering anesthetic
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175. ADMINISTRATION OF ANESTHETIC
Place pt. supine or semi-supine position
Dry site, apply topical X 1 min
Select appropriate drug for treatment (time)
Vasoconstrictor unless contraindicated
Weakest anesthetic in the minimum volume
(compatible with successful anesthesia)
Inject slowly (minimum of 60 sec / 1.8 ml)
Continually observe Never leave patient alone after injection
Use only aspirating syringe
Aspirate in two planes, before injecting
Use sharp, disposable needles of adequate diameter and length
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177. Use with Sedative Drugs
With conscious sedation, especially narcotics,
decrease dosage of both local anesthetic and
the sedative drug to avoid toxicity (additive
depressant effect).
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178. Recommended Dosage Levels
2% lidocaine - 2 mg/lb
2% lidocaine 1/100,000 epi - 2 mg/lb
2% carbocaine 1/20,00 neocobefrin - 2 mg/lb
In general, 2 mg/lb WITH or WITHOUT
vasoconstrictor
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179. Delivery Methods
Aspirating Syringe
ALWAYS ASPIRATE!!!
Loading the syringe
Place carpule in syringe. Engage harpoon. Place
needle on syringe and puncture carpule.
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180. Delivery Methods
Air Jet Syringe
LA injected at pressure of ~2000 psi
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181. Use of Topical
Benzocaine is best.
Allow at least one minute for application
(onset in 30 seconds).
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182. GENERAL TECHNIQUES
Use of Assistant
Assistant should be ready at all times to
restrain hands.
Assistant can help block view and keep patient
distracted.
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183. General Techniques
Body Control
Operator should be in
control of patient's
head - it may move
suddenly!!
Hands - at side, in
pockets, sit on them,
hold belly button.
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184. General Techniques
Syringe Management and Etiquette
HIDE IT!!!
Pass behind or over patient.
Block patient's view with your retracting
hand.
BE CONFIDENT.
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187. DISTRACTION
Verbal - chitter-chatter
(talk about anything)
Overwhelm patient with
stimulus
Pull on cheek, touch
face
Keep things moving
Pulling the tissue taut as
the needle enters makes
the procedure less
painful
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190. ANATOMIC DIFFERENCES
Mandible
Ramus is shorter vertically and
narrower anteroposteriorly.
Mandibular foramen is lower than in adult
(may be below occlusal plane
in < 4yo).
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191. SPECIFIC INJECTION SITES
FOR CHILDREN MANDIBLE
Inferior alveolar block - Injection site is
lower and more posterior.
Do not need to penetrate tissue as far as in
adult.
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192. Anesthesia Technique
Occasionally the mylohyoid will
have accessory innervation to the
mandibular molar. Infiltrate on
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the lingual.
193. SPECIFIC INJECTION SITES FOR CHILDREN
MANDIBLE
BILATERAL INFERIOR ALVEOLAR BLOCKS
SHOULD NOT BE ADMINISTERED TO
CHILDREN.
Bilateral blocks greatly increase the chance
of post anesthesia trauma
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194. SPECIFIC INJECTION SITES
FOR CHILDREN MANDIBLE
Extractions
Infiltration works in mandibular anterior
although block may be best for posterior
extractions (look at root length and
difficulty level).
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195. SPECIFIC INJECTION SITES
FOR CHILDREN MANDIBLE
Infiltration
Used effectively for incisor and canine
restorations.
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196.
BUCCAL NERVE BLOCK:
SUBMUCOSAL INFILTRATION
FIELD BLOCK
MENTAL NERVE BLOCK :
TARGET:
Mesio buccal fold apical to prim 1 and 2 molar
Inter-radicular area of 1 and 2 premolar
NEEDLE PENETRATION: just anterior to mental foramen
RULE OF 20: AGE OF CHILD X NO. OF TOOTH
4 X 4 = 16
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197. SPECIFIC INJECTION SITES
FOR CHILDREN MAXILLA
Apices of primary anterior teeth are at depth
of mucobuccal fold.
Inject at depth of mucobuccal fold.
Short or extra-short needle.
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198. SPECIFIC INJECTION SITES
FOR CHILDREN MAXILLA
Primary teeth and premolars - infiltrate
Permanent molars - PSA, MSA
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199.
FOR PRIMARY ANTERIOR TEETH:
Inj made close to gingival margin
Needle penetration: muco-buccal fold
FOR PERMANENT INCISORS:
Inj made close to muco-buccal fold
Small amount of sol deposited at apex
of opposite side of incisor
FOR FIRST PRIMARY MOLAR:
Bone is thin – sol deposited at apices of root
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200.
FOR SECOND PRIMARY MOLAR:
Dense overlying bone – suprapeiosteal inj ineffective
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201.
FOR ASA:
LANDMARK: loose alv tissue superior to max canine
FOR MSA:
LANDMARK: loose alv tissue apical to first prim molar or first premolar
For perm first molar and second prim molar – additional PSA block reqd
FOR PSA:
LANDMARK: red, loose alv tissue, apical to most post erupted molar tooth distal to zygomatic process
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202. NASOPALATINE NERVE BLOCK:
Penetration site: MM lateral to incisive papilla
TWO WAYS:
INTERDENTAL PAPILLARY APPROACH
USE OF PRESSURE-TOPICAL ANESTHETIC
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203. GREATER PALATINE NERVE
BLOCK
IN A CHILD WITH PRIMARY DENTITION: inj 10mm
post to distal surface of second primary molar
ALTERNATIVES:
BLANCHING TARGET AREA
INTRAPAPILLARY INJECTION
0.2-0.3 ml of sol is deposited
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204. Specific Injection Sites for
Children Maxilla
Primary molars (same as premolars) - Inject
over primary first molar.
Primary second molar may have innervation
from posterior superior alveolar nerve.
Inject behind tuberosity.
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205. Specific Injection Sites for
Children Maxilla
Permanent molars - PSA injection - Inject
behind tuberosity.
Also inject over MB root of permanent first
molar to anesthetize MSA.
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206. Specific Injection Sites for Children
Maxilla
Interdental papilla - To achieve palatal
anesthesia. Inject as go through
papilla from facial to lingual. Should see
blanching as inject.
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207. DO
BE CONFIDENT
Use good syringe etiquette
Keep talking
Maintain hand and head control
Have assistant stay alert
Shield and distract vision of the recipient and
neighbors.
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212. POST-ANESTHESIA
TRAUMA
Prevention:
Remind
both parent and child that area will remain
numb after the appointment.
Caution
that child should not to chew, bite or pick
at area. Extremely important for young children
and "first timers".
Sometimes
placing a cotton roll between the teeth
will help remind patient not to chew.
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213. CALCULATION OF MG. OF LOCAL
ANESTHETIC PER CARTRIDGE
2% solution = 20 mg/ml
Volume of cartridge = 1.8 ml
So for a 2% solution:
20mg/ml x 1.8 ml/ cartridge = 36.0 mg/ cartridge
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214. CALCULATION OF MG. OF LOCAL
ANESTHETIC PER CARTRIDGE
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215. CALCULATION OF MG. OF
VASOCONSTRICTOR PER CARTRIDGE
1:20,000 concentration = 0.05 mg/ml
Volume of cartridge = 1.8 ml
So for a 1:20,000 concentration:
0.05mg/ml x 1.8 ml/ cartridge = 0.09 mg/ cartridge
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216. Mg/Ml VALUES OF
CALCULATION OF MG. of
VASOCONSTRICTORS VASOCONSTRICTOR
PER CARTRIDGE
CONCENTRATION
Mg/Ml
VOLUME OF
CARTRIDGE
Mg PER
CARTRIDGE
1:1,000
1.0
1.8
1.8
1:2,500
0.4
1.8
.72
1:10,000
0.1
1.8
.18
1:20,000
0.05
1.8
.09
1:30,000
0.033
1.8
.06
1:50,000
0.02
1.8
.036
1:100,000
0.01
1.8
.018
1:200,000
0.005
1.8
.009
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221. pH ALTERATIONS
Alkalinization - ↑ RN:
Sodium
bicarbonate.
Rapid onset of action.
Carbonation :
Helps
in the rapid diffusion of local anesthetic through
the nerve membranes.
Decreases intracellular pH traps RNH+ in the cell.
Anesthetic drug must be administered immediately after
preparing the syringe.
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222. HYALURONIDASE
Breaks down intercellular cement.
Added to the anesthetic cartridge just before administering
the LA.
Causes rapid onset of anesthesia.
Allergic reactions have been reported.
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223. ULTRA –LONG ACTING LOCAL
ANESTHETICS
Biotoxins:
Tetradotoxin -puffer fish
saxitoxin -dinoflagelates.
Block Na channels of nerve membrane.
250,000 as potent as procaine.
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225.
Contraindications
Cardiac pacemakers
Neurological disorders
Pregnancy
Immaturity (in ability to understand) the concept of patient control of pain)
Very young pediatric patient
Older patients with senile dementia
Language communication difficulties
Advantages
No injection of drug
Patient is in control of the anesthesia
No residual anesthetic effect at the end of procedure
No needle
Residual analgesic effect remain for several hours
Disadvantages
Cost of the unit
Training
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Intra oral electrodes – weak link in the entire system.
230. REFERENCES.
Hand book of local anesthesia ………………………….5th ed Stanley F. Malamed.
Monheim’s Local anesthesia and pain control in dental practice….. 7 th ed.
Clinical Guideline on Appropriate Use of Local Anesthesia for Pediatric
Dental Patients ……………………………..……………. AAPD Reference manual 2005
Pediatric dentistry infancy through adolescence………….…. 4 th ed Pinkham.
Dentistry for child and adolescent……………………………….… 8 th ed McDonald.
Pediatric dentistry total patient care …………….……………Stephen H. Y. Wei.
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