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Local Anestheisa
Armamentarium
1.) The Syringe
2.) The Needle
3.) The Cartridge
Types of Syringes
Nondisposable:
Side and basal-loading, metallic, cartridge
type, aspirating or nonaspirating.
Pressure syringe: used in IL injection
techniques, especially in mandibular teeth
(types: pistol-grip, pen-grip).
Jet Injector (Needless)
Jet Injector (Needless)
Specialized syringes
Intraosseus syringe:
narrow surgical drill needed
Syringe Components
1.) Needle adapter
2.) Piston with harpoon
3.) Syringe barrel
4.) Finger grip
5.) Thumb ring
American Dental Association (ADA)
criteria for acceptance of LA syringes:










1-Durable and resterilzable or packaged in a sterile
container (if disposable).
2-Accept a wide variety of cartridges and needles of
different manufactures (universal use)
3-Inexpensive, light weight, and simple to use with
one hand.
4-Provide effective aspiration and the blood be easily
observed in the cartridge.
The incidence of positive aspiration may be as high
as 10%-15% in some injection techniques.
Assembling the syringe
system







Ensure syringe has been sterilized
Ensure the needle container seal is
intact
Break the seal by rotation
Screw needle to hub
Check the LA cartridge contents:








Expiry date
Cloudiness
Cracking
Air bubbles

Load the syringe with cartridge
Ensure free flow of LA
Holding the syringe






Hold the barrel rest with
the index and middle
fingers of the dominant
hand and the thumb rest
with any part of your
thumb.
The syringe should be
below the vision level
The other hand (dental
mirror) should reflect and
stretch the mucosa and
identify the landmarks
Dismantling the syringe
system


Remove needle either by:









Needle forceps
Finger protector
Single-handed pick up
Disposable syringe has a
built-in needle guard

Place the needle and the
glass cartridge in labelled
sharps container (Orange)
Return the syringe for
washing and autoclaving
The Needle
Gauge: the larger the gauge the smaller the
internal diameter of the needle
Usual dental needle gauges are 25,27, & 30
Length:
1-Long(approximately 40 mm "32-40 mm"), for
NB.
2-Short(20-25 mm).
3-Extra-short(approximately 15 mm), for PDL.
Components of the needle
1.) Bevel
2.) Shank (shaft)
3.) Hub
4.) Syringe adapter
5.) Syringe penetrating end
The Cartridge








Components: Cylinder, plunger,
diaphragm
Types: Standard – Self aspirating,
plastic, Glass
Contents: LA, VC, Vehicle,
preservative.
Volume: 1.8, 2.00 & 2.2 ML.
The Cartridge
The Cartridge






Should not be autoclaved
Stored at room temperature (21°C
to 22°C (70°F to 72°F)
Should not soak in alcohol
Should not be exposed to direct
sunlight
Packaging
Contents of Cartridge
Anesthetic Agent
Vasoconstrictor
Preservative for vasoconstrictor
Sodium chloride
Distilled water
Preparation of
Armamentarium
Loading the
Syringe
1.) remove syringe from sterile bag
2.) attach needle
3.) retract piston fully
4.) insert cartridge
5.) engage the harpoon
6.) carefully remove colored cap
Other Armamentarium
1) Topical Anesthetic (strongly
recommended)
-ointments, gels, pastes, sprays
2) Applicator sticks
3) Cotton gauze
Topical

Free nerve endings

Terminal nerve
endings

Main trunk

Infiltration

Nerve block
DentiPatch (lidocaine
transoral delivery system)
Preinjection
– 10-15 minutes exposure prior to
injection
 Root scaling/planing
– apply 5-10 minutes prior to beginning
procedure

Contents of Cartridge
Anesthetic Agent

The Ideal Local Anesthetic:
• Water soluble/stable in solution
• Non-irritating to nerve
• Low systemic toxicity
• Short induction period
• Adequate duration of action
• No post anesthetic side effects
• Vasoconstriction effect

Percent Solution
Different anesthetics come in various
concentrations
 These concentrations are given as a
percentage
• .5% = 5 mg/cc
• 1% = 10 mg/cc
• 2% = 20 mg/cc
 Multiply by 1.8cc to determine how many mg
are in a dental cartridge

Chemical Configuration of Local
Anesthetic Compounds in Dentistry



Amides
Esters
Amides vs Esters
Major difference is method of metabolism
– Amides: majority of the drug is metabolized in the
liver
– Use with caution in patients with severe liver disease
– Use lower dose to avoid toxicity
– Esters: metabolized in the plasma by
pseudocholinesterase
PABA is a major metabolite of ester metabolism
– Known allergen
• Atypical pseudocholinesterase deficiency
– Patients will not be able to metabolize; toxicity may ensue

Amide Local Anesthetics







Articaine
Bupivicaine
Etidocaine
Lidocaine
Mepivacaine
Prilocaine
Ester Local Anesthetics










Butacaine
Benzocaine
Cocaine
Chloroprocaine
Hexylcaine
Piperocaine
Procaine
Propoxycaine
Tetracaine
Nerve Conduction







Resting membrane potential -60 to -90
Stimulus
Slow depolarization
Threshold reached causing action
potential
Repolarization
Nerve conduction
At resting potential
– Axoplasm is negative (around -70mV)
– Membrane is freely permeable to K+
and Cl– Membrane is only slightly
permeable to Na+

Nerve conduction
Nerve excitation causes
– Increase in the permeability of the membrane
to Na+
– The rapid influx of Na+ to the interior of the
nerve cell causes the axoplasm to become
more positive
– The firing threshold is reached
(-50 to -60mV)
– An action potential is created

Nerve conduction
Repolarization
– At the end of the action potential, the
electric potential is positive (+40mV)
– The nerve membrane becomes
impermeable to Na+
– There is an efflux of K+
and there is a return to
normal resting potential

Mechanism of Action of Local
Anesthetic Agents






There are different unproven theories to
explain the exact mechanism of action of
local anesthetics
The basic fact is that sodium channels are
blocked preventing sodium ions from crossing
the membrane
This causes blockage of the formation of an
action potential
Henderson hasselbach
equation
Determines how much of a local
anesthetic will be in a non-ionized vs
ionized form
 Based on tissue pH and anesthetic Pka

Henderson Hasselbach cont






Injectable local anesthetics are weak bases
(pka=7.5-9.5)
When a local anesthetic is injected into tissue
it is neutralized and part of the ionized form
is converted to non-ionized
The non-ionized base is what diffuses into the
nerve
Henderson Hasselbach
Hence
• If the tissue is infected, the pH is lower (more
acidic) and according to the HH equation;
there will be less of the non-ionized form of
the drug to cross into the nerve (rendering the
LA less effective)
• Once some of the drug does cross; the pH in
the nerve will be normal and therefore the LA
re-equilibrates to both the ionized and
nonionized forms; but there are fewer cations
which may cause incomplete anesthesia

Factors affecting LA action
Lower pKa = more rapid onset (more
LA in non-ionized form to diffuse
through)
• Increased lipid solubility = increased
potency
• Increased protein binding = longer
duration of action

Maximum Recommended
Doses of Local Anesthetics
Vasoconstrictors










Constrict vessels and decrease blood flow to the site
of injection.
Absorption of LA into bloodstream is slowed,
producing lower levels in the blood.
Lower blood levels lead to decreased risk of overdose
(toxic) reaction.
Higher LA concentration remains around the nerve
increasing the LA's duration of action.
Minimize bleeding at the site of administration.
Naturally Occurring
Vasoconstrictors



Epinephrine
Norepinephrine
Vasoconstrictors should
be included unless
contraindicated
Mode of Action






Attach to and directly stimulate
adrenergic receptors
Act indirectly by provoking the release
of endogenous catecholamine from
intraneuronal storage sites
Combination of 1 and 2
Epinephrine (Adrenalin)




Most potent vasoconstrictor used in
dentistry
Concentrations of 1:50,000 to
1:200,000 in dental cartridges
Concentrations of
Vasoconstrictor
in Local Anesthetics




1:50,000
1:100,000
1:200,000





0.020mg/ml
0.010mg/ml
0.005 mg/ml
Calculation
1:50,000=
1gram/50,000ml=
1000mg/50,000ml=
1mg/50ml= 0.02mg/ml
Levonordefrin


One fifth as active as epinephrine
Vasoconstrictors - Unstable in
Solution
Sodium metabisulfite added
Known allergen
Max dose of vasoconstrictors





Healthy patient approximately 0.2mg
Patient with significant cardiovascular
history: 0.04mg
• How many carpules of 2% lidocaine
with 1:100,000 is max dose for CV
patient???
Max Dose for
Vasoconstrictors (CV patient)
1 carpule = 1.8cc
1:100,000=.01mg/cc
0.01 X 1.8cc= 0.018mg
0.04/0.018=2.22 carpules
In a healthy adult patient


0.2/0.018=11.1 carpules
Please Remember !!!






Principle 1- No drug ever exerts a
single
action
Principle 2- No clinically useful drug is
entirely devoid of toxicity
Principle 3- The potential toxicity of a
drug rests in the hands of the user

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