LA in Pedodontics


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LA in Pedodontics

  1. 1. Presented By JEAN MICHAEL Batch 4/RDCJM 1
  2. 2. PAIN• It is defined as an unpleasant sensational experience initiated by noxious stimulus & transmitted over a specialized neural network to CNS where it is interpreted as such JM 2
  3. 3. LOCAL ANESTHESIATransient loss of sensation in a circumscribedarea of the body caused by a depression ofexcitation in nerve endings or an inhibition ofthe conduction process in peripheral nerves. JM 3
  4. 4. CONSTITUENTS OF LOCAL ANESTHETIC SOLUTION1. Local anesthetic agent2. Vasoconstrictors3. Reducing agents4. Preservatives5. Fungicide6. Vehicle JM 4
  5. 5. Local Anesthetic AgentESTERS Esters of BENZOIC ACID Cocaine, Butacaine, Benzocaine, Tetracaine etc Esters of PARA-AMINOBENZOIC ACID Procaine, Chloroprocaine, propoxycaine etcAMIDES Bupivacaine, lidocaine, articaine, prilocaineQUINOLONES Centbucridine JM 5
  6. 6. VasoconstrictorsPyrocatechin derivativeEPINEPHRINE & NOREPINEPHRINEBenzol derivativeLEVONORDEFRINEPhenol derivativePHENYLEPHRINE JM 6
  7. 7. Functions of Vasoconstrictors• ↓ the blood flow to the injection site• Absorption of LA into CVS is slowed leading to lower LA level in blood• ↓ the risk of toxicity due to LA• ↑ the duration of action of the LA• ↓ bleeding and are useful when increased bleeding is anticipated JM 7
  8. 8. • Most commonly used agent – Phenylephrine (1:2500)• Limit – 4 mg at a time (Cardiac patients – 1/4th of normal dose)• Contraindication – THYROTOXICOSIS• If the LA solution is exposed to sunlight for a long time before administration, vasoconstrictor in the solution gets degraded by oxidation JM 8
  9. 9. Reducing Agent (Sodium metabisulphite) Preservative (Xylotox) Fungicide (Thymol) Vehicle(Modified Ringer’s solution) JM 9
  10. 10. Mechanism of Action of LASpecific Receptor Theory –1. Displacement Of Calcium ions from the Sodium Channel Receptor Site2. Binding of LA molecule to this receptor site3. Blockade of sodium conductance4. Decrease in Sodium Conductance5. Depression in the rate of electrical depolarization6. Failure to attain the threshold potential level7. Lack of development of propagated action potentials8. Conduction Blockade JM 10
  11. 11. Biotransformation (Alteration of the drug within the living organism)• Ester LAs are hydrolyzed in plasma by the enzyme pseudo-cholinesterase. The one that undergoes hydrolysis readily is the least toxic. Allergic reactions are mostly due to the major metabolic product – para-aminobenzoic acid• Amide LAs are primarily metabolized in the liver. Liver function and hepatic perfusion significantly influence the rate of biotransformation. JM 11
  12. 12. Techniques of Local Anesthesia JM 12
  14. 14. Local Infiltration• Small terminal nerve endings in the area of surgery are flooded with LA solution rendering them insensitive to pain. In this method, incision is made through the same area in which the solution has been deposited.• This technique is usually successful for treatment of mandibular deciduous canines, incisors and even in molars. JM 14
  15. 15. Field Block• Here the LA solution is deposited in proximity to the large terminal nerve branches so that the area to be anesthetized is circumscribed to prevent the central passage of afferent impulse• Maxillary injections administered above the apex of the tooth can be termed field blocks JM 15
  16. 16. Nerve Block• Method of securing local analgesia in which suitable local anesthetic solution is deposited within close proximity to the main nerve trunk, thus preventing nerve impulses from travelling centrally beyond that point. JM 16
  17. 17. Other Techniques• Intraligamentary• Intraseptal• Intrapapillary• Intrapulpal JM 17
  18. 18. The child should never see the injection needleThis creates anxiety and fear towards dental treatment JM 18
  19. 19. Keep the syringe awayfrom the Line of sightof the patient JM 19
  20. 20. Maxillary Injection TechniquesJM 20
  21. 21. • Supraperiosteal (Local infiltration)• Periodontal Ligament Injection• Intraseptal Injection• Intraosseous• Posterior Superior Alveolar Nerve Block• Middle Superior Alveolar Nerve Block• Anterior Superior Alveolar Nerve Block• Greater Palatine Nerve Block• Nasopalatine Nerve Block• Maxillary Nerve Block (Infraorbital Nerve Block) JM 21
  22. 22. Supraperiosteal Injection• Most frequently used technique for obtaining pulpal anesthesia in maxillary teeth• Indicated whenever dental procedures are confined to only one or two teeth JM 22
  23. 23. Nerves AnesthetizedLarge terminal branches of dental plexusAreas Anesthetized• The entire region innervated by the large terminal branches of dental plexus 1. Pulp and root area of the tooth 2. Buccal periosteum 3. Connective tissue 4. Mucous membrane JM 23
  24. 24. INDICATIONS• Pulpal anesthesia of the maxillary teeth when treatment is limited to only one or two teeth• Soft tissue anesthesia when indicated for surgical procedures in a circumscribed areaCONTRAINDICATIONS• Infection or acute inflammation in the area of injection• Dense bone covering the apices of teeth (maxillary central incisors and 1st molars) JM 24
  25. 25. ADVANTAGES• High success rates (>95%)• Technically easy injections• Usually entirely atraumaticDISADVANTAGES• Not recommended for large areas due to 1. Need for multiple needle insertion 2. Necessity to administer large total volumes of local anesthetic JM 25
  26. 26. TECHNIQUE• 25 or 27 gauge needle is used• Area of insertion – height of mucobuccal fold above the apex of the tooth being anesthetized• Target area – apical region of the tooth to be anesthetized• Landmarks 1. Mucobuccal fold 2. Crown of the tooth 3. Root contour of the tooth JM 26
  27. 27. PROCEDURE• Prepare the tissue at the injection site• Orient the needle so that bevel faces the bone• Lift the lip, pulling the tissue taut• Hold the needle parallel to the long axis of the tooth• Insert the needle into the height of the mucobuccal fold over the target tooth JM 27
  28. 28. • Advance the needle until its bevel is at or above the apical region of the tooth• Aspirate 2 times• If negative, deposit approximate 0.6 ml of LA over 20 seconds• Slowly withdraw the syringe• Make the needle safe• Wait for 3 to 5 minutes before starting the dental procedure JM 28
  31. 31. JM 31
  32. 32. JM 32
  33. 33. MINIMAL PAIN JM 33
  35. 35. Inferior Alveolar Nerve Block• Needle Used – 25 Gauge• Nerves Anesthetized – Inferior Alveolar Nerve Lingual Nerve• Site Of Injection – Region where the IAN enters the mandible through the Mandibular Foramen• Amount of solution deposited – 1 to 1.8 ml JM 35
  36. 36. Area anesthetized• Mandibular teeth of the injected side• Body of the mandible, inferior portion of the ramus• Buccal mucoperiosteum, mucous membrane anterior to the mandibular 1st molar• Anterior 2/3rd of tongue and floor of the mouth• Lingual soft tissue and periosteum JM 36
  37. 37. INDICATION• Procedures on multiple mandibular teeth in one quadrant• When buccal soft tissue anesthesia (anterior to the first molar) is necessary• When lingual soft-tissue anesthesia is necessaryCONTRAINDICATION• Infection or acute inflammation in the area of injection JM 37
  38. 38. TECHNIQUE• 25 gauge needle is used• Area of insertion – Mucous membrane on the medial side of the mandibular ramus near the mandibular foramen• Target area – Inferior alveolar nerve as it passes downward towards the mandibular foramen but before it enters the foramen JM 38
  39. 39. • Landmarks 1. Coronoid notch 2. Pterygomandibular raphae 3. Occlusal plane of the mandibular posterior teeth JM 39
  40. 40. LEFT RIGHT• Patient position – supine or semisuppine• Operator position – 1. Right IANB – 8 o’clock position 2. Left IANB – 10 o’clock JM 40
  41. 41. PROCEDURE• With the left thumb, palpate the coronoid notch• With the same finger, pull the buccal soft tissue laterally to gain visibility and make the tissue taut• The needle insertion point lies three fourths the anteroposterior distance from the coronoid notch to the deepest portion of pterigomandibular raphae JM 41
  42. 42. • Prepare the tissue of injection site• Place the barrel of the syringe in the corner of the mouth on the contralateral side• Penetrate the tissue with the needle and slowly advance till bony resistance is felt JM 42
  44. 44. • Average depth of penetration is 20 – 25 mm• When bone is contacted, withdraw 1 mm to prevent sub-periosteal injection• Aspirate• If negative, slowly deposit 1.5 ml of anesthetic over a period of 1 minute• Slowly withdraw the syringe till half of its length remains in the tissue JM 44
  45. 45. • Re-aspirate• If negative, deposit a portion of remaining anesthetic (.1 ml) to anesthetize lingual nerve• Withdraw the syringe slowly and make the needle safe• After about 20 seconds, return the patient to upright or semi-upright position• Wait for 3 to 5 minutes before commencing the dental procedure JM 45
  46. 46. Buccal Nerve Block• Needle used – 25 Gauge• Nerve Anesthetized – Buccal Nerve (branch of anterior division of mandibular nerve)• Site of injection – Mucous membrane distal and buccal to the most distal molar tooth in the arch• Amount of LA required - .3 ml JM 46
  47. 47. Area Anesthetized• Soft tissue and periosteum buccal to the mandibular molar teeth JM 47
  48. 48. INDICATION• When buccal soft tissue anesthesia is necessary for dental procedures in the mandibular molar regionCONTRAINDICATION• Infection or acute inflammation in the area of injection JM 48
  49. 49. TECHNIQUE• 25 Gauge long needle is recommended• Area of insertions – mucous membrane distal and buccal to the most distal molar tooth in the arch• Target area – Buccal Nerve as it passes over the anterior border of the ramus• Landmarks – mandibular molars & mucobuccal fold• Orientation of bevel – towards the bone JM 49
  50. 50. PROCEDURE• Operator position Right BNB – 8 o’clock position Left BNB – 10 o’clock position• Patient position – supine or semisupine• Prepare the tissue for needle penetration• With left index finger, pull the buccal soft tissues in the area of injection laterally to improve visibility and make the tissue taut JM 50
  52. 52. • Align the needle parallel to the occlusal plane and buccal to the teeth and direct it towards the injection site• Penetrate the mucous membrane at the injection site, distal and buccal to the last molar JM 52
  53. 53. • Advance the needle until mucoperiosteum is gently contacted• Depth of penetration – 1 to 2 mm• Aspirate• Slowly deposit .3 ml of LA over 10 seconds• Withdraw the syringe slowly and immediately make the needle safe• Wait for approximately 1 minute before commencing the dental procedure JM 53
  56. 56. • Here local anesthetic solution is delivered directly to the pulp using a bent needle• mostly used to anesthetize mandibular 1st molar which may be sometimes difficult to achieve using other procedures like nerve blocks in case of inflammation in the site of infection• Advantages of Intrapulpal injection – • Requires minimum volumes of LA solution • Immediate onset of action • Very few post operative complications JM 56
  57. 57. • Nerve anesthetized – Terminal nerve endings at the site of injection in the pulp chamber and canals of the involved tooth• Areas anesthetized – tissues within the injected toothINDICATION when pain control is necessary for pulpal extirpation or other endodontic treatment in the absence of adequate anesthesia from other technique JM 57
  58. 58. TECHNIQUE• Insert a 25 or 27 gauge short or long needle into the pulp chamber or the root canal• Wedge the needle firmly into the pulp chamber or root canal• Deposit .2 to .3 ml of anesthetic solution under pressure• Resistance to the injection of the drug should be felt Bend the needle, if necessary, to gain access to the canal JM 58
  59. 59. • When the intrapulpal injection is performed properly, a brief period of sensitivity (ranging from mild to very painful) usually accompanies the injection• Pain relief occurs immediately thereafter, permitting instrumentation to proceed atraumatically• Instrumentation may begin approximately 30 seconds after the injection JM 59
  60. 60. TOPICAL ANESTHESIA• It is the method of obtaining anesthesia by the application of suitable agent to an area of either the skin or mucous membrane through which it penetrates to anesthetize superficial nerve endings• It is commonly used to obtain anesthesia of the mucosa prior to injection JM 60
  61. 61. Topical anesthetic SpraysActive ingredient – 10% Lignocaine HydrochlorideOnset of Action – 1 minuteDuration of Action – 10 minutesAvailable in different fruit flavors JM 61
  62. 62. Technique• Dry the area of application (mucous membrane)• Spray an appropriate quantity of the solution into a small cotton roll• Place the cotton role on the site of injection in the sulcus• Wait for 1 minute before inserting the needle to allow the topical anesthetic to act JM 62
  63. 63. Topical Anesthetic Ointments & Jelly• Ointments – 5% Lignocaine (onset of action is 3-4 minutes)• Emulsions – 2% LignocaineBENZOCAINE –• Odorless white crystalline powder (soluble in alcohol and fatty oils)• Safe – due to its low aqueous solubility, It is very slowly absorbed from the oral tissues and wounds JM 63
  65. 65. EMLA (Eutectic Mixture of LA)• Mixture of LIGNOCINE & PRILOCAINE• EMLA cream is used for numbing the skin before inserting the needle• It is designed to go through intact skin• Potential for toxic effects of LA is minimal• Use in children under 6 months is contraindicated due to the possibility for developing methemoglobinemia due to prilocaine JM 65
  66. 66. Intraoral lignocaine patch• Contains 10% or 20% lignocaine• Placed for 15 minutes on the buccal mucosa of the maxillary or mandibular premolar area, 2 mm apical to the mucogingival junction JM 66
  67. 67. Electronic Dental Anesthesia• Uses the principle of Transcutaneous Electrical Nerve Stimulation (TENS)• Requires good patient co-operation• It increases salivary blood flow JM 67
  68. 68. Complications Of LA (Pediatric Patient) JM 68
  69. 69. NUMB FEELING• Invites the possibility of an unnecessary emotional upset of the childHow to Avoid ?• The dentist should explain beforehand to the child that he/she will experience the numbness after the administration of LA JM 69
  70. 70. LIP BITINGHow to avoid ?• Warning should be given immediately following injection procedure. Warning should be repeated before the child leaves the dental chair.• Parents should also be warned about this possible complication if not attended properly JM 70
  71. 71. JM 71
  72. 72. Complication due to Injection of LOCAL ANESTHETIC SOLUTION3 TYPES –1. Method of deposition of the drug2. Drug dosage dependent reactions3. Hypersensitivity reactions JM 72
  73. 73. Method of deposition of drugVASOVAGAL SYNCOPE• Due to peripheral pooling of blood and reduction in cerebral blood flow• Rarely encountered in children due to constant movement of extremities coupled with crying out loud which prevents the peripheral pooling of blood JM 73
  74. 74. BROKEN NEEDLE• Due to sudden movement during administration of the LA solutionFAILURE TO ACHIEVE ANESTHESIA• This may be due to 1. Improper Technique of administration 2. Normal anatomic Variation JM 74
  75. 75. FACIAL NERVE PARALYSIS• Encountered during IANB• Due to injection of LA solution into parotid gland• Facial Nerve gets temporarily paralyzed• Effects wears off over a period of time during which the eye needs to be protected JM 75
  76. 76. TRISMUS • Due to trauma to muscles or blood vessels of infra temporal fossa • Intramuscular or supramuscular injection of LA • Hemorrhage • Hematoma and scar formationHow to Avoid ? • Avoid repeated injections or multiple insertions into the same area • Use only minimum effective volume of LA JM 76
  77. 77. Drug Dosage Dependent Reactions• At Low levels - ↑ Heart rate and Cardiac Output• At High levels - ↓ Cardiac Output & Circulatory Failure• Methemoglobinemia – Caused by Benzocaine & PrilocainHow To Avoid ?• Use Of Aspiration Technique• Keeping the amount of agent administered below toxic limit JM 77
  78. 78. CAUSES OF TOXICITY• Use of excessive dose of LA• Inadvertent intravascular injection• Slow detoxification or biotransformation• Slow elimination or redistributionMajority of the toxic reactions to LA are immediate, mild and transientThey can be avoided by closely monitoring during the injection, injecting slowly and withdrawing the needle at the first signs of an adverse response JM 78
  79. 79. TOXICITY DUE TO VASOCONSTRICTORS• They causes local ischemia and thus retard their own absorption• Patients with ischemic heart diseases and hypertension are at high risk of toxicity if administrated intravascularly JM 79
  80. 80. Manifestation Of Toxicity •Concentration of LA in Plasma Cardiac Depression • Coma • Convulsions • Unconsciousness • Muscular twitching • Visual and auditory disturbances, light headedness, numbness of tongue JM 80
  81. 81. Hypersensitivity (rare)Manifests as• Utricaria• Facial edema• BreathlessnessMethyl paraben (protein) is the main allergent• It has been replaced in recent times JM 81
  82. 82. JM 82