Regardless of the trigger, the mechanism of syncope is similar in the various vasovagal syncope syndromes. In it, the nucleus tractussolitarius of the brainstem is activated directly or indirectly by the triggering stimulus, resulting in simultaneous enhancement of parasympathetic nervous system (vagal) tone and withdrawal of sympathetic nervous system tone.This results in a spectrum of hemodynamic responses:On one end of the spectrum is the cardioinhibitory response, characterized by a drop in heart rate (negative chronotropic effect) and in contractility (negative inotropic effect) leading to a decrease in cardiac output that is significant enough to result in a loss of consciousness. It is thought that this response results primarily from enhancement in parasympathetic tone. On the other end of the spectrum is the vasodepressor response, caused by a drop in blood pressure (to as low as 80/20) without much change in heart rate. This phenomenon occurs due to vasodilation, probably as a result of withdrawal of sympathetic nervous system tone. The majority of people with vasovagal syncope have a mixed response somewhere between these two ends of the spectrum. One account for these physiological responses is the Bezold-Jarisch reflex.
Techniques of regional anesthesia
PRESENTED BY –DR. SHEETAL KAPSE
1. Definition of LA1. Basic injection techniques2. Techniques of regional anesthesia- for maxillary teeth- for mandibular teeth4. Conclusion5. Recourses
Reversible loss of sensation in acircumscribed area of the bodycaused by a depression of excitationin nerve ending or an inhibition of theconduction process in peripheralnerves.MALAMED (1980)
Hemophilia is the absolutecontraindications of localanesthesia.Thyrotoxicosis is thecontraindication of localanesthesia with adrenaline.
• Nothing that is done by a dentist for a patient is ofgreater importance than the administration of the drugwhich prevents pain during dental treatment.• Most of the emergency situations - vasodepressorsyncope(common faint)• Local anesthetic can & should be administered in a non-painful or atraumatic manner .
The atraumatic injection technique was developed over many years byDr. NathanFriedman & the department of human behavior at theUniversity of Southern California School of Dentistry.There are 2 components to an atraumaticinjections –1. Technical aspect2. Communication aspect
STEP 1 : USE A STERILIZED SHARPNEEDLE• Stainless steel disposable needles.• use of needle not wider than 25 gauge.• patient can not differentiate among 25, 27& 30 gauge needles.• 23 gauge & larger needles are associatedwith increased pain
STEP 2 : Check the flow oflocal anesthetic solution• A few drops of local anesthetic solutionshould be expelled from the syringe toensure the free flow of the solution.
STEP 3 : DETERMINE WHETHER OR NOTTO WARM THE ANESTHETIC CARTRIDGEOR SYRINGE This is for the cartridges stored in refrigerators or anycool areas, which should be brought to roomtemperature before use. Holding the metal syringe in the palm for half a minuteis sufficient.
STEP 4 : POSITION THE PATIENT Physiologically sound position before & during the injection. Vasodepressor syncope (common faint)- Anxiety The sign & symptoms will be –light headedness,dizziness,tachycardia & palpitationunconsciousness Medical condition of the patientis considered.
STEP 5 : DRY THE TISSUE2 x 2 inch gauze –• remove any debris .• Retracting the lip .
STEP 6 : APPLY TOPICALANTISEPTIC (OPTIONAL) At the site of injection . Betadine (povidene iodine), Merthiolate(thimerosal) Alcohol containing antiseptics - burning of softtissue .
STEP 7A : APPLY TOPICALANESTHETIC• Directly at the site of needle penetration with the cottonapplicator.• Excessive amount – large area of soft tissue anesthesia,- unpleasant taste• Remain in contact with mucosa for 2 minutes (minimum 1minute).• Anesthesia of the outermost2-3 mm .
STEP 7B : COMMUNICATEWITH PATIENT• Communicate with the patient in a positive way.• Injection , shot, pain, hurt
STEP 8 : ESTABLISH A FIRMHAND REST Tissue penetration may be accomplishedreadily, accurately & without inadvertent nicking oftissue.Palm down Palm up Palm up & fingersupport
• 2 techniques should beavoided – No syringe stabilization of anykind Placing the arm holding thesyringe directly on patient’s armor shoulder.
STEP 9 : MAKE THE TISSUE TAUT This permits the sharp stainlesssteel needle to cut through themucous membrane withminimum resistance. Loose tissue are pushed & tornby the needle as it is insertedproducing more discomfort oninjection & more postoperativesoreness.
STEP 10 : KEEP THE SYRINGE OUTOF THE PATIENT’S LINE OF VISION Assistant should pass the syringe to the administratorbehind the patient’s line of vision.
STEP 11A : INSERT THE NEEDLEINTO THE MUCOSA The bevel of needle should be oriented towards thebone. Gently insert. With firm hand rest & adequate tissue penetrationAtraumatic procedure
STEP 11 B : WATCH &COMMUNICATE WITH THE PATIENT• Patient’s face should be observed forevidence of any discomfort.• Signs of discomfort – furrowing of brow orforehead & blinking of eyes.• Communicate in a positivemanner.
STEP 12 : INJECT SEVERALDROPS OF SOLUTION(OPTIONAL)The soft tissue in front of the needle may beanesthetized to with a few drops of localanesthetic solution.
Step 12 & 13 are carried out together. Wait for 2-3 seconds for anesthesia to developadvance the needle within tissue Aspiration is not required . Only 1 or 2 drop (<1 mg) .STEP 13 : SLOWLY ADVANCETRE NEEDLETOWARDSTHETARGET
STEP 14 : DEPOSITE SEVERAL DROPS OFLOCAL ANESTHETIC BEFORE TOUCHINGTHE PERIOSTEUM The periosteum is richly innervated. Regional block techniques that requiresthis are –1. Gow-Gates mandibular nerve block2. Infraorbital nerve block
STEP 15 : ASPIRATE Minimizes the possibility of an intravascularinjections. Care should be taken to remain the needleunmoved. Any sign of blood is a positive aspiration. Aspiration should be performed twice(rotate barrel of syringe 45 degreefor second aspiration test ).
STEP 16 A : SLOWLY DEPOSITE THE LOCALANESTHETIC SOLUTION• Reason -Preventing the solution from tearing the tissue into which it isdeposited• Ideal rate of deposition of solution – 1ml/60 sec.• 1.8 ml cartridge takes approximately 2 min.• A more realistic time span in a clinical situation is 60 sec. for a full1.8 ml cartridge.• There is evidence in the surgical literature that the success of sometechniques is increased with slower injection speeds.Rucci F S, Pippa P, Boccaccini A, Barbagli R. Effect of injection speed on anaestheticspread during axillary block using the orthogonal two-needle technique. Eur J Anaesth1995; 12: 505-511.
STEP 17 : SLOWLY WITHDRAWTHE SYRINGE Cap it immediately by Scoop technique . Needles should not be reused. The acrylic needle holder can be used.
STEP 18 : OBSERVE THE PATIENT Most adverse drug reactions - during injection orwithin 5-10 min. Patient should never be left unattended afteradministration of a local anesthetic.
STEP 19: RECORD THE INJECTION ONPATIENT RECORD Local anesthetic agent Vasoconstrictor used (if any) Dose Needle used Injections given Patient’s reaction
2. Field blockdeposited in proximity to thelarger nerve branches
3. Nerve block(1.8 – 2.0 ml)depositing the LA solution withinclose proximity to a main nervetrunk
4. Intraligamentary (0.2 ml)- depositing the LA solution within PDLthrough gingival sulcus.- Provides 30-35 min of anesthesia.- Indicated in patient with bleeding disorder& young handicapped patients .5. Intraseptal (0.1 ml)It is used to avoid IANB to work inmandibular primary molars.
6. IntrapapillaryFor palatal & lingual anesthesia.7. IntrapulpalIn case of pulp therapy whenother techniques have failed.
8. IntraosseousFor 1 tooth when other techniquefails.Perforate within attach gingiva about 2 mm below thegingival margin of the adjacent teeth in the vertical planebisecting the interdental papilla .
1. Supraperiosteal /Infiltration2. Posterior superior alveolar nerve block3. Middle superior alveolar nerve block4. Anterior superior alveolar nerve block5. Nasopalatine nerve block6. Greater palatine nerve block7. Infiltration of palatal tissue8. AMSA9. P-ASA
SUPRAPERIOSTEAL /PARAPERIOSTEAL / INFILTRATIONADVANTAGES1. High success rate (>95 %)2. Technically easy3. Usually atraumaticDISADVANTAGES1. Anesthesia for larger arearequires multiple penetrations– pain.2. Larger volume of localanesthetic.INDICATIONS1. Maxillary teeth2. 1-2 teeth3. Soft tissue anesthesiaCONTRAINDICATIONS1. > 2 teeth2. Infection & inflammation3. Dense bone
• Area of insertion• Target area• Landmarks –mucobuccal foldcrown of toothroot contour of toothWait for 3-5 min.0.6 ml / 20sec.
SUBJECTIVENumbness over area ofinjection.OBJECTIVENo pain duringprocedureFAILURE OFANESTHESIANeedle tip is too lowNeedle tip is too farCOMPLICATIONPain while needle touchesthe periosteum.
Highly successful technique > 95% Potential for hematoma formation Short needle is recommended Depth of needle insertion- 16-20 mm10-14 m for children Aspirate several times
ADVANTAGES1. Atraumatic2. High success rate (>95 %)3. Less no. of penetration4. Equivalent volume0.6 x 3 = 1.8 mlDISADVANTAGES1. Hematoma formation2. No bony landmark3. Mesiobuccal root of 1M is notanesthetized in 28% casesINDICATIONS1. 2 or more Maxillary molars2. When supraperiostealinjection are contraindicatedor failedCONTRAINDICATIONHemophilic patients
• Area of insertion• Target area• Landmarks –mucobuccal foldmaxillary tuberosityinfratemporal surface of maxillaAnterior border & coronoid processof mandiblezygomatic process of maxillaDeepth of needle penetration – 16 mmWait for 3-5 min.0.9-1.8 ml / 30-20sec.
SUBJECTIVENumbness over area ofinjection.OBJECTIVENo pain duringprocedureFAILURE OFANESTHESIA1. Needle tip is too low2. Needle tip is too lateral3. Needle tip is too posterior4. Accessory innervation fromgreater palatine nerve.COMPLICATIONSHematoma formationMandibular anesthesia
• Landmarks –Infraorbital notchInfraorbital ridgeInfraorbital depressionpupilmucobuccal foldcrown of toothroot contour of toothpenetration depth – 16 mmWait for 3-5 min.0.69-1.2 ml / 30-40 sec.
SUBJECTIVENumbness over areasupplied by ASA, MSA& IO nerveOBJECTIVENo pain duringprocedureFAILURE OFANESTHESIA1. Needle tip is too low2. Needle tip is too medial3. Needle tip is too lateral4. Accessory innervation fromnasopalatine nerve.COMPLICATIONHematoma over lowereyelid(rare)
Generally painful Prepare the patient psychologically CCLAD – better results Adequate topical anesthesia Pressure anesthesia – ischemia , blanching Control over the needle 27 guage short needle Rapid injection should be avoided
ADVANTAGES1. Less no. of penetration2. Less volume - 0.45 – 0.6 mlDISADVANTAGES1. No homeostasis except in thearea of injection2. Potentially traumaticINDICATIONS1. >2 Maxillary molars2. Soft & hard tissueanesthesia for surgicalprocedureCONTRAINDICATIONS1. 1 - 2 teeth2. Infection & inflammation
0.45-0.6 /30 sec.• Area of insertion• Target area• Landmarks –• 2nd & 3rd maxillary molars• palatal gingival margine of 2M & 3M• Midline of palate• A line approximately 1cm towardsmidline from free gingival margine• Approach• Depth = <10 mmWait for 2-3 min.
SUBJECTIVENumbness overposterior portion ofpalateOBJECTIVENo pain duringprocedureFAILURE OFANESTHESIATechnically difficultNeedle tip is too anteriorInadequate anesthesia of PMCOMPLICATION1. Ischemia & necrosis with strongvasoconstrictor2. Hematoma (rare)3. Occasionally soft palateanesthesia4. Solution ma squirt back - bitter
ADVANTAGES1. Less no. of penetration2. Less volumeDISADVANTAGES1. No hemostasis2. Most traumatic intraoralinjectionINDICATIONS1. >2 Maxillary teeth2. Soft tissue anesthesiaCONTRAINDICATIONS1. 1- 2 teeth2. Infection & inflammation
0.45 ml / 15-30 sec.• Area of insertion• Target area• Landmarks –maxillary central incisorsincisive papilla in midline of palate• Wait for 2-3 min.
Advantage –Relative atraumaticAmount of solution –1. 0.3 ml / 30 sec in labial frenum2. 0.3 ml / 30 sec in labialinterdental papilla3. 0.3 ml / 30 sec lateral to incisivepapillaDisadvantage –1. Multiple penetration2. Stablization of needle becomesdifficult3. Syringe comes in line of patient’svision• Wait for 2-3 min.• Landmarks –labial frenumlabial interdental papillaincisive papilla
SUBJECTIVENumbness over area ofanterior palateOBJECTIVENo pain duringprocedurePrecautions –1. Against pain – don’t inject solutiondirect in papillatoo rapidlytoo much volume2. Against infection – depth of penetration not more than 5 mm
FAILURE OF ANESTHESIA1. Unilateral anesthesia2. Inadequate anesthesia to canineCOMPLICATION1. Ischemia & necrosis with strongvasoconstrictor2. Solution may squirt back - bitter
ADVANTAGES1. Acceptable hemostasis2. Less area of numbnessDISADVANTAGES1. Traumatic2. Anesthesia for larger arearequires multiple penetrationsINDICATIONS1. Hemostasis2. Palatogingival pain controlCONTRAINDICATIONS1. Infection & inflammation2. > 2 teeth
0.2-0.3 ml• Area of insertion• Target area• Landmarks –attached gingiva , 5-10 mm fromfree gingival margine• Penetration depth = 3-5 mm
SUBJECTIVENumbness over area ofanterior palateOBJECTIVENo pain duringprocedureFAILURE OF ANESTHESIAHowever high success rate ifvasoconstrictor is used butInflamed tissue continue tobleedCOMPLICATION1. Ischemia & necrosis with strongvasoconstrictor2. Solution may squirt back - bitter
Other common name – palatal approach anteriormiddle superior alveolar nerve anesthesia. Newly described technique Reported by FRIEDMAN & HOCHMAN IN1997, along with development of CCLAD system. Real field block Dental pluxes near the apices of premolars are ofchief concern
INDICATIONS1. With CCLAD system2. Anesthesia of multiple maxillary teeth & softtissue3. anterior asthetic restorativeprocedures, priodontal scaling & rootplanning4. When facial approach for supraperiostealinjection have failed.CONTRAINDICATIONS1. Infection & inflammation2. Thin palate3. Patient can not tolerate 3-4min of administration time4. Procedure of > 90 min.
1. pulpal anesthesia to multiple maxillary teeth withsingle site of injection2. less no. of penetration3. Less volume of solution4. Muscles of facial expression are not anesthetized5. Less postoperative inconvenience6. Atraumatic with CCLAD system
1. Requires experience & skill2. Slow administration (0.5 ml/min)3. Operator fatigue4. May require supplemental anesthesia for incisors5. Too rapid administration – excessive ischemia
0.5 ml/min. & 1.4-1.8 ml• Area of insertion• Target area• Landmarks –between 1PM & 2PMbetween midpalatine line & freegingival margine
SUBJECTIVENumbness of teeth & softtissue extends fromcentral incisor to distalpart of 2PM on the sideof injection.OBJECTIVE• Blanching• No pain duringprocedureFAILURE OFANESTHESIA1. Additional anesthesia forincisors2. Inadequate solution reaches topluxes.COMPLICATION1. Palatal ulcer2. Unexpected contact withnasopalatine nerve3. Solution may squirt back
Other common name – palatal approach maxillaryanterior field block. Newly described technique Reported by FRIEDMAN & HOCHMAN IN 1997, alongwith development of CCLAD system. 1st dental injection providing bilateral pulpal and labial& palatal mucoperiostel anesthesia Dental pluxes near the apices of anteriors &Nasopalatine nerve are of chief concern Along with CCLAD system – atraumatic
INDICATIONS1. With CCLAD system2. Anesthesia of multiple maxillary anteriorteeth & soft tissue3. Bilateral anesthesia with single injection.4. Anterior aesthetic restorativeprocedures, periodontal scaling & rootplanning5. When facial approach for supraperiostealinjection have failed.
CONTRAINDICATIONS1. Canines with large root2. Infection & inflammation3. Thin palate4. Patient can not tolerate 3-4 min ofadministration time5. Procedure of > 90 min.
1. pulpal anesthesia to bilateral maxillary teeth withsingle site of injection2. less no. of penetration3. Less volume of solution4. Muscles of facial expression are not anesthetized5. Less postoperative inconvenience6. Atraumatic with CCLAD system
1. Requires experience & skill2. Slow administration (0.5 ml/min)3. Operator fatigue4. May require supplemental anesthesia for incisors5. Too rapid administration – excessive ischemia
0.5 ml/min. & 1.4-1.8 ml• Area of insertion• Target area• Landmarks –Incisive papilla
SUBJECTIVENumbness of teeth & softtissue extends fromcentral incisor to distalpart of canine bilaterallyOBJECTIVE• Blanching• No pain duringprocedureFAILURE OFANESTHESIA1. Additional anesthesia forcanine2. Inadequate solution reaches topluxes.COMPLICATION1. Palatal ulcer2. Unexpected contact withNasopalatine nerve3. Solution may squirt back
Other common name – maxillary nerveblock,2nd division block. An effective method of achieving profoundanesthesia of hemimaxilla. 2 approaches – greater palatine canalapproach- high tuberosity approach
INDICATIONS1. Pain control in surgical procedures.2. When anesthesia through supraperiostealinjection & nerve block have failed.3. Diagnostic & therapeutic purpose.
• Body of mandible• Mandibular teeth• Mucous membrane and underlying tissue anteriorto molar
ADVANTAGES1. Wider area of anesthesiawith a single site of injectionINDICATIONS1. Multiple teeth in 1 qurdrantCONTRAINDICATION1. Infection & inflammation2. Children3. Physically & mentallyhandicapped patients4. Hemophilic patientsDISADVANTAGES1. Inadequate anesthesia in 15-20 %2. Positive aspiration in 10-15% (heighest)3. Intraoral landmarks are not consistently reliable.4. Younger patient – soft tissue injury
Anatomic Variations• Mandible- Mandibular foramen in children 4 years old and less isbelow the plane of occlusion. The foramen movessuperiorly in the ramus with the eruption of 6’sAdultsChildren
• Position of the patient-body ofthe mandible is parallel to thefloor.
Depth of penetration – 20-25 mm1.5ml / 60 sec.Wait for 3-5 min.
SUBJECTIVENumbness over area ofsupply of inferior alveolarnerve & lingual nerveOBJECTIVENo pain duringprocedureFAILURE OFANESTHESIA1. Needle tip is too low2. Needle tip is too medial3. Needle tip is too anterior4. Accessory innervations from longbuccal, lingual &mylohyoid, occasionallyauriculotemporal5. Anatomical variationsCOMPLICATIONSHematoma formationTrismusTransient facial nerve paralysis
1. High success rate (95%) – GOW-GATE TECHNIQUE2. Less positive aspiration3. Overcomes case of bifid inferior alveolarnerve & canal4. less no. of penetration1. Requires experience & skill2. Late onset of anesthesia
Mental nerveIcisive nerveMandibular nerve1. GEORGE ALBERT EDWARDS GOW-GATES (1973)2. VAZIRANI -AKINOSI CLOSED MOUTH MANDIBULARBLOCK (1960-1977)3. EXTRAORAL APPROACH
1.8 ml+1.2ml / min.• Area of insertion• Target area• Landmarks –soft tissue distal to 2Mmesiopalatal cusp of maillary 2Mintertragic notchcorner of mouth
Area of insertion: soft tissue overlyingthe medial border of the mandibularramus directly adjacent to maxillaryTuberosity.Inject to depth of 25mm1.5-1.8ml• Landmarks –- mucogingival junction of maxillary last molar- maxillary tuberosity- coronoid notch
• Landmarks –- Midppoint of zygomatic arch- zygomatic notch- coronoid process of ramus- lateral pterygoid plateDEPTH – 4.5 cm
SUBJECTIVE1. tingling & numbness overlower lip & tongueOBJECTIVE• No pain duringprocedureFAILURE OFANESTHESIA1. Flaring nature of ramus2. Needle is too low3. Overinsertion or underinsertion
1. Hematoma <2% in GOW-GATE technique<10% in VAZIRANI- AKINOSI technique2. Trismus (rare)3. Transient facial nerve paralysis.
1. 10% LIGNOCAINEHYDROCHLORIDE2. ETHYL CHLORIDEOnset of anesthesia = 1 min.Duration Of Action = 10 min.
• Mixture of lignocaine 2.5% &prilocaine 2.5%.• anesthesia for intact skin.• Mild skin blanching & edema mayoccur• Contraindicated in infants under ageof 6 months- because the metabolites ofprilocaine can causemethemoglobinemia.
• Liposomes arecomprised of lipid layerssurrounded by aqueouslayers.• Penetrate the stratumcorneum because theyresemble the lipidbilayers of the cellmembrane.• available as an ELA-Max.• Is used for thetemporary relief of painresulting from minor cuts4% Lidocaine cream in a liposomalmatrix
• 0.5% tetracaine,• 0.05% epinephrine,• 1.8% cocaine,• was the first topical anesthetic mixture found tobe effective for nonmucosal skin lacerations.• Not used now a days.
• (Electromotive Drug Administration (EMDA)) is atechnique using a small electric charge to delivera medicine or other chemical through the skin.
• This is a technique in which asmall amount of localanesthetic solution ispropelled as a jet intosubmucosa without the useof hypodermic needle.
• The wand local anesthesiasystem is a computer controlledinjection device. Thewand/compuDent systemadministers local anesthetic attwo specific rates of delivery.• The slow rate is 0.5ml/min and• fast rate is 1.8ml/min .• There is a 4.5 seconds ofaspiration cycle.
• electronic , preprogrammed delivery device thatprovides the control needed to make the patient’s localanesthetic injection experience as pleasant aspossible• Standard dental local anesthetic cartridges & dentalneedles may be used.
• This method ofachieving localanesthesia involves theuse of the principle ofTRANSCUTANEOUSELECTRICAL NERVESTIMULATION (TENS)which causes relief ofpain.
1. IMPLANTS2. NEUROLOGICAL DISORDERS- POST CEREBRAL STROKE- STATUS EPILEPTICUS- H/O TRANSIENT ISCHEMICATTACK3. PREGNANCY4. IMMATURITY1. NO NEED FOR NEEDLE2. NO RESIDUAL ANESTHETIC EFFECT3. ANELGESIC EFFECT OVER SEVERALHOURS.
• 5 to 8 times more potent thanLidocaine.• Available as 0.5 % solution form• It is used for topical & infiltrationanesthesia.• In therapeutic dose there is noCNS & CVS adverse effect.
• Addition of SODIUMBICARBONATECauses increase in pH to the 7.2which provides early onset ofanesthesia.• Too high pH causes rapidprecipitation of drug base &decrease in shelf life of LA.
• Enzyme that breaks down theintracellular cements, so helps ineasy diffusion of LA.• Added just before theadministration of LA solution.• Added as 1/8 th part of LAcartridge.
CONCLUSION• The administrator of local anesthetics who adheres tothese basic steps develops a reputation amongpatients as a PAINLESS DOCTOR.• It is not possible to guarantee that every injection willbe absolutely atraumatic because the reaction of bothpatient & doctor are far too variable.
• BOOKS – MALAMAD 5TH EDITION- TEXTBOOK OF PEDODONICS -BY SHOBHATONDON- LOCAL ANALGESIA IN DENTISTRY – BY D HROBERTS& J HSOWRAY- MONHEIM’S LOCAL ANESTHESIA & PAINCONTROL IN DENTAL PRACTICE – BYRICHARD BENNET7TH EDITION.