LA

1. Dr.ANIZ
KARPAGA VINAYAGA INSTITUTE OF
DENTAL SCIENCE
LOCAL ANESTHESIA IN
PERIODONTICS

2.  DEFINITION
 COMPOSITION
 CLASSIFICATION
 MECHANISM OF ACTION
 TECHNIQUES
 ANATOMIC LANDMARKS
 COMPLICATIONS
 RECENT ADVANCES
CONTENTS

3. LA Is defined as loss of sensation in a
circumscribed area of the body caused by
depression of excitation in nerve endings or an
inhibition of conduction process in the
peripheral nerves. ( F. MALAMED 1980 )
DEFINITION

4. COMPOSITION
INGREDIENTS FUNCTIONS
Lignocaine HCl 2% (21.3mg) Anesthetic agent
Adrenaline 1:80,000 (0.0125) Vasoconstrictor
Sodium metabisulfite (0.5mg) Preservative
Methyl paraben (1.0mg)
Sodium chloride (0.6mg) Isotonicity of solution to the
tissues
Sodium hydroxide Maintain pH
Thymol Fungicidal
Distilled water Dilution
Nitrogen bubble 1-2mm in diameter, prevent
oxygen from trapping in cartridge

5. CLASSIFICATION OF LOCAL
ANAESTHESIA
BASED ON CHEMICAL COMPOSITION:
1. ESTERS
a. Esters of benzoic acid
Butacaine
Cocaine
Benzocaine
Hexylcaine
Piperocaine
Tetracaine
b. Esters of Para-amino benzoic acid
Chlorprocaine
Procaine
Propoxycaine
2. AMIDES
Articaine
Bupivacaine
Dibucaine
Etidocaine
Lidocaine
Prilocaine
Mepivacaine
Ropivacaine
3. QUINOLINE
Centbucridine

6. • Low potency - Procaine, chlorprocaine
• Intermediate potency- lidocaine, prilocaine
• High potency - Tetracaine, bupivacaine, mepivacaine
BASED ON POTENCY:

7. Blocks depolarization
Blocks nerve conduction
MECHANISM OF ACTION
 ACTS AS SODIUM CHANNEL BLOCKER

8. THEORIES
THEORIES ACTIONS
Acetylcholine theory
Acetyl choline neurotransmitter
Calcium displacement
theory
Displacement of calcium from
membrane site
Surface charge theory
change electric potential at
membrane surface
Membrane expansion
theory
LA molecules diffuses to
hydrophobic regions of
excitable membranes
Specific receptor
theory
Most accepted theory
Acts by binding to specific
receptors on sodium channel

9. EFFECT OF PH
LA are weak bases. penetration through cell
membrane and lipid barrier is more in un ionized
state.
During inflammation, Acidosis occurs which partly
ionizes the LA.
LA unable to cross the cell membrane

10. LIVER DISEASE
1. AMIDE LOCAL ANAESTHETICS
• Lidocaine, bupivacaine are
Primarily metabolized in liver
hence not preferred.
• Articaine has less toxicity than
lidocaine because it is partly
metabolized in blood and partly in
liver and half life is about 20
minutes – so preferred in liver
damage patients
ESTER LOCAL ANAESTHETICS
• Metabolized by enzyme
pseudocholinesterase in the
plasma
• Eg. Benzocaine, butacaine
• Chlorprocaine- hydrolysed
rapidly, least toxic

11. RENAL DISEASE
Esters completely hydrolysed
in plasma  small
concentration in urine
Bupivacaine is contraindicated
ESTERS ARE PREFERRED
OVER AMIDES

12.  Anti histamine property
 Does not affect CVS
parameter
 Intrinsic
vasoconstriction
QUINILONES
CENTBUCRIDINE
ALLERGIC TO LIDOGAINE

13. SIDE EFFECTS
1. CVS
Hypotension
Decrease myocardial depolarization
Decrease force of contraction
Ventricular tachycardia
2.CNS
Generalised depression
At low concentration- suppress seizures
At high concentrations- causes seizures
3. Respiratory system
Smooth muscle relaxation

14. MAXIMUM RECOMMENDED DOSE
3 FORMULATIONS
Lignocaine 2%
without
vasoconstrictor
Lignocaine 2% with
vasoconstrictor
1:80,000
Lignocaine 2% with
vasoconstrictor
1:100000
LA RECOMMENDED
DOSE (mg/kg)
LIDOCAINE (2%) 4.4
LIDOCAINE (2%)
WITH ADRENALINE
7
ARTICAINE(4%) 7
For 60 kilograms,
10 syringes (18ml) – LA with adrenaline
7 syringes (13ml) – LA without adrenaline

15. PARTS OF THE METAL SYRINGE
1. Needle adapter
2. Piston with harpoon
3. Syringe barrel
4. Finger grip
5. Thumb ring

16. PARTS OF CARTRIDGE
PARTS:
Cylinder
Plunger
Diaphragm
Volume:
1.8, 2.00 and
2.2 ml

17. PARTS OF PLASTIC SYRINGE
1.Plunger
2. Barrel
3. Needle adapter
4. Needle
5. Protective cover

18. PARTS OF NEEDLE
PARTS:
 Bevel
 Shaft
 Hub
 Syringe adaptor
 Cartridge penetration

19.  25 gauge
 27 gauge
 30 gauge
GAUGES
GAUGES &
Larger the gauge, smaller the internal diameter

20.  Long- 40mm
 Short- 20-25mm
 Extra short- 15mm
LENGTHS

21. 20mm, 23 guage
Friction lock
40 mm, 26 gauge
Threaded type
DISPO VAN / UNOLOK

22. TECHNIQUES
MAXILLARY ARCH
1. Supraperiosteal infiltration
2. Posterior superior alveolar
3. middle superior alveolar
4. anterior superior alveolar
5. Nasopalatine nerve block
6. Greater palatine nerve block
7. Palatal infiltration

23. MANDIBULAR TISSUE
1.Inferior alveolar nerve block
2.Long buccal nerve block
3. Lingual nerve block
4. Mental nerve block
5.Gow gates Mandibular block
6. Vazirani- Akinosi closed mouth technique

24. POSTERIOR SUPERIOR
ALVEOLAR NERVE BLOCK
NEEDLE: 25- or 27- gauge needle
Target area:
posterior border of maxilla
Landmarks :
Mucobuccal fold, maxillary tuberosity, zygomatic process of maxilla
Area of insertion:
Height of mucobuccal fold above maxillary 2nd molar

25. SUPRAPERIOSTEAL INJECTION
NEEDLE: 25- or 27- gauge , short needle
Target area:
Apical region of the tooth
Landmarks
Mucobuccal fold, crown of the tooth, root contour of the tooth
Area of insertion:
Height of mucobuccal fold above apex of the teeth

26. INFERIOR ALVEOLAR NERVE
BLOCK
Needle: 25 gauge long needle
Area of insertion:
Mucous membrane on medial side of
mandibular ramus, at intersection of
horizontal (height of injection) and vertical
lines (anteroposterior plane of injection)
Target area:
Inferior alveolar nerve as it passes
downwards towards the mandibular
foramen but before it enters into foramen
Landmarks:
Coronoid notch
Pterygomandibular raphae
Occlusal plane

27. MENTAL NERVE BLOCK
Needle: 25-/ 27- gauge needle
Target area:
Mental nerve as it exists from foramen
Anatomical landmark:
Mandibular premolar, mucobuccal fold
Area of insertion:
Mucobuccal fold at or just anterior to
mental foramen

28. TYPES OF ANAESTHESIA
 Mucosal
 Infiltration
 Field block
 Nerve block
 Intraligamentary
 Intraosseous
 Intrapulpal
 Intraseptal
 Intrapapillary

29. COMPLICATIONS
LOCAL
1.Haematoma
2. Needle breakage
3.Allergy
4.Facial nerve paralysis
5.Trismus
6.Soft tissue injury
7.Pain or burning sensation
8.Failure to achieve anaesthesia
9. Local necrosis
10. Post anaesthetic intraoral lesions
SYSTEMIC
1. Overdose
2. Allergic reactions to
local anaesthesia

30. HEMATOMA
 Most common in Posterior Superior Alveolar Nerve Block
 Due to trauma to the pterygoid plexus of veins
 Immediate Compression
 Ice pack
 Reassure patient

31. NEEDLE BREAKAGE
 Don’t change the direction after insertion , if needed to
change direction withdraw and reinsert
 Don’t insert up to the hub .
 Surgical reentry

32. ALLERGY
Manifestations Signs/symptoms Management
Localized skin Erythema, edema,
pruritis
Oral antihistamine
(Benadryl 25-50mg)
Generalised skin
reaction
Pruritus, urticarial,
macular rash
Oral antihistamine
(Benadryl 25-5mg)
IM diphenhydramine
25-50mg
Respiratory
implication
Bronchoconstriction,
laryngeal edema,
dyspnea
Epinephrine IM or SC
(0.3mg)
Anaphylactic shock
bronchoconstriction,
edema, dyspnea,
marked hypotension,
cardiovascular
collapse
Epinephrine IM or SC
(0.3mg), oxygen,
BLS/CPR

33. FACIAL NERVE PARALYSIS
Improper placement of the needle into the inferior part of
the parotid gland resulting in trauma to facial nerve
Temporary paralysis of facial nerve
Patient reassured and recovery within 3 hours to 24 hours

34. TRISMUS
 Trauma of the lateral and medial pterygoid
muscles OR injection into the ptergo mandibular
space
 Barbed needle
 Multiple injections

35. SOFT TISSUE INJURY LOCAL NECROSIS
POST ANESTHETIC INTRAORAL LESIONS

36. OVERDOSE
Reversal agent for lignocaine - PHENTOLAMINE MESYLATE
For lignocaine toxicity:
Benzodiazepine
Epinephrine
Lipid emulsion therapy
Allergy - steroids, epinephrine, anti - histamines
Seizures – midazolam
Average toxicity threshold- 4.5 mg/kg of body weight

37. RECENT ADVANCES
1. TENS (Transcutaneous Electrical
Nerve Stimulation)
2. Jet injection
3. Computer controlled system – WAND
4. ORAQIX- INTRA SULCULAR DELIVERY
SYSTEM-
5. DENTIPATCH

38. Small, battery-operated
device that has leads
connected to sticky
pads called electrodes.
 Eliminating or reducing the pain of local anaesthetic
injection.
 Pain Gate Mechanism- A beta (Aβ) sensory fibres 
reduces the transmission of the noxious stimulus from
the ‘c’ fibres.
 Also used in Rx of TMJ pain & Trismus.
TENS
Transcutaneous Electrical Nerve Stimulation

39. JET INJECTION
 Trans mucosal injection of lidocaine solution for
anesthetic purposes
 Rapid, minimally invasive delivery system
 Produces surface anesthesia instantly
 Alternative to topical anesthetics

40. COMPUTER CONTROLLED SYSTEM – WAND
 Computer controlled administrative device
 Reduces pain
2 specific rates of delivery
 Slow rate: 0.5ml/min
 Fast rate: 1.8ml/min
PARTS
 needle
 Disposable wand like syringe held by pen grasp
 Foot control- regulates delivery of LA solution at a precision
Factors
Metered flow rate , constant pressure, controlled volume

41.  For full mouth scaling
 Oraqix is a non-injectable, pH neutral anesthetic
 Used in inflamed tissue
 conjunction with injectable anesthetics
 Maximum dose is 5 full cartridges (8.5ml)-
ORAQIX – INTRA SULCULAR DELIVERY SYSTEM

42.  Patch contains 10-20% lidocaine
 Applied to the buccal mucosa
for 15 minutes
 Provide topical anesthesia by
releasing lidocaine
DENTIPATCH

43. La should not be administered exactly over the graft to
be harvested because it will cause blanching means it
will displace all the blood present inside which is
important for graft survival
FREE GINGIVAL GRAFT

44.  Administering the LA too close to the frenum or in the
vestibule will result in bulging of the tissue which
will make the procedure difficult.
 It has be administered at a higher level
VESTIBULOPLASTY AND
FRENECTOMY

45.  ADMISTERING LA IN THE FLOOR OF MOUTH
 PRECAUTIONS SHOULD BE TAKEN NOT TO INJUTE
THE SUBMANDIBLUAR DUCTS AND DEEP LINGUAL
VEINS
TONGUE TIE

46.  Infection
 wrong selection of local anesthetic solution
 Technical mistakes
 Anatomical variations with accessory innervation
 Anxiety of the patient.
CAUSES FOR FAILURE

47.  Administration speed
 Failure to aspirate
 Pre mucosal anesthesia
 Inadequate technique
COMMON MISTAKES

48. CONCLUSION

49. Thank you