LOCAL ANESTHESIA IN
DENTISTRY

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INDIAN DENTAL ACADEMY
Leader in continuing dental education
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HISTORY


500’s: Coca leaves were first used by Peruvians for
psychotropic properties.



1850’s: German chemist Albert ...
….History


1884 : Local anesthesia used in dentistry by Halsted
and Hall



1905 : Procaine synthesized by Einhorn



...
DEFINITON.
“Loss of sensation in a circumscribed area of
the body caused by a depression of
excitation in nerve endings or...


REGIONAL ANALGESIA: loss of pain sensation over
a portion of the anatomy without loss of
consciousness



REGIONAL ANE...
CLASSIFICATION

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BASED ON CHEMICAL STRUCTURE



ESTERS:



Benzoic acid esters:

AMIDES:


Articaine





Bupivacaine





Benzocai...
STRUCTURES OF AMIDES
AND ESTERS
R3
Ester:

R1 —COO—R —N
2
R4
R3

Amide:

R 1 —NHCO—R —N
2
R4

R1 — Lipophilic aromatic res...
Based on biological site and mode of action
Class A
Class BClass CClass D

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Based on the source
Natural

Synthetic

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Others
Based on duration of action
Short



eg: Lidocaine HCl 2%, Mepivacaine HCl 3%

Intermediate duration –




Long

Short ...
Based on mode of application
Topical

Injectable

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NEROPHYSIOLOGY

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MODE OF ACTION OF LOCAL
ANESTHETIC…
Local anesthetic agents interfere with excitation
process in a nerve membrane in one o...
THEORIES OF MECHANISM
OF ACTION OF L.A…


Ca2+ DISPLACEMENT THEORY



SURFACE CHARGE THEORY

(Wei-1969)



ACETYLCHOLIN...
ACETYL CHOLINE THEORY

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MEMBRANE EXPANSION
THEORY

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SPECIFIC RECEPTOR THEORY

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CHEMICAL REACTON OF LA
RNHOH + HCl  RNHCl + H2O
Weak strong
acid
water
Base
acid
salt
RNHCl  RNH+ + CI-

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EFFECT OF PH
Basic environment (higher pH)
RNH+ > RN + H+
Acidic environment (low pH)
RNH+ < RN + H+

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RNH+ displaces calcium ions for the sodium channel receptor site.
↓ which causes
Binding of the local anesthetic molecules...
HENDERSON – HASSELBALCH EQUATION



Log Base

=

pH – pKa

Acid

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INDIVIDUAL LOCAL ANESTHETIC
AGENTS…
Drug

pka

ph

Conc

Onset

½ life

2-4%

6-10 min

½ hr

used
Procaine

9.1

5-6.5
3....
PHARMACOKINETICS

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UPTAKE


Oral route :
 “Hepatic



first pass effect”. 72% Lignocaine.

Topical route:
 Tracheal

mucosa. (lignocaine....
DISTRIBUTION.


High conc seen in well purfused organs such as brain,
kidney, lungs, heart.



Level of drug in blood de...
BITRANSFORMATION.


Esters:







Amides:









Pseudocholinesterase.
Succinylcholine.
Atypical pseudo cho...
EXCRETION.


Kidneys are the primary
excretory organs.



Less % of parent molecules
of ester anesthetics.



Large% of...
SYSTEMIC ACTIONS.


CNS.



CVS.



LOCAL TISSUE TOXICITY.



RESPIRATORY SYSTEM.



MISCELLANEOUS.


Neuromuscular ...
CNS-Pathophysiology
Local anesthetics cross blood-brain barrier, producing
CNS depression as level rises
eg. LIDOCAINE
Blo...
CVS-Pathophysiology
Local anesthetics exert a lesser effect on the
cardiovascular system
eg. LIDOCAINE
Blood Level

Action...
MINIMAL TO MODERATE
OVERDOSE.
SIGNS
Talkativeness
Excitability
Apprehension
Slurred speech
Stutter( Muscular twitching /
t...
MODERATE TO HIGH OVER
DOSE.
Generalized tonic-clonic seizure activity
followed by
Generalized CNS depression
Depressed BP,...
LOCAL TISSUE TOXICITY.
 RESPIRATORY SYSTEM.
 MISCELLANEOUS.


Neuromuscular blockade.
 Drug interactions.


 Potenti...
FACTORS AFFECT THE REACTION OF
LOCAL ANESTHETICS
pKa:
 Local anesthetics have two forms, ionized and nonionized. The
noni...
Protein binding:


The more tightly local anesthetics bind to the protein, the longer
the duration of onset action.

Vaso...
VASOCONSTRICTORS


Decrease blood flow



Lower anesthetic blood levels



Decrease the risk of toxicity



Increases ...
ADRENERGIC RECEPTORS


Ahlquist in 1948



Two types


Alpha (α) – vasoconstriction





α1  excitatory – post syna...
EPINEPHRINE


Most potent and widely used vasoconstrictor in dentistry



Source: 80% of medullary secretion, also avail...


Vasculature
 Vasoconstriction

in skin, mucous membrane &

kidneys
 Vasodilation

in skeletal muscle in small doses

...


Termination of Epinephrine



COMT and MAO





Reuptake

Excreted unchanged in urine (1%)

Clinical Manifestations...


Maximum Dose for Dental Appointment


Normal healthy patient
0.2 mg. per appointment



Significant cardiovascular im...
ARMAMENTARIUM

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SYRINGE

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NEEDLE

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ANESTHETIC SOLUTION

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TOPICAL ANESTHETIC


Minimize sensation of needle penetrating the
soft tissue.



Used in greater concentration than LA ...
TOPICAL ANESTHETIC AGENTS
Lidocaine

Benzocaine



14-20% liquid, gel
Onset 30 seconds





5% ointment, gel, liquid

...
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RECOMMENDATIONS


For the administration of local dental anesthesia,
dentists should select aspirating syringes that meet...
BASIC INJECTION
TECHNIQUE
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

Use sterile sharp needle.



Check the temperature of the local
anesthetic solution



Check the flow of local anesth...
Dry the tissue.
Apply topical antiseptic.
Apply topical anesthetic.

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













Establish a firm hand rest.
Make the tissue taut.
Keep the syringe out of the patients line of ...


Indications :






Contraindications :








Comparatively simple, safe technique
Minimized volume of solut...
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TECHNIQUES
OF
LOCAL ANESTHESIA

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TECHNIQUES
OF
MAXILLARY ANESTHESIA

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LOCAL INFILTRATION
FIELD BLOCK
NERVE BLOCK

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MAXILLARY INJECTION
TECHNIQUES


Supraperiosteal



Periodontal ligament



Intraseptal injection



Posterior superio...
LOCAL INFILTRATION

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LOCAL INFILTRATION


Areas anesthetized:







Indications:






Entire area innervated by the large terminal ...


Advantages:






Disadvantages:






Not suitable for large areas
Multiple needle insertions
Large volumes of...
Technique


Apply topical



Landmarks:


Mucobuccal fold.



Long axis of tooth.



Insert needle: At height of muco...


Signs and Symptoms:





Safety Feature:





Numbness
Absence of pain during dental therapy

Minimum opportunity...
POSTERIOR SUPERIOR
ALVEOLAR NERVE BLOCK
Nerve Anesthetized:
Posterior Superior Alveolar Nerve (PSA)
- for maxillary molars...
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

Indications for PSA Block:





Contraindication:








Atraumatic
High success rate
Less number of injection...
Technique


25 gauge, long needle



Landmarks:



Maxillary tuberosity





Mucobuccal fold
Zygomatic process of ma...


Failures of Anesthesia:



Needle not deep enough





Needle too lateral
Needle too far superior

Complications :
...
MIDDLE SUPERIOR ALVEOLAR
NERVE BLOCK


Nerve Anesthetized:




Middle Superior Alveolar Nerve

Areas Anesthetized:


M...
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

Indications :





Contraindications :






Minimized number of injections
Minimized volume of solution

Disadva...
Technique - MSA


Landmarks / Area of Insertion :










Apply topical
Position patient and identify landmarks...


Failures of Anesthesia:


Needle inserted too high, or not high enough



Deposition of solution too far laterally

w...
INFRAORBITAL NERVE BLOCK


Nerves Anesthetized:








Anterior Superior Alveolar Nerve
Middle Superior Alveolar N...
NERVES ANESTHETIZED

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AREAS ANESTHETIZED

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

Indications :



Supraperiosteal injections ineffective





Anesthesia of more than two maxillary teeth
Inflammati...


Advantages :






Disadvantages:







Comparatively simple, safe technique
Minimized volume of solution
Min...
Technique




Apply topical
Position patient and identify landmarks
Landmarks :






Mucobuccal fold above first p...


Signs and Symptoms :




Numbness in teeth and soft tissues





Tingling and numbness of lower eyelid, side of
nos...
Failures of Anesthesia
Bone contact below infraorbital foramen
Needle deviates laterally or medially
Complications :
Hemat...
ANTERIOR MIDDLE SUPERIOR
ALVEOLAR NERVE BLOCK.

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PALATAL ANESTHESIA

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NERVES ANESTHETIZED.

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GREATER PALATINE NERVE
BLOCK



Anterior Palatine Nerve
Areas anesthetized:






Indications




Pain control in ...
Greater Palatine Nerve Block


Disadvantages





Alternatives:





Local infiltration in each area
Maxillary Nerv...
Greater Palatine Nerve Block


Area of Insertion




Precautions








Position - open wide, extend & turn head
...
NASOPALATINE NERVE
BLOCK

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Nasopalatine Nerve Block


Indications:




Pain control in anterior hard and/or soft tissues

Contraindications:



...
Nasopalatine Nerve Block


Alternatives





Local infiltration
Maxillary Nerve Block

Aspiration




< 1% positive
...
Nasopalatine Nerve Block


Technique



Landmarks - incisive papilla, central incisors



Approach - lateral to incisi...
TECHNIQUES
OF
MANDIBULAR ANESTHESIA

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MANDIBULAR ANESTHESIA


Lower success rate than Maxillary anesthesia



Related to bone density



Less access to nerve...
MANDIBULAR NERVE BLOCKS


INFERIOR ALVEOLAR



BUCCAL



LINGUAL



MENTAL - INCISIVE



GOW-GATES



AKINOSI

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INFERIOR ALVEOLAR NERVE
BLOCK


Not a complete mandibular nerve block.



Requires supplemental buccal nerve block



M...
Inferior Alveolar Nerve Block


Indications



Buccal anterior soft tissue





Multiple mandibular teeth
Lingual ane...
Inferior Alveolar Nerve Block


Alternatives


Mental nerve block



Incisive nerve block



Anterior infiltration


...
Inferior Alveolar Nerve Block
Technique
Apply topical
Area of insertion:
medial ramus, mid-coronoid notch,
level with occl...
Inferior Alveolar Nerve Block
Precautions
Do not inject if bone not contacted
Avoid forceful bone contact
Failure of Anest...
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Long Buccal Nerve Block





Anterior branch of Mandibular nerve (V3)
Provides buccal soft tissue anesthesia adjacent ...
Buccal Nerve Block
Alternatives
Buccal infiltration
Gow-Gates
PDL
Intraseptal

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Buccal Nerve Block


Technique






Apply topical
Insertion distil and buccal to last molar
Target - Long Buccal ne...
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Mental Nerve Block




Terminal branch of IAN as it exits mental foramen
Provides sensory innervation to buccal soft ti...
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INFILTRATION

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Incisive Nerve Block
Terminal branch of IAN     
Originates in mental foramen and proceeds
anteriorly
Good for bilateral a...
Incisive Nerve Block


Nerves anesthetized





Areas Anesthetized








Lack of lingual or midline anesthesia
...
ALTERNATIVE INJECTION
TECHNIQUES.

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INTRAPULPAL

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INTRASEPTAL

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INRA OSSEOUS

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COMPLICATIONS
IN
ANESTHESIA
ADMINISTRATION
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LOCAL COMPLICATIONS
IN
ANESTHESIA
ADMINISTRATION
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Local Complications


Needle breakage



Trismus



Pain on injection



Hematoma



Burning on injection



Infecti...
NEEDLE BREAKAGE


Causes







Prevention







Unexpected movement
Small needle size
Bent needles
Defective ...
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PAIN ON INJECTION


Causes



Dull needles



Rapid deposit of solution





Careless technique

Needles with barbs
...
BURNING ON INJECTION


Causes


pH of solution



Rapid injection



Contamination



Warmed solutions

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PERSISTENT ANESTHESIA
OR PARESTHESIA


Causes







Prevention




Trauma to nerve
Hematoma
Neurolytic agents (al...
TRISMUS


Causes








Prevention








Trauma to muscles or blood vessels
Contaminated anesthetic soluti...
HEMATOMA



The effusion of blood into extravascular spaces
Prevention









Care with needle placement
Minimi...
INFECTION


Causes







Prevention






Needle contamination
Improper handling of armamentarium
Infection at ...
EDEMA


Causes



Infection



Allergy



Hemorrhage





Trauma during injection

Irritating solutions

Management...
SLOUGHING OF TISSUE


Causes





Topical anesthetic
Prolonged ischemia

Management


Observation



Documentation

...
LIP CHEWING


Management


Analgesics



Antibiotics



Saline rinses



Lip lubricants

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FACIAL NERVE PARALYSIS


Cause: Anesthesia of peripheral Facial nerve branches



Prevention



Avoid over penetration...
POST ANESTHETIC
INTRAORAL LESIONS
Recurrent apthous
Herpes Simplex

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SYSTEMIC
COMPLICATIONS

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ADVERSE DRUG REACTIONS


Direct extensions of usual effects






Altered recipient







Side effects
Overdose...
OVERDOSE


Dose related



Systemic distribution



Extension of pharmacologic effects



Selective CNS or CVS depress...
ALLERGIC REACTIONS


Not dose related



May be systemic or localized



Unrelated to pharmacological effects



Exagg...
IDIOSYNCRACY REACTION


Unexplained by any known mechanism of the
drug’s action



Neither overdose nor allergic reactio...
CAUSE OF OVERDOSE LEVELS


Total dose is too large



Absorption is too rapid



Intravascular injection



Biotransfo...
INTRAVASCULAR INJECTION
Occurrence varies with type of injection:
Nerve Block

% positive aspirate

Inf. alveolar

11.7

M...
CLINICAL
MANIFESTATIONS
of
OVERDOSE

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Minimal to Moderate
SIGNS
Talkativeness
Excitability
Apprehension
Slurred speech
Stutter( Muscular twitching /
tremors )
E...
Moderate to High
Generalized tonic-clonic seizure activity
followed by
Generalized CNS depression
Depressed BP, heart rate...
Pathophysiology
Local anesthetics cross blood-brain barrier, producing
CNS depression as level rises
eg. LIDOCAINE
Blood L...
Pathophysiology
Local anesthetics exert a lesser effect on the
cardiovascular system
eg. LIDOCAINE
Blood Level

Action Pro...
VASOCONSTRICTOR OVERDOSE
Clinical manifestations:
Fear, anxiety
Tenseness
Restlessness
Tremor
Weakness
Throbbing headache
...
ALLERGIC REACTIONS
Type Mechanism

Time Clinical Example

I Antigen induc. sec/min Angioedema,
Anaphylaxis
IV Cell mediate...
ALLERGENS IN LOCAL


Esters - usually to the Para-amino-benzoicacid product



Na bisulfite or metabisulfite - found in
...
PREVENTION
of
SYSTEMIC
COMPLICATIONS

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PRIOR TO TREATMENT


Complete review of medical status
(including vital signs)



Anxiety / Fear should be assessed and
...
ADMINISTRATION OF ANESTHETIC













Place pt. supine or semi-supine position
Dry site, apply topical X 1 ...
LOCAL ANESTHESIA FOR
CHILDREN

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Use with Sedative Drugs
With conscious sedation, especially narcotics,
decrease dosage of both local anesthetic and
the se...
Recommended Dosage Levels


2% lidocaine - 2 mg/lb



2% lidocaine 1/100,000 epi - 2 mg/lb



2% carbocaine 1/20,00 neo...
Delivery Methods
Aspirating Syringe


ALWAYS ASPIRATE!!!



Loading the syringe


Place carpule in syringe. Engage harp...
Delivery Methods
Air Jet Syringe


LA injected at pressure of ~2000 psi

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Use of Topical


Benzocaine is best.
Allow at least one minute for application
(onset in 30 seconds).

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GENERAL TECHNIQUES
Use of Assistant


Assistant should be ready at all times to
restrain hands.



Assistant can help bl...
General Techniques
Body Control


Operator should be in
control of patient's
head - it may move
suddenly!!



Hands - at...
General Techniques
Syringe Management and Etiquette


HIDE IT!!!



Pass behind or over patient.



Block patient's vie...
SYRINGE MANAGEMENT
AND ETIQUETTE

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EUPHEMISMS


Tooth jelly



Sleepy juice/medicine



Bubble blower



Mosquito bite, pinch



Tooth will take a nap a...
DISTRACTION









Verbal - chitter-chatter
(talk about anything)
Overwhelm patient with
stimulus
Pull on cheek, to...
DESENSITIZATION

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ANATOMIC DIFFERENCES

www.indiandentalacademy.com
ANATOMIC DIFFERENCES
Mandible


Ramus is shorter vertically and
narrower anteroposteriorly.



Mandibular foramen is low...
SPECIFIC INJECTION SITES
FOR CHILDREN MANDIBLE


Inferior alveolar block - Injection site is
lower and more posterior.

...
Anesthesia Technique

Occasionally the mylohyoid will
have accessory innervation to the
mandibular molar. Infiltrate on
ww...
SPECIFIC INJECTION SITES FOR CHILDREN
MANDIBLE


BILATERAL INFERIOR ALVEOLAR BLOCKS
SHOULD NOT BE ADMINISTERED TO
CHILDRE...
SPECIFIC INJECTION SITES
FOR CHILDREN MANDIBLE
Extractions


Infiltration works in mandibular anterior
although block may...
SPECIFIC INJECTION SITES
FOR CHILDREN MANDIBLE
Infiltration


Used effectively for incisor and canine
restorations.

www....


BUCCAL NERVE BLOCK:





SUBMUCOSAL INFILTRATION
FIELD BLOCK

MENTAL NERVE BLOCK :


TARGET:







Mesio bucca...
SPECIFIC INJECTION SITES
FOR CHILDREN MAXILLA


Apices of primary anterior teeth are at depth
of mucobuccal fold.



Inj...
SPECIFIC INJECTION SITES
FOR CHILDREN MAXILLA


Primary teeth and premolars - infiltrate



Permanent molars - PSA, MSA
...


FOR PRIMARY ANTERIOR TEETH:





Inj made close to gingival margin
Needle penetration: muco-buccal fold

FOR PERMANE...


FOR SECOND PRIMARY MOLAR:


Dense overlying bone – suprapeiosteal inj ineffective

www.indiandentalacademy.com


FOR ASA:




LANDMARK: loose alv tissue superior to max canine

FOR MSA:





LANDMARK: loose alv tissue apical to...
NASOPALATINE NERVE BLOCK:


Penetration site: MM lateral to incisive papilla



TWO WAYS:


INTERDENTAL PAPILLARY APPRO...
GREATER PALATINE NERVE
BLOCK


IN A CHILD WITH PRIMARY DENTITION: inj 10mm
post to distal surface of second primary molar...
Specific Injection Sites for
Children Maxilla


Primary molars (same as premolars) - Inject
over primary first molar.


...
Specific Injection Sites for
Children Maxilla


Permanent molars - PSA injection - Inject
behind tuberosity.



Also inj...
Specific Injection Sites for Children
Maxilla


Interdental papilla - To achieve palatal
anesthesia. Inject as go through...
DO


BE CONFIDENT



Use good syringe etiquette



Keep talking



Maintain hand and head control



Have assistant s...
DON’T:


Openly display syringe



“S(hot)”, “N(eedle)”, or “H(urt)” word



Inject too fast

www.indiandentalacademy.c...
POST-ANESTHESIA
TRAUMA


The number one postoperative complication of local
anesthesia in children.

www.indiandentalacad...
www.indiandentalacademy.com
POST-ANESTHESIA
TRAUMA

Minor to major. Always painful.
www.indiandentalacademy.com
POST-ANESTHESIA
TRAUMA
Prevention:
 Remind

both parent and child that area will remain
numb after the appointment.

 Ca...
CALCULATION OF MG. OF LOCAL
ANESTHETIC PER CARTRIDGE


2% solution = 20 mg/ml



Volume of cartridge = 1.8 ml



So for...
CALCULATION OF MG. OF LOCAL
ANESTHETIC PER CARTRIDGE

www.indiandentalacademy.com
CALCULATION OF MG. OF
VASOCONSTRICTOR PER CARTRIDGE


1:20,000 concentration = 0.05 mg/ml



Volume of cartridge = 1.8 m...
Mg/Ml VALUES OF
CALCULATION OF MG. of
VASOCONSTRICTORS VASOCONSTRICTOR
PER CARTRIDGE
CONCENTRATION

Mg/Ml

VOLUME OF
CARTR...
Other Post-Anesthesia
Conditions

Blanching due
to
vasoconstrictor

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Other Post-Anesthesia
Conditions

Hematoma due to local anesthesia
www.indiandentalacademy.com
RECENT ADVANCES
FUTURE TRENDS IN
CONTROL…

www.indiandentalacademy.com

AND
PAIN
CENTBUCRIDINE


Quinalone derivative



Five to eight times the potency of lidocaine



It does not effect CNS & CVS si...
pH ALTERATIONS


Alkalinization - ↑ RN:
 Sodium

bicarbonate.
 Rapid onset of action.



Carbonation :
 Helps

in the...
HYALURONIDASE


Breaks down intercellular cement.



Added to the anesthetic cartridge just before administering
the LA....
ULTRA –LONG ACTING LOCAL
ANESTHETICS


Biotoxins:


Tetradotoxin -puffer fish



saxitoxin -dinoflagelates.



Block N...
TENS

www.indiandentalacademy.com


Contraindications





Cardiac pacemakers
Neurological disorders
Pregnancy
Immaturity (in ability to understand) th...
Computer Controlled Local Anesthetic
Delivery System (CCLADS)

www.indiandentalacademy.com
JET INJECTORS

www.indiandentalacademy.com
Eutectic Mixture of Local Anesthetic
(EMLA)

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………………………conclusion
www.indiandentalacademy.com
REFERENCES.


Hand book of local anesthesia ………………………….5th ed Stanley F. Malamed.



Monheim’s Local anesthesia and pain...
THANK YOU

www.indiandentalacademy.com
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Local anesthesia in dentistry /certified fixed orthodontic courses by Indian dental academy

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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

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Local anesthesia in dentistry /certified fixed orthodontic courses by Indian dental academy

  1. 1. LOCAL ANESTHESIA IN DENTISTRY www.indiandentalacademy.com
  2. 2. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  3. 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. www.indiandentalacademy.com
  4. 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 www.indiandentalacademy.com
  5. 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) www.indiandentalacademy.com
  6. 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. www.indiandentalacademy.com
  7. 7. CLASSIFICATION www.indiandentalacademy.com
  8. 8. BASED ON CHEMICAL STRUCTURE   ESTERS:  Benzoic acid esters: AMIDES:  Articaine   Bupivacaine   Benzocaine Cocaine  Etidocaine Para-amino benzoic  Lidocaine esters:  Mepivacaine  Prilocaine  Tetracaine  Chlorprocaine  Procaine  Propoxycaine  QUINOLINE:  Centbucridine www.indiandentalacademy.com
  9. 9. STRUCTURES OF AMIDES AND ESTERS R3 Ester: R1 —COO—R —N 2 R4 R3 Amide: R 1 —NHCO—R —N 2 R4 R1 — Lipophilic aromatic residue. R2 — Aliphatic intermediate connector. R3 , R4 — Alkyl groups www.indiandentalacademy.com
  10. 10. Based on biological site and mode of action Class A Class BClass CClass D www.indiandentalacademy.com
  11. 11. Based on the source Natural Synthetic www.indiandentalacademy.com Others
  12. 12. Based on duration of action Short  eg: Lidocaine HCl 2%, Mepivacaine HCl 3% Intermediate duration –   Long Short duration –   Intermediate eg: Lidocaine HCl 2% + epinephrine 1:1,00,000 Long duration–  eg: Bupivacaine HCl 0.5% + epinephrine 1:2,00,000, Etidocaine www.indiandentalacademy.com
  13. 13. Based on mode of application Topical Injectable www.indiandentalacademy.com
  14. 14. NEROPHYSIOLOGY www.indiandentalacademy.com
  15. 15. www.indiandentalacademy.com
  16. 16. www.indiandentalacademy.com
  17. 17. www.indiandentalacademy.com
  18. 18. www.indiandentalacademy.com
  19. 19. www.indiandentalacademy.com
  20. 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 www.indiandentalacademy.com
  21. 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 www.indiandentalacademy.com (Goldman-1966) (Lee-1976) (Strichartz-1987)
  22. 22. ACETYL CHOLINE THEORY www.indiandentalacademy.com
  23. 23. MEMBRANE EXPANSION THEORY www.indiandentalacademy.com
  24. 24. SPECIFIC RECEPTOR THEORY www.indiandentalacademy.com
  25. 25. CHEMICAL REACTON OF LA RNHOH + HCl  RNHCl + H2O Weak strong acid water Base acid salt RNHCl  RNH+ + CI- www.indiandentalacademy.com
  26. 26. EFFECT OF PH Basic environment (higher pH) RNH+ > RN + H+ Acidic environment (low pH) RNH+ < RN + H+ www.indiandentalacademy.com
  27. 27. www.indiandentalacademy.com
  28. 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 www.indiandentalacademy.com Conduction blockade
  29. 29. HENDERSON – HASSELBALCH EQUATION  Log Base = pH – pKa Acid www.indiandentalacademy.com
  30. 30. www.indiandentalacademy.com
  31. 31. www.indiandentalacademy.com
  32. 32. INDIVIDUAL LOCAL ANESTHETIC AGENTS… Drug pka ph Conc Onset ½ life 2-4% 6-10 min ½ hr used Procaine 9.1 5-6.5 3.5-5.5 Propoxycaine - - 0.4% 2-3 min - Lidocaine 7.9 6.5 2% 2-3 min 1.6 hr 4.5 3% 1.5-2 1.9 hr 3-3.5 2% min 4.5 4% 2-4 min 1.6 hr 4% 2-3 min 1.25 5-5.5 Mepivacaine Prilocaine 7.6 7.9 3-4 Articaine 7.8 4.4-5.2 hrs Bupivacaine 8.1 4.5-6 :3-4.5 0.5% 6-10 min Etidocaine 7.7 4.5 1.5% 1.5 3www.indiandentalacademy.com min 3-3.5 2.7 hr 2.6 hr
  33. 33. PHARMACOKINETICS www.indiandentalacademy.com
  34. 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). www.indiandentalacademy.com
  35. 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.” www.indiandentalacademy.com
  36. 36. BITRANSFORMATION.  Esters:      Amides:       Pseudocholinesterase. Succinylcholine. Atypical pseudo cholinesterase. PABA (cause allergic reactions). More complicated. Hepatic microsomal enzymes. Liver function and perfusion play an important role. Intermediate products cause complications. Prilocaine metabolite: orthotoluidine - methhemoglobinemia. Lilocaine metabolites: monoethyl glycine xylidide & xylidide - sedation www.indiandentalacademy.com
  37. 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. www.indiandentalacademy.com
  38. 38. SYSTEMIC ACTIONS.  CNS.  CVS.  LOCAL TISSUE TOXICITY.  RESPIRATORY SYSTEM.  MISCELLANEOUS.  Neuromuscular blockade.  Drug interactions.  Malignant hyperthermia. www.indiandentalacademy.com
  39. 39. CNS-Pathophysiology Local anesthetics cross blood-brain barrier, producing CNS depression as level rises eg. LIDOCAINE Blood Level Action Produced < .5 ug/ml - no adverse CNS effects 0.5-4 ug/ml - anticonvulsant 4.5-7.5 ug/ml - agitation,irritability (pre - convulsant) > 7.5 ug/ml - tonic-clonic seizures Analgesia. Mood elevation. www.indiandentalacademy.com
  40. 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 www.indiandentalacademy.com
  41. 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 www.indiandentalacademy.com
  42. 42. MODERATE TO HIGH OVER DOSE. Generalized tonic-clonic seizure activity followed by Generalized CNS depression Depressed BP, heart rate Depressed respiratory rate www.indiandentalacademy.com
  43. 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 www.indiandentalacademy.com
  44. 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. www.indiandentalacademy.com
  45. 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. www.indiandentalacademy.com
  46. 46. VASOCONSTRICTORS  Decrease blood flow  Lower anesthetic blood levels  Decrease the risk of toxicity  Increases duration of action  Decrease bleeding www.indiandentalacademy.com
  47. 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 www.indiandentalacademy.com
  48. 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 www.indiandentalacademy.com
  49. 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 www.indiandentalacademy.com
  50. 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. 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 www.indiandentalacademy.com
  52. 52. ARMAMENTARIUM www.indiandentalacademy.com
  53. 53. SYRINGE www.indiandentalacademy.com
  54. 54. NEEDLE www.indiandentalacademy.com
  55. 55. ANESTHETIC SOLUTION www.indiandentalacademy.com
  56. 56. TOPICAL ANESTHETIC  Minimize sensation of needle penetrating the soft tissue.  Used in greater concentration than LA in order to penetrate the mucous membrane. www.indiandentalacademy.com
  57. 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 www.indiandentalacademy.com
  58. 58. www.indiandentalacademy.com
  59. 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. www.indiandentalacademy.com
  60. 60. BASIC INJECTION TECHNIQUE www.indiandentalacademy.com
  61. 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. www.indiandentalacademy.com
  62. 62. Dry the tissue. Apply topical antiseptic. Apply topical anesthetic. www.indiandentalacademy.com
  63. 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. www.indiandentalacademy.com
  64. 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: www.indiandentalacademy.com
  65. 65. www.indiandentalacademy.com
  66. 66. www.indiandentalacademy.com
  67. 67. TECHNIQUES OF LOCAL ANESTHESIA www.indiandentalacademy.com
  68. 68. TECHNIQUES OF MAXILLARY ANESTHESIA www.indiandentalacademy.com
  69. 69. LOCAL INFILTRATION FIELD BLOCK NERVE BLOCK www.indiandentalacademy.com
  70. 70. www.indiandentalacademy.com
  71. 71. MAXILLARY INJECTION TECHNIQUES  Supraperiosteal  Periodontal ligament  Intraseptal injection  Posterior superior alveolar nerve block  Middle superior alveolar nerve block  Anterior superior alveolar nerve block  Maxillary (second division) nerve block  Greater (anterior) palatine nerve block  Nasopalatine nerve block www.indiandentalacademy.com
  72. 72. LOCAL INFILTRATION www.indiandentalacademy.com
  73. 73. www.indiandentalacademy.com
  74. 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 www.indiandentalacademy.com
  75. 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 www.indiandentalacademy.com
  76. 76. Technique  Apply topical  Landmarks:  Mucobuccal fold.  Long axis of tooth.  Insert needle: At height of mucobuccal fold  Target area: Apex of tooth  Aspirate, deposit approx. 0.6-1 ml solution www.indiandentalacademy.com
  77. 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. www.indiandentalacademy.com
  78. 78. POSTERIOR SUPERIOR ALVEOLAR NERVE BLOCK Nerve Anesthetized: Posterior Superior Alveolar Nerve (PSA) - for maxillary molars and buccal tissue www.indiandentalacademy.com
  79. 79. www.indiandentalacademy.com
  80. 80. www.indiandentalacademy.com
  81. 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% www.indiandentalacademy.com
  82. 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 www.indiandentalacademy.com
  83. 83.  Failures of Anesthesia:   Needle not deep enough   Needle too lateral Needle too far superior Complications :  Hematoma  Mandibular anesthesia www.indiandentalacademy.com
  84. 84. MIDDLE SUPERIOR ALVEOLAR NERVE BLOCK  Nerve Anesthetized:   Middle Superior Alveolar Nerve Areas Anesthetized:  Maxillary premolars and buccal tissues www.indiandentalacademy.com
  85. 85. www.indiandentalacademy.com
  86. 86. www.indiandentalacademy.com
  87. 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 www.indiandentalacademy.com
  88. 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 www.indiandentalacademy.com
  89. 89.  Failures of Anesthesia:  Needle inserted too high, or not high enough  Deposition of solution too far laterally www.indiandentalacademy.com
  90. 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 www.indiandentalacademy.com
  91. 91. NERVES ANESTHETIZED www.indiandentalacademy.com
  92. 92. AREAS ANESTHETIZED www.indiandentalacademy.com
  93. 93. www.indiandentalacademy.com
  94. 94. www.indiandentalacademy.com
  95. 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..) www.indiandentalacademy.com
  96. 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 www.indiandentalacademy.com
  97. 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 www.indiandentalacademy.com
  98. 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 www.indiandentalacademy.com
  99. 99. Failures of Anesthesia Bone contact below infraorbital foramen Needle deviates laterally or medially Complications : Hematoma (rare) Positive aspirations - 0.7 % www.indiandentalacademy.com
  100. 100. ANTERIOR MIDDLE SUPERIOR ALVEOLAR NERVE BLOCK. www.indiandentalacademy.com
  101. 101. www.indiandentalacademy.com
  102. 102. PALATAL ANESTHESIA www.indiandentalacademy.com
  103. 103. NERVES ANESTHETIZED. www.indiandentalacademy.com
  104. 104. www.indiandentalacademy.com
  105. 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) www.indiandentalacademy.com
  106. 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 www.indiandentalacademy.com
  107. 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 www.indiandentalacademy.com
  108. 108. NASOPALATINE NERVE BLOCK www.indiandentalacademy.com
  109. 109. www.indiandentalacademy.com
  110. 110. www.indiandentalacademy.com
  111. 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 www.indiandentalacademy.com
  112. 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 www.indiandentalacademy.com
  113. 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 www.indiandentalacademy.com
  114. 114. TECHNIQUES OF MANDIBULAR ANESTHESIA www.indiandentalacademy.com
  115. 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 www.indiandentalacademy.com
  116. 116. MANDIBULAR NERVE BLOCKS  INFERIOR ALVEOLAR  BUCCAL  LINGUAL  MENTAL - INCISIVE  GOW-GATES  AKINOSI www.indiandentalacademy.com
  117. 117. INFERIOR ALVEOLAR NERVE BLOCK  Not a complete mandibular nerve block.  Requires supplemental buccal nerve block  May require infiltration of incisors or mesial root of first molar  Nerves anesthetized   Mental  Incisive   Inferior Alveolar Lingual Areas Anesthetized  Mandibular teeth to midline  Body of mandible, inferior ramus  Buccal mucosa anterior to mental foramen  Anterior 2/3 tongue & floor of mouth  Lingual soft tissue and periosteum www.indiandentalacademy.com
  118. 118. Inferior Alveolar Nerve Block  Indications   Buccal anterior soft tissue   Multiple mandibular teeth Lingual anesthesia. Contraindications  Infection/inflammation at injection site  Patients at risk for self injury (eg. children) 10%-15% positive aspiration www.indiandentalacademy.com
  119. 119. Inferior Alveolar Nerve Block  Alternatives  Mental nerve block  Incisive nerve block  Anterior infiltration  Periodontal ligament injection (PDL)  Gow-Gates  Akinosi  Intraseptal www.indiandentalacademy.com
  120. 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 www.indiandentalacademy.com
  121. 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 www.indiandentalacademy.com
  122. 122. www.indiandentalacademy.com
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  124. 124. www.indiandentalacademy.com
  125. 125. www.indiandentalacademy.com
  126. 126. www.indiandentalacademy.com
  127. 127. www.indiandentalacademy.com
  128. 128. Long Buccal Nerve Block     Anterior branch of Mandibular nerve (V3) Provides buccal soft tissue anesthesia adjacent to mandibular molars Not required for most restorative procedures. Indications   Contraindications   Infection/inflammation at injection site Advantages    Anesthesia required - mucoperiosteum buccal to mandibular molars Technically easy High success rate Disadvantages www.indiandentalacademy.com
  129. 129. Buccal Nerve Block Alternatives Buccal infiltration Gow-Gates PDL Intraseptal www.indiandentalacademy.com
  130. 130. Buccal Nerve Block  Technique      Apply topical Insertion distil and buccal to last molar Target - Long Buccal nerve as it passes anterior border of ramus Insert approx. 2 mm, aspirate Inject 0.3 ml of solution, slowly    Landmarks - 25-27 gauge needle Area of insertion:  - Mucosa adjacent to most distal Mandibular molars  Mucobuccal fold Complications Hematoma (unusual) Positive aspiration 0.7 %      www.indiandentalacademy.com
  131. 131. www.indiandentalacademy.com
  132. 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 www.indiandentalacademy.com
  133. 133. www.indiandentalacademy.com
  134. 134. www.indiandentalacademy.com
  135. 135. INFILTRATION www.indiandentalacademy.com
  136. 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   www.indiandentalacademy.com
  137. 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 % www.indiandentalacademy.com
  138. 138. ALTERNATIVE INJECTION TECHNIQUES. www.indiandentalacademy.com
  139. 139. INTRAPULPAL www.indiandentalacademy.com
  140. 140. INTRASEPTAL www.indiandentalacademy.com
  141. 141. INRA OSSEOUS www.indiandentalacademy.com
  142. 142. COMPLICATIONS IN ANESTHESIA ADMINISTRATION www.indiandentalacademy.com
  143. 143. LOCAL COMPLICATIONS IN ANESTHESIA ADMINISTRATION www.indiandentalacademy.com
  144. 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 www.indiandentalacademy.com
  145. 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 www.indiandentalacademy.com
  146. 146. www.indiandentalacademy.com
  147. 147. PAIN ON INJECTION  Causes   Dull needles  Rapid deposit of solution   Careless technique Needles with barbs Prevention  Careful technique  Sharp needles  Topical anesthetic  Slow injections  Room temperature solutions www.indiandentalacademy.com
  148. 148. BURNING ON INJECTION  Causes  pH of solution  Rapid injection  Contamination  Warmed solutions www.indiandentalacademy.com
  149. 149. PERSISTENT ANESTHESIA OR PARESTHESIA  Causes      Prevention   Trauma to nerve Hematoma Neurolytic agents (alcohol, phenol) Intraneural injection Careful injection technique Management     Patient counseling and reassurance Documentation Follow-up Appropriate referral www.indiandentalacademy.com
  150. 150. TRISMUS  Causes       Prevention       Trauma to muscles or blood vessels Contaminated anesthetic solutions Hemorrhage Infection Excessive anesthetic volume Sharp needles Proper care and handling of cartridges Aseptic technique and clean injection site Atraumatic insertion Minimal injections and volume Management   Examination Conservative therapy     passive ROM therapy analgesics heat www.indiandentalacademy.com muscle relaxants
  151. 151. HEMATOMA   The effusion of blood into extravascular spaces Prevention        Care with needle placement Minimize injections Don't probe with needle Modify technique short needles penetration depth Management with      IAN block Infraorbital block Mental Nerve block Buccal block PSA block www.indiandentalacademy.com
  152. 152. INFECTION  Causes      Prevention     Needle contamination Improper handling of armamentarium Infection at injection site Improper handling of tissue Disposable needles Proper care of equipment Aseptic technique Management    Usual sign is trismus Trismus persists (1-3 day resolution ) Antibiotics, if suspicious www.indiandentalacademy.com
  153. 153. EDEMA  Causes   Infection  Allergy  Hemorrhage   Trauma during injection Irritating solutions Management  Address cause and treat accordingly www.indiandentalacademy.com
  154. 154. SLOUGHING OF TISSUE  Causes    Topical anesthetic Prolonged ischemia Management  Observation  Documentation www.indiandentalacademy.com
  155. 155. LIP CHEWING  Management  Analgesics  Antibiotics  Saline rinses  Lip lubricants www.indiandentalacademy.com
  156. 156. FACIAL NERVE PARALYSIS  Cause: Anesthesia of peripheral Facial nerve branches  Prevention   Avoid over penetration   Bone contact when injecting Avoid arbitrary injection Management  Reassure patient  Documentation  Consider deferring dental care www.indiandentalacademy.com
  157. 157. POST ANESTHETIC INTRAORAL LESIONS Recurrent apthous Herpes Simplex www.indiandentalacademy.com
  158. 158. SYSTEMIC COMPLICATIONS www.indiandentalacademy.com
  159. 159. ADVERSE DRUG REACTIONS  Direct extensions of usual effects     Altered recipient      Side effects Overdose Local toxic effects Disease process Emotional disturbances Genetic aberrations Idiosyncracy Allergic reaction   Immediate - anaphylaxis Delayed - contact dermatitis www.indiandentalacademy.com
  160. 160. OVERDOSE  Dose related  Systemic distribution  Extension of pharmacologic effects  Selective CNS or CVS depression www.indiandentalacademy.com
  161. 161. ALLERGIC REACTIONS  Not dose related  May be systemic or localized  Unrelated to pharmacological effects  Exaggerated immune system response www.indiandentalacademy.com
  162. 162. IDIOSYNCRACY REACTION  Unexplained by any known mechanism of the drug’s action  Neither overdose nor allergic reaction  Unpredictable; treat symptoms www.indiandentalacademy.com
  163. 163. CAUSE OF OVERDOSE LEVELS  Total dose is too large  Absorption is too rapid  Intravascular injection  Biotransformed too slowly  Eliminated too slowly www.indiandentalacademy.com
  164. 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 www.indiandentalacademy.com
  165. 165. CLINICAL MANIFESTATIONS of OVERDOSE www.indiandentalacademy.com
  166. 166. Minimal to Moderate 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 www.indiandentalacademy.com
  167. 167. Moderate to High Generalized tonic-clonic seizure activity followed by Generalized CNS depression Depressed BP, heart rate Depressed respiratory rate www.indiandentalacademy.com
  168. 168. Pathophysiology Local anesthetics cross blood-brain barrier, producing CNS depression as level rises eg. LIDOCAINE Blood Level < .5 ug/ml Action Produced - no adverse CNS effects 0.5-4 ug/ml - anticonvulsant 4.5-7.5 ug/ml - agitation, irritability > 7.5 ug/ml - tonic-clonic seizures www.indiandentalacademy.com
  169. 169. 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 www.indiandentalacademy.com
  170. 170. VASOCONSTRICTOR OVERDOSE Clinical manifestations: Fear, anxiety Tenseness Restlessness Tremor Weakness Throbbing headache Perspiration Dizziness Pallor Respiratory difficulty Palpitations www.indiandentalacademy.com
  171. 171. ALLERGIC REACTIONS Type Mechanism Time Clinical Example I Antigen induc. sec/min Angioedema, Anaphylaxis IV Cell mediated 48 hrs Contact dermatitis www.indiandentalacademy.com
  172. 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 www.indiandentalacademy.com
  173. 173. PREVENTION of SYSTEMIC COMPLICATIONS www.indiandentalacademy.com
  174. 174. PRIOR TO TREATMENT  Complete review of medical status (including vital signs)  Anxiety / Fear should be assessed and managed before administering anesthetic www.indiandentalacademy.com
  175. 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 www.indiandentalacademy.com
  176. 176. LOCAL ANESTHESIA FOR CHILDREN www.indiandentalacademy.com
  177. 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). www.indiandentalacademy.com
  178. 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 www.indiandentalacademy.com
  179. 179. Delivery Methods Aspirating Syringe  ALWAYS ASPIRATE!!!  Loading the syringe  Place carpule in syringe. Engage harpoon. Place needle on syringe and puncture carpule. www.indiandentalacademy.com
  180. 180. Delivery Methods Air Jet Syringe  LA injected at pressure of ~2000 psi www.indiandentalacademy.com
  181. 181. Use of Topical  Benzocaine is best. Allow at least one minute for application (onset in 30 seconds). www.indiandentalacademy.com
  182. 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. www.indiandentalacademy.com
  183. 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. www.indiandentalacademy.com
  184. 184. General Techniques Syringe Management and Etiquette  HIDE IT!!!  Pass behind or over patient.  Block patient's view with your retracting hand.  BE CONFIDENT. www.indiandentalacademy.com
  185. 185. SYRINGE MANAGEMENT AND ETIQUETTE www.indiandentalacademy.com
  186. 186. EUPHEMISMS  Tooth jelly  Sleepy juice/medicine  Bubble blower  Mosquito bite, pinch  Tooth will take a nap and feel fat & fuzzy. www.indiandentalacademy.com
  187. 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 www.indiandentalacademy.com
  188. 188. DESENSITIZATION www.indiandentalacademy.com
  189. 189. ANATOMIC DIFFERENCES www.indiandentalacademy.com
  190. 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). www.indiandentalacademy.com
  191. 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. www.indiandentalacademy.com
  192. 192. Anesthesia Technique Occasionally the mylohyoid will have accessory innervation to the mandibular molar. Infiltrate on www.indiandentalacademy.com the lingual.
  193. 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 www.indiandentalacademy.com
  194. 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). www.indiandentalacademy.com
  195. 195. SPECIFIC INJECTION SITES FOR CHILDREN MANDIBLE Infiltration  Used effectively for incisor and canine restorations. www.indiandentalacademy.com
  196. 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 www.indiandentalacademy.com
  197. 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. www.indiandentalacademy.com
  198. 198. SPECIFIC INJECTION SITES FOR CHILDREN MAXILLA  Primary teeth and premolars - infiltrate  Permanent molars - PSA, MSA www.indiandentalacademy.com
  199. 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 www.indiandentalacademy.com
  200. 200.  FOR SECOND PRIMARY MOLAR:  Dense overlying bone – suprapeiosteal inj ineffective www.indiandentalacademy.com
  201. 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 www.indiandentalacademy.com
  202. 202. NASOPALATINE NERVE BLOCK:  Penetration site: MM lateral to incisive papilla  TWO WAYS:  INTERDENTAL PAPILLARY APPROACH  USE OF PRESSURE-TOPICAL ANESTHETIC www.indiandentalacademy.com
  203. 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 www.indiandentalacademy.com
  204. 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. www.indiandentalacademy.com
  205. 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. www.indiandentalacademy.com
  206. 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. www.indiandentalacademy.com
  207. 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. www.indiandentalacademy.com
  208. 208. DON’T:  Openly display syringe  “S(hot)”, “N(eedle)”, or “H(urt)” word  Inject too fast www.indiandentalacademy.com
  209. 209. POST-ANESTHESIA TRAUMA  The number one postoperative complication of local anesthesia in children. www.indiandentalacademy.com
  210. 210. www.indiandentalacademy.com
  211. 211. POST-ANESTHESIA TRAUMA Minor to major. Always painful. www.indiandentalacademy.com
  212. 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. www.indiandentalacademy.com
  213. 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 www.indiandentalacademy.com
  214. 214. CALCULATION OF MG. OF LOCAL ANESTHETIC PER CARTRIDGE www.indiandentalacademy.com
  215. 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 www.indiandentalacademy.com
  216. 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 www.indiandentalacademy.com
  217. 217. Other Post-Anesthesia Conditions Blanching due to vasoconstrictor www.indiandentalacademy.com
  218. 218. Other Post-Anesthesia Conditions Hematoma due to local anesthesia www.indiandentalacademy.com
  219. 219. RECENT ADVANCES FUTURE TRENDS IN CONTROL… www.indiandentalacademy.com AND PAIN
  220. 220. CENTBUCRIDINE  Quinalone derivative  Five to eight times the potency of lidocaine  It does not effect CNS & CVS significantly  Vacharajini et al www.indiandentalacademy.com
  221. 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. www.indiandentalacademy.com
  222. 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. www.indiandentalacademy.com
  223. 223. ULTRA –LONG ACTING LOCAL ANESTHETICS  Biotoxins:  Tetradotoxin -puffer fish  saxitoxin -dinoflagelates.  Block Na channels of nerve membrane.  250,000 as potent as procaine. www.indiandentalacademy.com
  224. 224. TENS www.indiandentalacademy.com
  225. 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  www.indiandentalacademy.com Intra oral electrodes – weak link in the entire system.
  226. 226. Computer Controlled Local Anesthetic Delivery System (CCLADS) www.indiandentalacademy.com
  227. 227. JET INJECTORS www.indiandentalacademy.com
  228. 228. Eutectic Mixture of Local Anesthetic (EMLA) www.indiandentalacademy.com
  229. 229. ………………………conclusion www.indiandentalacademy.com
  230. 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. www.indiandentalacademy.com
  231. 231. THANK YOU www.indiandentalacademy.com

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