Local anesthesia in pediatric dentistry

LOCAL ANESTHESIA IN PEDIATRIC
DENTISTRY
Dr Lilavanti Vaghela
MDS in Pediatric and Preventive Dentistry

Contents
• Definition of LA
• Classification
• Composition
• General structure of LA
• Mode of action
• Metabolism
• Maximum recommended doses
• Armamenterium
• Types of injection procedure
• Anesthesia for maxillary and mandibular region
• Complications
• Recent advances in LA techniques
• References

Pain
• Pain is an unpleasant emotional experience usually initiated by noxious stimulus
and transmitted over a specialized neural network to the CNS where it is
interpreted as such.
- (mohims)
Local anesthesia
• Reversible loss of sensation in a circumscribed area of the body caused by a
depression of a excitation in nerve ending or an inhibition of the conduction
process in peripheral nerves.
(Stanley F Melamed 1980)

History
❑ The first local anesthetic was Cocaine which was isolated from coca leaves
(Erythroxylum coca ) by Albert Niemann in Germany in 1860s
❑ The very first clinical use of Cocaine was in 1884 by Sigmund Freud who used it
to wean a patient from morphine addiction.
❑ It was Freud and his colleague Karl Kollar who first noticed its anesthetic
effect. Kollar first introduced it to clinical ophthalmology as a topical ocular
anesthetic.
❑ Also in 1884, Dr. William Stewart Halsted was the first to describe the injection
of cocaine into a sensory nerve trunk
❑ The use of cocaine for local and regional anesthesia rapidly spread throughout
Europe and America.
Monheim’s local anesthetsia and pain control in dental practice by
Richard bennet 7th edi

❑ The toxic effects of cocaine were soon identified resulting in many deaths
among both patients and addicted medical staff.
❑ Local anesthesia was in profound crisis until the development of modern
organic chemistry which led to the synthesis of pure cocaine in 1891.
❑ New amino ester local anesthetics were synthesized between 1891 and 1930
❑ In addition, amino amide local anesthetics were prepared between 1898 and
1972
❑ The first modern local anesthetic agent was lidocaine (trade name Xylocaine) by
Nils lofgren. It was invented in the 1940s
Monheim’s local anesthetsia and pain control in dental
practice by Richard bennet 7th edi

❑ Prior to its introduction, Nitrous oxide gas and procaine (plus alcohol in the form
of whiskey) were the major sources of pain relief during dental procedures.
Monheim’s local anesthetsia and pain control in dental practice by
Richard bennet 7th edi

Various methods of inducing local anesthesia
• Mechanical trauma
• Low temperature
• Anoxia
• Neurolytic agents like alcohol and phenol
• Chemical agents like local anesthesia
handbook of local anesthesia by stanley F. malamed 6th edition

Ideal properties of LA
1. It should be non irritating to tissues.
2. It should not cause any permanent alteration in nerve structure
3. Its systemic toxicity should be low
4. It must be effective regardless of whether it is injected into tissues or
applied locally to mucous membrane.
5. Short duration of onset of anesthesia.
6. Adequate duration of anesthetic action.

• Additional properties added by Benntt(2002)
7. It should have potency sufficient to give complete anesthesia without the use of
harmful concentrated solutions.
8. It should be relatively free from allergic reactions.
9. It should be stable in solution and readily undergo biotransformation in the
body.
10. It should be sterile or capable of sterilize by heat without deterioration.

Classification of LA
• Based on composition
• Based on duration of action
• Based on potency
• Based on mode of administration
• Based on source
• Based on site of action

CLASSIFICATION OF LOCAL ANESTHETICS
ESTERS AMIDES QUINOLINE
Esters of
benzoic acid
Esters of
Para-amino
benzoic acid
Butacaine
Cocaine
Benzocaine
Hexylcaine
Tetracaine
Chloroprocaine
Procaine
Propoxycaine
Articaine
Bupivacaine
Dibucaine
Etidocaine
Lidocaine
Mepivacaine
prilocaine
Centbucridine

ACC TO DURATION OF ACTION
Ultra short acting (less than 30 mins)---2% plain lignocaine
3%plain mepivacaine
4% prilocaine
Short acting (45-75mins)-----procaine
chloroprocaine
Medium acting (90-150mins)---lidocaine
prilocaine
Long acting (180 mins or longer)---bupivacaine
ropivacaine
tetracaine

ACC TO POTENCY:
Minimal anesthetic concentration that blocks impulse conduction within a
specified period of time
▪ high potency
▪ less potent

Based on mode of action:
• Topical
• Injection

BASED ON SITE OF ACTION:
CLASS A: Agents acting at receptor site on external surface of nerve membrane
eg: Biotoxins
CLASS B: agents acting at receptor sites on internal surface of nerve membrane
eg: scorpion venom
CLASS C: agents acting by receptor independent physio-chemical mechanism
eg: Benzocaine
CLASS D: agents acting in combination of receptor dependent-independent
mechanism
eg: Lidocaine, Mepivacaine, Prilocaine

COMPOSITION
1.Local anesthetic agent
• Lignocaine hydrochloride 2% is most commonly used local anesthetic agent.
• 2% lignocaine mean…….
• 2g in 100 ml
or
• 20mg in 1 ml
• USES- CONDUCTION BLOCKADE

2. vasoconstrictor
Adrenaline in the concentration of 1:50,000 to 1:200,000 is commonly used.
1:200000 means….
1 gm in------------- 200,000 ml
Or
1mg in-----------------200 ml (0.02 mg/ml)
handbook of local anesthesia by stanley F.
malamed 6th edition

Uses of vasoconstrictor
• ↓ 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
malamed 6th edition

3.Antioxident / reducing
• Sodium metabisulphite is used to prevent the oxidation of the vasoconstrictor.
• It oxidized to form sodium metabisulfate.
• Sodium metabisulfite is acidic and increases acidity of solution.
• Therefore old local anesthetic solutions cause burning or discomfort during
injection.
malamed 6th edition

4.Preservative agent
• Methylparaben
( hypersensitive reaction due to methyl paraben= caprylhydro cuprienotoxin)
5.Fungicide
• Thymol is used as fungicide
malamed 6th edition

6.Isotonic agent
• Sodium chloride is used to make the solution isotonic with the tissues.
• It makes the solution alkaline.
7.Vehicle
• Distilled water is used as vehicle.
• It produces the volume of the solution and act as diluent.
malamed 6th edition

Mode of action of local anesthesia
Theories of local anesthesia
malamed 6th edition

malamed 6th edition

• Ultra structure of nerve
malamed 6th edition

A nerve has a resting potential which is –ve electrical potential existing
across the nerve membrane produced by differing concentrations of ions on
either side of nerve membrane. The inside of nerve is –ve in relation to
outside.
malamed 6th edition

3. Repolarization –
• at the end of depolarization permeability of Na again decreases & high K
permeability is restored, so K moves freely out of the cell & original
electrochemical equilibrium & resting potential are reachieved.
malamed 6th edition

1. ACETYLCHOLINE THEORY by Dett Barn in 1967.
2. CALCIUM DISPLACEMENT THEORY by Goldman in 1966.
3. SURFACE CHARGE THEORY by Wei in 1969.
4. MEMBRANE EXPANSION by Lee in 1976
5. SPECIFIC RECEPTOR THEORY by strichartz 1987
malamed 6th edition

ACETYLCHOLINE THEORY
• by Dett Barn in 1967
• A.C. was involved in the nerve conduction as a neurotransmitter at
nerve synapse.
Drawback –
• No any evidence of involvement of N.T. along the body of neuron
malamed 6th edition

CALCIUM DISPLACEMENT THEORY
• by Goldman in 1966
• LA nerve block was produced by the displacement of ca++ that control the
permeability of Na+
Drawback
• Varing concentration of ca++ does not affect the potency of LA
malamed 6th edition

SURFACE CHARGE THEORY
• by Wei in 1969.
• LA is act by binding to nerve membrane and changing the electrical potential at
the membrane
There are some evidence that,
• Resting potential of nerve membrane is unaltered by LA
• LA act within the membrane channels rather than the surface
malamed 6th edition

• MEMBRANE EXPANSION THEORY (Lee, 1976):
LA diffuse to hydrophobic regions of nerve membrane expanding critical regions
of nerve membrane
Prevent increase in permeability of sodium ions
malamed 6th edition

• This theory not prove for benzocaine as it does not exits in cationic form-----still
exhibit potent anesthetic activity
malamed 6th edition

SPECIFIC RECEPTOR THEORY (Strichartz , 1987):
La act by binding to specific receptors on sodium channel
malamed 6th edition

Calcium ions are present in bound form within the nerve cell membrane at sodium
ion channel receptor site
LA molecules displaces these calcium ions from the
sodium channel receptor site
Binding of the LA molecule to this receptor site.
Blockade of the sodium channel..
in sodium conductance
NERVE CONDUCTION
malamed 6th edition

Depression of the rate of depolarization
Failure to achieve the threshold potential level
Lack of development of propagated action potential
CONDUCTION BLOCKADE
malamed 6th edition

DISSOCIATION OF LA
➢ LA are weakly basic in nature…..
➢ They are made water soluble by combining with a strong acid
➢ LA are available as salts for clinical use.
➢ The salt is both water soluble and stable if dissolved in either sterile water or
saline.
In this solution it exists simultaneously as
1. uncharged molecule(base)
2. positively charged molecules (cation)
RNH +ve RN + H +ve
malamed 6th edition

Factors Affecting the Reaction of Local Anesthetics
Lipid solubility
All local anesthetics have weak bases
Protein binding
The more tightly local anesthetics bind to the protein, the longer the duration of
action.
malamed 6th edition

pH influence
Usually at range 7.6 – 8.9
Decrease in pH shifts equilibrium toward the ionized form, delaying the onset
action.
Higher pH, hydrogen ion concentration is decreased, LA
agent will exist in the free base form.
pKa (dissociation constant)
Those anesthetic agents having high pKa will have few molecules present as the free base at
normal tissue pH.
Those with low pKa provide large no of free base molecules
malamed 6th edition

Vasodilatation
Greater vasodilator activity =increased blood flow to region= rapid removal of
anesthetic solution from injection site
Thus , anesthetic potency and duration are decreased
Tissue diffusibility (non nervous)
Increased tissue diffusibility = decreased time of onset
malamed 6th edition

• Order of sensory function block
1. pain
2. cold
3. warmth
4. touch
5. deep pressure
6. motor
malamed 6th edition

ESTER GROUP AMIDE GROUP
Primary site of
biotransformation is –
LIVER
Liver function – significantly
influences
biotransformation
BIOTRANSFORMATION
malamed 6th edition

• Allergic reactions that occur in response to ester LA are not related to the
parent compound but to its major metabolic product: PABA
• Atypical pseudocholinesterase : 1:2800 persons, inability to hydrolyze ester LA
and related compounds (succinylcholine), increased potential for toxicity.
• Persons with pseudocholinestrease are unable to hydrolyze succinylcholine at a
normal rate, so duration of apnea is prolonged.
• A familial trait, so proper history should be taken.
malamed 6th edition

• Liver function and hepatic perfusion significantly influence the rate of
biotransformation of an amide local anesthetic.
• Patients with lower than usual hepatic blood flow( hypotension, CHF) or poor
liver function(cirrhosis) are unable to biotransform at a normal rate.
• Increased anesthetic blood levels and increase in toxicity.
• Metabolites of amide LA may produce significant clinical activity.
• Sedative effect of lidocaine is due to its metabolites:monoethylglycinexylidide
and glycinexylidide.
malamed 6th edition

EXCRETION
• Kidneys are the primary excretory organs for both the local anesthetic and its
metabolites
• A percentage of given dose of local anesthetic drug is excreted unchanged in
the urine.
• Significant renal disease (ASA IV to V) represents a relative contraindication to
the administration of LA.
• This includes patients undergoing dialysis, and those with chronic
glomerulonephritis or pyelonephritis.
malamed 6th edition

SYSTEMIC ACTIONS OF LOCALANESIA
CENTRAL NERVOUS SYSTEM:
• Local anesthetics readily cross the blood brain barrier their pharmacological
action on CNS is depression.
• At low blood levels there is no CNS effects of any significance.
• With further increase in blood level preconvulsive signs and symptoms may be
seen(4.5 – 7 micro gm/ml)
• At higher levels, the primary clinical manifestation is generalized tonic-clonic
convulsive episodes. (>7.5microgm/ml)
malamed 6th edition

• Some local anesthetics (procaine, lidocaine, mepivicaine, and Prilocaine) have
demonstrated anticonvulsant properties.
malamed 6th edition

The cerebral cortex has neurons that are essentially inhibitory and other that are
facilitatory (excitatory ). And a state of balance is maintained between the degree
of effect exerted by each
Brain
Inhibitory facilitatory
Impulse impulse
At preconvulsant anesthetic blood levels , the balance is tipped in favor of
excitatory input.
Brain
Impulse impulse
Depressed excited
malamed 6th edition

At high convulsive levels inhibitory neurons is entirely depressed ,
Brain
Impulse impulse
Blocked unopposed
Further increase in the L.A level leads to the depression of both
inhibitory and excitatory pathway causing generalized CNS depression
Blockage of both inhibitory and facilitatory impulse
malamed 6th edition

CARDIOVASCULAR SYSTEM:
• Local anesthetics have direct action on myocardium and peripheral
vasculature.
• ON MYOCARDIUM: Local anesthetics modify electrophysiological events in
manner similar to their actions on peripheral nerves.
• LA drugs decreases electrical excitibility of the myocardium , decreases
the conduction rate, and decreases the force of contraction….
malamed 6th edition

➢ The usual sequence of local anesthetic induces actions on the CVS are as follows:
➢ At non overdose levels: there is no change in BP because of increased cardiac
output and heart rate.(.5-2 micro gram/ml)
➢ At levels approaching yet still below, overdose level: a mild degree of hypotension
is noted(1.8-5 micro gram/ml)
➢ At overdose level: profound hypotension because of decreased cardiac output and
decreased peripheral resistance.(5-10 micro gm/ml)
➢ At lethal levels: CVS collapse is noted this is caused by massive peripheral
vasodilation and decreased heart rate. (>10micro gm/ml)
malamed 6th edition

0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
5.5
6.0
6.5
7.0
7.5
8.0
8.5
9.0
9.5
10
Cardiovascular system Central nervous system
LA Blood levels mg/ml
0.5
0.5
2.0
2.0
1.8
5.0
4.0
4.5
7.0
7.5
10.0
10.0
Normal blood level following
intraoral injection. No CNS reaction
0.5 – 4.0 Anticonvulsant action 2
to 3mg/kg
4.5 – 7.0 CNS manifest as
excitation
7.5 – 10.0 CNS depression manifest
as tonic –clonic seizures
10.0+ Generalized CNS depression
Normal blood level following
intraoral injection. No CVS
reaction
1.8 – 5.0 Antiarrhythmic actions
5.0 – 10.0 Massive peripheral
vasodilatation , Myocardial
depression
10.0 Intensive myocardial
depression, Cardiac arrest
malamed 6th edition

RESPIRATORY SYSTEM
• Local anesthetic drugs exert a dual effect on respiration.
• At non overdose levels they have a direct relaxant actions on bronchial smooth
muscles.
• At overdose level they may produce respiratory arrest as a result of
generalized CNS depression.
malamed 6th edition

VASOCONSTRICTORS
They are important because of following reasons;
By constricting blood vessels, vasoconstrictors decrease blood flow to the site of
injection.
Absorption of LA to CVS is slowed resulting in lower anesthetic blood levels.
Lower LA blood level decrease the risk of LA toxicity.
Higher volumes of LA agent remain in and around the nerve for longer period
thereby increasing the duration of action.
Vasoconstrictor decrease the bleeding at the site of their administration.
malamed 6th edition

PHARMACOLOGY OF EPINEPHRINE
Proprietary name: ADRENALINE
Mode of action: Epinephrine acts directly on both alpha and beta adrenergic
receptors, beta effects predominant.
SYSTEMIC ACTIONS:
CARDIOVASCULAR SYSTEM :
Increased cardiac output
Increased stroke volume
Increased heart rate
Increased strength of contraction
Increased systolic and diastolic pressures
malamed 6th edition

CORONARY ARTERIES:
Epinephrine produces dilation of coronary arteries
BLOODPRESSURE:
Systolic BP is increased diastolic pressure is decreased when small doses are
administered.
on large doses the diastolic pressure is increased
RESPIRATORY SYSTEM:
Epinephrine is a potent dilator of the smooth muscle of the bronchioles. It is the drug
of choice for management of acute asthma.
CNS: Therapeutic dose is not a CNS stimulant. Its CNS stimulating action becomes
prominent when excessive dose is administered.
malamed 6th edition

• PROCAINE:
• Classification: ester
• Prepared by – Alferd Einhorn ,1904-1905
• Chemical formula: 2diethyleaminoethyl 4aminobenzoate hydrochloride.
• Metabolism: hydrolyzed rapidly in plasma by plasma pseudocholinesterase
• Excretion: more then 2% unchanged in urine(90% as PABA, 8% as
diethyleaminoethanol).
• Vasodilating properties: produces the greatest vasodilation of all currently
used local anesthetics.
• Trade name - novocain
POTENCY TOXICITY ONSET pKa
1 1 6-10 9.1
malamed 6th edition

PROPXYCAINE
➢ Classification : ester
➢ 2-diethylaminoethyl 4-amino-2-propoxybenzoate
➢ Prepared by – Clinton and Laskowski,1952
➢ Hydrolyzed in both plasma and liver
MAXIMUM DOSAGE
6.6mg/kg
MAXIMUM TOTAL ANAESTHETIC DOSAGE
should not exceed 400mg
POTENCY TOXICITY ONSET pKa pH
7-8 7-8 9-14 8.9 NA
malamed 6th edition

LIDOCAINE
• Classification: Amide
• Chemical formula: 2diethyleamino2,6acetoxyldidehydrochloride
• Prepared by Nils Lofgren in 1943
• Metabolism: in the liver
• Excretion: via kidneys; less than 10% unchanged, more than 80% various
metabolites
• Vasodilating properties: considerably less than those of procaine; however, more
than those of Prilocaine or mepivacaine
POTENCY TOXICITY ONSET pKa pH pH(WT.
VASOCONSTR
ICTOR)
HALF LIFE EFFECTIVE
DENTAL
CONC.(%)
2 2 2-4 7.9 6.5 5-5.5 90min 2
malamed 6th edition

MAXIMUM DOSAGE
4.4mg/kg
7mg/kg (wt vasoconstrictor)
TOTAL MAXIMUM DOSAGE
300mg
500mg(wt vasoconstrictor)
malamed 6th edition

Proprietary
name
Manufactur
er
%
L.A
Vasoconstrictor Duration
analgesia
of
Lidocaine
HCl
Alphacaine
Xylocaine
Many
generics
Carlisle labs
Dentsply
2 ------
Pulpal
5-10
soft
tissue
60-120
Lidocaine
HCl
Alphacaine
Lignospan
Octocaine
Xylocaine
Many
generics
Carlisle labs
Septodont
Novocol
Dentsply
2 Epinephrine 1:
50000 60 180-300
malamed 6th edition

MEPIVACAINE
➢ Classification: Amide
➢ Chemical formula: 1-N-methyl pipecolic-acid 2,6,dimethyl-anilide
➢ Prepared by – A.F.Ekenstam ,1957, introduced in dentistry in 1960
➢ Metabolism: in the liver
MAXIMUM DOSAGE
6.6mg/kg
400mg
VASOCONSTR
ICTOR)
HALF LIFE EFFECTIVE
DENTAL
CONC.(%)
2 1.5 2-4 7.6 4.5 3-3.5 1.9hr 3
malamed 6th edition

Proprietary
name
Manufacturer % L.A Vasoconstrictor Duration
analgesia
of
mepivacaine
HCl
Aristocaine
Carbocaine
Isocaine
Polocaine
scandonest
Many generics
Carlisle labs
Dentsply
2 ------
Pulpal
20-40
soft tissue
120-180
mepivacaine
HCl
Aristocaine
Isocaine
Polocaine
scandonest
Carbocaine
Many generics
Carlisle labs
Dentsply
Kodak
Septodont
novocal
2
levonordefrin 1: 20000 60 180-300
Carbocaine Kodak 2 Epinephrine 1: 200000 45-60 120-240
Scandonest 2% Septodont 2 Epinephrine 1: 200000 60 120-300
malamed 6th edition

BUPIVACAINE
➢ Prepared by : A.F.Ekanstam,1957
➢ Chemical formula: 1butyl 2’,6’pipecoloxylidine hydrochloride
➢ Metabolism: in the liver by amidases
Excretion: via kidneys 16% of anesthetic dose is excreted unchanged
VASOCONSTR
ICTOR)
HALF LIFE EFFECTIVE
DENTAL
CONC.(%)
8 0.5 6-10 8.1 4-6 3-4.5 2.7hr 0.5
malamed 6th edition

MAXIMUM DOSAGE
2mg/kg
2mg/kg(with vasoconstrictor)
175mg
225mg (with vasoconstrictor)
Proprietary
name
Manufacture
r
%
L.A
analgesia
of
Marcaine Kodak .5 Epinephrine
1:200000
Pulpal
90-180
soft
tissue
240-540
malamed 6th edition

PRILOCAINE
➢ Classification- Amide
➢ 2-Propylamino-o-proplionotoluidide
hydrochloride
➢ Prepared by – Lofgren and Tegner , 1953
MAXIMUM RECOMMENDED DOSAGE
7.9mg/kg
600mg
VASOCONSTR
ICTOR)
HALF LIFE EFFECTIVE
DENTAL
CONC.(%)
2 1 2-4 7.9 4.5 3-4 1.6hr 4
malamed 6th edition

Proprietary
name
Manufacturer % L.A Vasoconstrictor Duration
analgesia
of
Prilocaine HCl
Citanest plain
Many
generics
Dentsply
4 ------
Pulpal
10-15(inf)
40-60
( nerve
block)
soft tissue
90-150
(inf)
120-240
(n.block)
Prilocaine HCl
Citanest plain
Many
generics
Dentsply
4 Epinephrine 1: 20000 60 180-300
malamed 6th edition

ETIDOCAINE
➢ Classification – Amide
➢ 2-(N-Ethylpropylamino)butryo 2,6-xylidide hydrochloride
➢ Prepared by – Takman,1971
➢ Metabolised in liver
MAXIMUM RECOMMENDED DOSAGE
4mg/kg
400mg
VASOCONSTR
ICTOR)
HALF LIFE EFFECTIVE
DENTAL
CONC.(%)
4 4 1.30-3 7.7 4.5 3-4.5 2.6 hr 1.5
malamed 6th edition

ARTICAINE
➢ Classification-Amide
➢ 3-N-Propamino-proprionylamino-2 carbomethoxy-4-methylthiopene
hydrochloride
➢ Prepared by – H.Rusching et al ,1969
MAXIMUM RECOMMENDED DOSE
7mg/kg
TOTAL MAXIMUM DOSE
500MG
3 2 1-3 7.8 NA 4.4-5.2 1.25 4.6
VASOCONST
RICTOR)
HALF LIFE EFFECTIVE
DENTAL
CONC.(%)
malamed 6th edition

Proprietary
name
Manufacture
r
%
L.A
analgesia
of
Septocaine Septodont 4 Epinephrine
1:100000
Pulpal
60-75
soft
tissue
180-360
Septanest N
Astracaine
Ultracaine D-
S
Septodont
Densply
Hoeschst
4 Epinephrine
1:200000
45-60 120-300
malamed 6th edition

malamed 6th edition
POTENCY TOXICITY ONSET pKa
1 1 6-10 9.1
1.5 0.5 6-12 8.7 NA
7-8 7-8 9-14 8.9 NA
Procaine
2-chloroprocaine
Propoxycaine

malamed 6th edition
VASOCONSTR
ICTOR)
HALF LIFE EFFECTIVE
DENTAL
CONC.(%)
2 2 2-4 7.9 6.5 5-5.5 90min 2
Lignocaine
2 1.5 2-4 7.6 4.5 3-3.5 1.9hr 3
8 0.5 6-10 8.1 4-6 3-4.5 2.7hr 0.5
2 1 2-4 7.9 4.5 3-4 1.6hr 4
3 2 1-3 7.8 NA 4.4-5.2 1.25 4.6
mepivacaine
bupivacaine
etidocaine
articaine

➢ MALAMED et al- found that 4 percent articaine with epinephrine 1:100,000
provided clinically effective pain relief during most dental procedures and
had a time to onset and duration of anesthesia appropriate for clinical use .
JAm Dent Assoc. 2000 May;131(5):635-42
➢ MALAMED et al- found that articaine is as effective as lidocaine and
effective local anesthetic for use in pediatric dentistry.
J Pediatr Dent. 2000 Jul-Aug;22(4):307-11
JAm Dent Assoc. 2000 May;131(5):635-42
J Pediatr Dent. 2000 Jul-Aug;22(4):307-11

➢ Hase et al – On comparing anesthetic efficacy of articaine versus lidocaine as a
supplemental buccal infiltration of the mandibular first molar after an inferior
alveolar nerve block .The authors found that articaine resulted in a higher
success rate than with lidocaine
J Am DenAssoc.2008Oct;139(10):1312.
➢ Haas-Epidemiological studies have suggested that the 4% solutions used in
dentistry, namely prilocaine and articaine, are more highly associated with
paresthesia.
J Am Coll Dent. 2006 Fall;73(3):5-10.
J Am DenAssoc.2008Oct;139(10):J Am Coll Dent. 2006 Fall;73(3):5-10.

Selection Of Local Anesthesia
During the selection of LA the patients size and age must be considered…doses
must be reduced in accordance with patients Age, Size.
On reducing the dosage in accordance with patients Age ,YOUNGS RULE may
be followed
1. child's dose = child age X adult dose
age+12
2. patients body weight , CLARKS RULE may be followed
child's dose = child weight X adult dose
150
malamed 6th edition

Rule of 10
• A method of providing a guide as to whether an infiltration or a block injection
of local analgesic is appropriate for a child requiring treatment to a mandibular
tooth.
• The primary tooth to be anaesthetized is assigned a number from 1 to 5
according to its location in the dental arch (central incisor = 1, second molar =
5).
• This number is added to the age of the child (in years), and if the number is 10
or less then an infiltration analgesic is most appropriate; if greater than 10, then
an inferior dental nerve block is likely to be more effective.
malamed 6th edition

Rlue of 25
• Acco. To this a dentist can safely use 1 cartridge of anesthetic for every 25
pounds of patient weight
• That is 1 cart = 25 pound
2 cart = 50 pound
3 cart = 75 pound
malamed 6th edition

Local anesthetic calculations: avoiding trouble with pediatric patients
Mana Saraghi, DMD n Paul A. Moore

Local anesthetic calculations: avoiding trouble with pediatric
patients Mana Saraghi, DMD n Paul A. Moore

Pediatric Dentistry Infancy through Adolescent 5th edition – Cassamassimo
, Field ,Mctigue ,Nowak

Mcdonald and avery’s dentistry for child and adolescent 1st south
Asian edition

CENTBUCRINIDE
➢ A quinoline derivative
➢ 5 – 8 times the potency of lidocaine
➢ Does not affect CNS and CVS adversly. (Except in very large doses)
➢ Vacharanjani et al compared the effiecy of a 0.5% centbucrinide with that of 2%
lidocaine for dental extractions in 120 patients the degree of analgesia obtained
was same as that of lidocaine with no serious side effects.
➢ In overdose it was same as lidocaine,,true stimulant of CNS
➢ Trade name
➢ Centoblok

LIGNOCAINE
• Prepared by Nils Lofgren in 1943
• Classification: Amide
• Metabolism: in the liver
• Excretion: via kidneys; less than 10% unchanged, more than 80% various
metabolites
• Good for both surface application as well as injection
• Available in variety of forms
malamed 6th edition

• Uses
• Topical application
• Infiltration
• Nerve block
• Epidural and spinal anesthesia
• Eg, xylocaine, gesicaine
• 4%topical solution
• 2% jelly
• 2% viscous
• 5% ointment
• 1 and 2% injection
• 5% heavy ( for spinal anesthesia)
• 100mg/ml spray ( 10 mg per puff)
malamed 6th edition

Early central effect of lidocaine
• Depressant
• Drowsiness
• Mental clouding
• Altered taste
• Tinnitus
Overdose cause
• Muscle twitching
• Convulsion
• Cardiac arrythmia
• Fall in BP
• Respiratory arrest
malamed 6th edition

Bupivacaine
➢ Prepared by : A.F.Ekanstam,1957
➢ Metabolism: in the liver by amidases
Excretion: via kidneys 16% of anesthetic dose is excreted unchanged
• Onset of action longer ---may take >5min
• Less intense and relatively short lasting (<2hr), while soft tissue may remain
anesthetized for up to 8hrs.
malamed 6th edition

• Uses
• 0.25-0.5% solution injected epidurally produce adequate analgesia without
significant motor blockage
• As a result, it has very popular in obstetrics and for post operative pain relief by
continuous epidural infusion
• Because of high lipid solubility it distributes more in tissues than in blood after
spinal /epidural injection---- so less likely to reach to foetus ( when used during
labour)
• Bupivacaine 0.5% less frequently used in dentistry
malamed 6th edition

Eg, Marcain 0.5%, 1% ( for spinal )
• Sensorcaine 0.25%, 0.5% ( 0.5% heavy inj)
Drawback
• More prone to prolong QTc interval
• Ventricular tachycardia
• Cardiac depression
malamed 6th edition

ARTICAINE
➢ Classification-Amide
➢ Prepared by – H.Rusching et al ,1969
malamed 6th edition

• Compared with lidocaine, articaine is 1.5 times as potent and only 0.6 times as
toxic and has been shown to be superior in achiving successful anesthesia
following infiltration
• The use of inferior alveolar nerve blocks (IANB) can be almost eliminated in
children by using articaine due to its ability to effective anesthetise teeth up to
first permanent molar region.
• In addition, diffusion of anesthetic agent on to palatal surface may also
eliminate the discomfort of palatal infiltration.
• Soft tissue anesthesia is prolonged, but the risk of other adverse reactions is
similar to other local anaesthetic agents
R. Leith*, K. Lynch**, A.C. O’Connell* Articaine use in children: A review European Archives
of Paediatric Dentistry 13 (Issue 6). 2012294,2012

• The current child dosage recommendation for articaine is 7mg/kg , however
some authors have advocated a lower limit of <5mg/kg for children aged 4-
12yrs if used in conjunction with sedative agent.
R. Leith*, K. Lynch**, A.C. O’Connell* Articaine use in children: A review European
Archives of Paediatric Dentistry 13 (Issue 6). 2012294, 2012

R. Leith*, K. Lynch**, A.C. O’Connell* Articaine use in children: A review European Archives of Paediatric Dentistry
13 (Issue 6). 2012294, 2012

• The application of a topical anesthetic may help minimize discomfort caused
during administration of local anesthesia.
• Effective up to 2-3mm in depth to reduce painful needle penetration of the oral
mucosa
• Topical anesthetic agents are available in gel, liquid, ointment, patch, and
aerosol forms
• FDA has issued a warning about the use of compounded topical anesthetics and
the risk of methemoglobinemia.
• Risk of acquired methemoglobinemia has been associated primarily with two
local anesthetics: prilocaine and benzocaine
AAPD Guideline on Use of Local Anesthesia for
Pediatric Dental Patients,2017

• Prilocaine is available topically combined with lidocaine and in an injectable
form
• Benzocaine, the most commonly used topical anesthetic, is available in
concentrations up to 20% and comes in liquid, spray, and gel forms.
• Lidocaine is available as a topical solution or ointment up to 5% and as a spray
up to 10% concentration.

• Recommendations:
1. Topical anesthetic may be used prior to the injection of a local anesthetic to
reduce discomfort associated with needle penetration.
2. The pharmacological properties of the topical agent should be understood.
3. A metered spray is recommended if an aerosol preparation is selected.
4. Systemic absorption of the drugs in topical anesthetics must be considered
when calculating the total amount of anesthetic administered.

Compounded topical anesthetics also are available
• Two of the more common formulations contain
• 20 % lidocaine,
• 4% tetracaine,
• 2% phenylephrine or 10 % lidocaine,
• 10 % prilocaine,
• 4% tetracaine, and
• 2% phenylephrine.
• Use
• orthodontic procedures for gingival contouring and placement of mini-screw
implants to aid tooth movement
• pediatric dentistry to anesthetize palatal tissues prior to injection and for
extraction of loose primary teeth without the need for an injection
malamed 6th edition

WATER INSOLUBLE
➢ Ethly Aminobenzoate
(Benzocaine)
➢ Lidocaine Base
WATER SOLUBLE
➢ Benzyl Alcohol
➢ Propylene glycol
➢ Polyethylene glycol
malamed 6th edition

BENZOCAINE
ETHYL P-AMINOBENZOATE
➢ Poorly soluble in water
➢ Localized allergic reaction may occur following prolonged and
repeated use.
malamed 6th edition

Availability
a. Aerosol
1. Americaine
2. Hurricaine
b. Gel
1. Americaine anesthetic lubricant
2. Anbesol
3. Baby orabase
c. Gel patch
Topicale gel patch
d. Ointment
1. Benzodent
2. Cora caine
e. Solution
1. Anbesol maximum strength
2. Gingicaine
3. Hurricaine
malamed 6th edition

LIDOCAINE
➢ Is available in two forms for topical application lidocaine base and lidocaine
hydrochloride.
➢ LIDOCAINE BASE: Which is poorly soluble in water used in 5% concentration
indicated in ulcerated abraded or lacerated tissue.
➢ LIDOCAINE HYDROCHLORIDE: which is available as a water soluble preparation
used in 2% concentration
➢ Penetrates tissue more efficiently then base form
➢ Greater risk of toxicity then base form.
malamed 6th edition

Availability
Lidocaine base
a. Aerosol : 10 mg metred spray
-xylocaine
b. Ointment : 50 mg/ml
-octocaine
c. Patch (2X1X2)
Dentipatch
d. Solution
Xylocaine
Lidocaine hydrochloride
a. Oral topical solution ---20mg/ml
- xylocaine viscous
b. Solution ---20mg/ml
- Xylocaine
malamed 6th edition

TETRACAINE HYDROCHLORIDE
➢ Very potent
➢ Highly lipid soluble
➢ Duration of action – 45min-1hr
➢ Available in liquid,ointment,gel,spray
Availability
Aerosol : 0.7mg/metred spray
Supracaine
malamed 6th edition

ARMAMENTERIUM
Equipments Necessary For La Administration:
➢ Syringe
➢ Needle
➢ Cartridges
➢ Anesthetic Agent
➢ Topical Anesthetic
malamed 6th edition

Syringe
• Syringe word comes from a Greek word called “syrinx” which means tube.
• First needle was developed in 1863 by Alenxander wood and Charles Pravaz
• Combined together hollow pointed needle and metal syringe.
malamed 6th edition

Types of Syringe
Syringes types available in dentistry
1. Non disposable
a. Breech loading, metallic, cartridge type, aspirating
b. Breech loading, plastic, cartridge type, aspirating
c. Breech loading, metallic, cartridge type, self aspirating
d. Pressure syringe for periodontal ligament injection
e. Jet injector
2. Disposable syringes
3. Safety syringes
4. Computer controlled local anesthetic system
malamed 6th edition

• Parts of syringe
malamed 6th edition

Advantages Disadvantages
Visible cartridge
Aspiration with one hand
Autoclavable
Rust resitant
Long lasting
Weight (heavier than plastic
syringes)
Syringe may be too large for small
operators
Possibility of infection with improper
care
malamed 6th edition
Eliminates metallic look
Light weight
Easy to use
Possibility of infection with improper care
autoclaving not possible
METAL
PLASTIC

Breech loading , metallic , cartridge type, self aspirating
• Introduced in 1981 in United States
• The incidence of positive aspiration may be as high as 10-15%- Barlett (1972)
malamed 6th edition

• Pressure syringe
• Introduced in the late 1970
• Can be used for anesthetizing a single tooth
• Advantages
1. Measured dose administered
2. Nonthreatening
3. Cartridges are protected
• Disadvantages
Cost
malamed 6th edition

Disposable syringes
• Plastic disposable syringes are available in variety of sizes with an assortment of
needle gauges.
• These syringes contain a Leur Lock screw on needle attachment.
Advantages
• Disposable
• Lightweight
Disadvantages
• Aspiration is difficult, requires 2 hands
• Does not accept prefilled cartridges
malamed 6th edition

Safety syringe
• In recent years there has been more effort towards development of safety
syringes.
• Use of safety syringe minimizes the risk of accidental needle stick injury to the
health provider.
malamed 6th edition

Advantages
1. Single use disposable
2. Sterile until opened
3. Lightweight
Disadvantages
1. Cost more than reusable syringe
2. May feel awkward to a first time user
malamed 6th edition

NEEDLE
malamed 6th edition

Needle gauges used in dentistry
Gauge Outer diameter Inner diameter
25 0.51 0.25
27 0.41 0.20
30 0.31 0.15
Gauge
Gauge refers to the diameter of the needle- smaller the number
greater the diameter.

Minimizing needle deflection
• In order to reduce needle deflection Birotational Insertion Technique (BRIT) is
used.
• In this technique the operator rotates the needle in back and forth rotational
movement while advancing the needle through the tissues
malamed 6th edition

malamed 6th edition
Cartridge
1. Cylindrical glass tube
2. Stopper (plunger)
3. Aluminium cap
4. Diaphagram

Local anesthetic solution Color of cartridge band
Atricaine Hcl 4% with epinephrine 1: 100000 Gold
Bupivacaine 0.5% with epinephrine 1:200000 Blue
Lidocaine HCl 2% Light blue
Lidocaine HCl 2% with epinephrine 1: 50000 Green
Lidocaine HCl 2% with epinephrine 1: 100000 Red
Mepivacaine HCl 3% Tan
Mepivacaine HCl 2% with levonordefrin 1:20,000 Brown
Prilocaine Hcl 4% Black
Prilocaine Hcl 4% with epinephrine 1:200000 Yellow
malamed 6th edition

Nitrogen bubble
• A small bubble 1-2mm in diameter
• Composed of nitrogen gas
• It present to prevent oxygen from being trapped in the cartridge and destroying
the vasopressor.
Large bubble
• May be present with a plunger that is extruded beyond the rim of the cartridge,
is a result of freezing of anesthetic solution
malamed 6th edition

malamed 6th edition
Allergy test for LA
Skin testing via patch, prick, intradermal,
subcutaneous
Injection areas and examples of reactions to
test solutions.
Scale: - = no visible change;
+ = 1-2 cm change in diameter (wheal or
erythema);
++ = 2-3 cm change in diameter (wheal or
erythema);
+++ = diameter > 3 cm
(wheal with erythema).

• Post-Allergy Test Sequence
1. If no response to the skin testing occurs, an intraoral injection may be given to
confirm the result with the selected local anesthetic.
2. The patient should be observed for 1-1.5 hours after the last injection to
determine that no delayed reaction will occur and to insure the patient’s safety.
3. If a reaction occurs, the patient must be monitored and appropriately treated,
then referred for additional medical treatment, if necessary.
malamed 6th edition

The child should never see the
injection needle
This creates anxiety and fear
towards dental treatment
Keep the syringe away
from the Line of sight
of the patient

points to be kept in mind regarding the difference b/w the child and adult patient
1.Density and calcification of maxillary and mandibular bone
2.Anatomic structures
3.Penetration site of the needle
4.Depth of needle penetration
5.Emotional aspect

1.Nerve block
2.Field block
3.Local infiltration
TYPES OF INJECTION PROCEDURES

• Inferior alveolar nerve block
• Lingual nerve block
• Long buccal nerve block
• Mental nerve block
• Alternative techniques of IANB
ANAESTHESIA FOR THE MANDIBULAR TISSUE
Handbook of Local Anesthesia. Stanley F Malamed. 5th Edition.

Nerve anaesthetized-
Inferior alveolar nerve and its
sub division
• Mental nerve
• Incisive nerve
• Lingual nerve
INFERIOR ALVEOLAR NERVE BLOCK

AREAANESTHETIZED
• 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

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
Mcdonald nad avery’s dentistry for the child and adolescent ,8th edition

• Patient position – supine or semi suppine
• Operator position –
1. Right IANB – 8 o’clock position
2. Left IANB – 10 o’clock

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 .

• 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

ABOVE 12 YEARS
6 – 12 YEARS
BELOW 6 YEARS
PEDIATRIC PATIENT
(Lampshire, 1947; Shiere, 1950; Olsen, 1956; O'mullane, 1971;
Benham, 1976; McDonald et al., 2004; Kanno et al., 2005; Pinkham et
al., 2005).

• Average depth of penetration is 15 mm. but it depends upon age and size of
mandible.
• When bone is contacted, withdraw 1 mm to prevent sub-periosteal injection
• Aspirate
• If negative, slowly deposit 1.5-1.8 ml of anesthetic over a period of 1 minute
• Slight withdraw the needle and take to the same side.

• Re-aspirate
• If negative, deposit a portion of remaining anesthetic (0.3-0.5 ml) to anesthetize
lingual nerve
• Withdraw the syringe slowly and make the needle safe
• Wait for 3 to 5 minutes before commencing the dental procedure

• 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 - 0.3-0.5 ml
Buccal Nerve Block

Area Anesthetized
• Soft tissue and periosteum buccal to the
mandibular molar teeth
INDICATION
• When buccal soft tissue anesthesia is necessary for
dental procedures in the mandibular molar region

• 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
TECHNIQUE

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

• 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

• Advance the needle until mucoperiosteum is gently contacted
• Depth of penetration – 1 to 2 mm
• Aspirate
• Slowly deposit 0.3-0.5 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

Recommended volumes of LA

• True mandibular nerve block.
• Nerves anasthetized :
• Inferior alveolar
• Mental
• Incisive
• Lingual
• Mylohyoid
• Auriculotemporal
• Buccal
Gow-Gates technique

Indications
• When multiple procedures in mandibular teeth
• When buccal soft tissue anesthesia, from third molar to midline
• When conventional IANB is unsuccessful
Contraindication
• Infection / acute inflammation
• Physically/mentally handicapped adults
malamed 6th edition

• Target area : lateral side of the condyle neck

Landmarks
Extraoral
• Intertragic notch
• Corner of the mouth
Intraoral
• Mucobuccal fold
• Cusp of maxillary second molar

• According to yamada 1981 gow gates shows higher percentage of success rate
then conventional IANB.
• But it has drawback of difficulty in administration in children.
Gow gates block in children
Mcdonald and avery’s dentistry for the child and adolescent 8th edi

• Nerves anesthetized:
• Inferior alveolar
• incisive
• Mental
• Lingual
• Mylohyoid
• indications: same as IANB and limited mouth opening
• Contraindications: infection to site of injection, no access to lingual area of
ramus.
Vazirani-Akinosi closed mouth technique

• Landmarks:
• Target area:

• In Children: Malamed suggests that it is not contraindicated but very difficult to
administer it as of smaller head size and mandible.

Mental nerve block
nerve anesthetized
Mental, a terminal branch of inferior alveolar nerve
malamed 6th edition

LAND MARKS
Mandibular premolars
Mucobuccal fold
• AREA ANESTHETIZED
• Buccal mucous membranes anterior to mental foramen to mid line and skin of
lower lip
• TECHNIQUE
AREA OF INSERTION :mucobuccal fold at or just anterior to mental foramen
TARGET AREA : mental nerve as it exits mental foramen
malamed 6th edition

MAXILLARYARCH ANESTHESIA
TEHNIQUES

1.Infiltration
2.Anterior superior alveolar nerve block
3.Posterior superior alveolar nerve block
4.Middle superior alveolar nerve block
5.Nasopalatine nerve block
6.Greater palatine nerve block
ANAESTHESIA FOR MAXILLARY TISSUES

Maxillary
Posterior Superior Alveolar Nerve Block
Maxillary molars (with exception of mesiobuccal
root of maxillary 1st molar in some cases), hard
and soft tissue on buccal aspect
Middle Superior Alveolar Nerve Block
Mesiobuccal root of maxillary 1st molar (in some
cases), premolars and surrounding hard and soft
tissue on buccal aspect
Anterior Superior Alveolar Nerve
Block/Infraorbital Nerve Block
Maxillary central and lateral incisors andcanine,
surrounding hard and soft tissue on buccal
aspect, mesiobuccal root of maxillary 1st molar
(in some cases)
Greater Palatine Nerve Block
Palatal mucosa and hard palate from 1st
premolar anteriorly to posterior aspect of the
hard palate, and to midline medially
Nasopalatine Nerve Block
Hard and soft tissue of lingual aspect of maxillary
anterior teeth from distal of canine on one side to
distal of canine on the contralateral side
Maxillary Nerve Block
Hemimaxilla on side of injection (teeth, hard and
soft, buccal and lingual tissue)

• In local infiltration the nerve endings in the area of the surgery
are flooded with local anesthestic solution.
• Landmark- Mucobuccal fold.
• Needle used- 1inch, 25 gauge needle
• Amount- 0.45 to 0.6 ml
Labial/buccal infiltration
Handbook of Local Anesthesia. Stanley F Malamed. 5th Edition
.

Palatal Infiltration Anesthesia:
Indications:
Palatogingival pain control for rubber dam clamps, retraction cord placement and small surgical
procedures

-Target area is the palatal tissue 5 to 10 mm from the free gingival margin
-Masticatory mucosa of the hard palate is only 3 to 5 mm thick
-Palatal Infiltrations are safe areas anatomically to deposit anesthetic

malamed 6th edition
Anterior Superior Alveolar Nerve Block
(ASA)

Handbook of Local Anesthesia. Stanley F Malamed. 5th Edition
.
MIDDLE SUPERIOR ALVEOLAR NERVE

POSTERIOR SUPERIOR ALVEOLAR NERVE BLOCK

• Instruct the child to partially closed the mouth to allow cheek and lips to be
stretched laterally.
• The tip of the dentist’s left forefinger will rest in the concavity in the mucobuccal
fold.
• Ball of the finger is in contact with the posterior surface of zygomatic surface.
• Bennett suggest that the finger to be on a plane at right angles to the occlusal
surface of the maxillary teeth and at 45◦ to the patient’s sagittal plane.
• The index finger should point the direction of the needle during the injection

Mcdonald nad avery’s dentistry for the child
and adolescent ,8th edition

• Intraligamentary (Periodontal ligament) anaesthesia
• Intrapulpal anaesthesia
• Intraosseous anaesthesia
• Intraseptal anaesthesia
Supplementary Techniques

Needle: 25 gauge.
• The solution is injected along periodontal membrane of teeth, usually
0.2 ml, delivered via a specifically designed system which comprises of
high pressure syringes and ultrafine needles.
• This technique can anaesthetize only single individual tooth
Intraligamentary (Periodontal ligament) anesthesia

• Indication : for obtaining anaesthesia which require direct instrumentation of the pulp
tissue.
• 25 or 27 G needle is inserted directly into the pulp chamber. The needle should be
held firmly or wedged into the pulp chamber or the root canal.
Intrapulpal Anaesthesia

• The local anaesthetic solution is deposited directly into the cancellous bone
adjacent to the tooth to be anaesthetised, between the two cortical plates of bone .
• Intraosseous injection is usually an adjunct, and is used when conventional
methods have been Tried and failed.
Intraosseous Injection Technique

• A needle is forced gently into the porous interseptal bone on either side of the
tooth under pressure into the cancellous bone.
• More effective in children and young adults.
Indication
where the intraligamentary anaesthesia is not quite effective.
• Technique
The injection is given in the septum of two adjoining teeth, in between the two
cortical plates.
Intra septal Anaesthesia

COMPLICATIONS OF LOCALANESTHESIA

Local Complications
Paresthesia
Hematoma
Pain on Injection
Facial Nerve Paralysis
Infection
Trismus
Needle Breakage
Soft TissueInjury
Edema
Ocular Complications

Systemic Complications
Overdose Allergy
Introduction
Predisposing Factors
Clinical Manifestations
Management

Rare because of using of disposable needles.
Needle Breakage

Causes:
1. Bending of the needle.
2. Sudden unexpected movement of the patient.
3. Entire length of the needle inserted into the soft tissue.

Prevention:
1. Use large-gauge needles,specially with Inferior Alveolar
Nerve and Posterior Superior Alveolar Nerve.
2. Use long needles.
3. Do not insert a needle into tissues to itshub.
4. Do not redirect a needle once it is
inserted into tissue.

Management :
➢ When a needle breaks ( visible):
1. Stay calm.
2. Instruct the patient not to move and
let his mouth open.
3. If the fragment visible, remove it with
hemostat or a Magill intubation
forceps.
➢ When a needle breaks ( not-visible):
1. No incision orprobing.
2. Calmly inform the patient.
3. Referral Oral Surgeon, takeradiograph
and determine if it is superficial,
remove and flowup.

❖ Amaurosis “temporary blindness“.
❖ Mydriasis “Pupillary dilation”
❖ Ptosis “droopyeyelid”
❖ Diplopia “doublevision”
Ocular Complications

Prevention :
❖ Aspiration before actualinjection.
❖ Inject slowly.
Treatment :
❖Reassure the patient that is transient.
❖Cover the affected eye with gauze dressing.
❖Refer patients to an ophthalmologist for evaluation if it last more than 6
hours
❖Regular follow-up
Causes :
Orbital injection :
• Inadvertent injection into the orbit through the
inferior orbital fissure.

Paresthesia
Causes :
➢ Trauma to the nerve.
➢ Local Anesthesia solution contaminated by alcohol or sterliziating
solution near a nerve produce irritation, resulting edema and
increased pressure in the region of the nerve leading to
paresthesia.
➢ Hemorrhage-increased pressure-paresthesia.

Prevention :
➢ Proper care and handling to injection control and
cartridge.
Management :
➢ Most paresthesia resolve within 8 weeks without
treatment.
➢ Sequences of management:
➢ Reassuring the patient.
➢ Examine the patient and follow up each 2 months.
➢ If sensory deficit is still more than 1year, consultation with
neurologist andoral surgeon.
Pharmacology of Local Anesthetics Used in Oral Surgery -Joseph A. Giovannitti

Occur when anesthesia is introduced into deep lobe
of the parotidgland.
Facial Nerve Paralysis

Causes :
◦ Transient FNP caused by local anesthesia into capsule of the parotid
gland, which is located at posterior border of the mandibularramus.
◦ Usually it occur during Inferior Alveoar Nerve Block or
Vazirani-Akinosi Nerve Block.

Prevention :
➢ Proper care and handling to
injection control andcartridge.
➢ Management :
1. Reassuring the patient.
2. Contact lenses should be removed.
3. An eye patched should be applied to affected eye or manually
close the lower eyelid periodically to keep the cornea lubricated.

Pain and difficult of opening often after posterior superior alveolar or
inferior alveolar nerve block.
Onset 1-6dayspost-treatment.
Trismus

Causes :
➢ Trauma to the muscles or blood vessels in the
infratemporal fossa.
➢ Local Anesthesia solution contaminated by alcohol or cold
sterliziating solution produce irritation of the muscles.
➢ Low-grade infection.

Prevention :
1. Use sharp, sterile, disposable needle.
2. Proper care and handling to injection control and cartridge.
3. Atraumatic injection and avoid repeating of it.

Management :
➢ Heat therapy.
➢ Warm salinerinse.
➢ Muscle relaxation ifnecessary
➢ Physiotherapy for 5 min. each 3-4
hours.
➢ If there is infection, antibiotic
described for 7days.
➢ Improvement start within 2-3 days
and recovery range 4-20 weeks.
➢ Surgical intervention in some cases.

Trauma to the lip or the tongue caused by biting or chewing these tissue
while still anesthetized, specially withchildren.
Soft-Tissue Injury

Prevention :
◦ A cotton roll placed between the lips and the teeth.
◦ Warn the patient.

Management :
◦ Analgesic forpain.
◦ Antibiotic if there isinfection.
◦ Warm saline rinse to aid in decreasing the swelling.
◦ Petroleum jelly to cover the lesion and minimize the
irritation.

The effusion of the blood into extravascular spaces can result from
inadvertently a blood vessel.
Casued by nicking to the artery or vein.
Most occur with IANB and PSAnerve block.
7 to 14days the hematoma will be presented.
Hematoma

Prevention :
1. Knowledge of normal anatomy.
2. Use shorter needle for PSA nerve block.
3. Minimize the number of the needle penetration.
Management :
1. Direct pressure applied on to the site of bleeding.
2. Apply cold moist towels to affected area
3. Advice the patient about soreness and limitation of the
mouth openingpossibility.

Causes :
1. Careless injection and callous attitude “Palatal Injection
always hurt”.
2. Dull of the needle because of multiple injection.
3. Rapid deposition of the local anesthetic solution.
Pain on injection

Prevention :
◦ Adhere to proper techniques of
injection, both anatomical and
psychological.
◦ Sharp needles.
◦ Topical anesthetic.
◦ Inject slowly.
◦ Temperature of thesolution.

Causes :
◦ Contamination of the needle, now become rarely after
introduction of the sterile disposable needle and glass cartridge.
Management :
◦ Antibiotic
Infection

Causes :
1. Trauma.
2. Infection.
3. Allergy, angioedema.
4. Hemorrhage.
5. Injection of irritating
solution(alcohol, cold
solution).
Edema

Management :
1. Minimal degree edema --- just analgesic for pain and will
• resolve in severaldays.
2. If large degree edema and sign and symptom of infection--
- antibiotic should be prescribed.

Systemic Complications

◦ Overdose reaction is occurring when the drug access to
the circulatory system.
◦ Normally there is constant absorption of the drug from its site of
admission into the circulatory system and a steady removal from
the blood by the liver.
Overdose

• Predisposing Factors
➢ Patient Factors:
▪ Age.
▪ Weight.
▪ Medications.
▪ Gender.
▪ Presence of disease.
▪ Mental attitude.
malamed 6th edition
➢ Drug Factors:
▪ Vasoactivity.
▪ Concentration.
▪ Dose.
▪ Route of administration.
▪ Rateof injection.
▪ Vascularityof the injection site.
▪ Presence of vasoconstrictors.

Clinical manifestation
• Sweating
• Vomiting
• Failure to follow command
• Elevated blood pressure, heart rate, respi rate
• Tonic- clonic seizure in high dose
• CNS depression, myocardial depression,
• Cardiac arrest
malamed 6th edition

1. Use a needle no smaller than 25
gauge.
2. Aspirate in at least two planes
beforeinjection.
3. Slow inject the
anesthetic.
Prevention

1. Mild Overdose:
1. rapid onset(>5 minutes)
2. Slow onset (>15minutes)
2. Severe Overdose:
1. Rapid onset (within 1minute)
2. Slow onset (5 to 15minutes)
Management

1. Basic Emergency Management:
1. Position.
2. Circulation.
3. Airway.
4. Breathing.
5. Definitive Care.
P-C-A-B-D

Mild Overdose:“Patient conscious”
Slow onset (>5 minutes):
• P-C-A-B
• Reassure the patient.
• Administer oxygen via nasal canal.
• Monitor and record vital signs.
• Emergency medical assistance before patient discharge.

Severe Overdose: “Patient unconscious”
Rapid onset(within 1minute)
• P-C-A-B
• Protect thepatient.
• Immediately call onemergency
• medical assistance.
• Continue Basic life support (BLS)
• IV anticonvulsants (diazepam 5 mgmin. or midazolam
1mmin.) “if seizures protract more than 4 min.”

Severe Overdose:“Patient unconscious”
Slow onset (5 to 15minutes)
• P-C-A-B
• IV anticonvulsants (diazepam 5 mgmin. or midazolam 1
mmin.) and oxygen administration.
• Immediately callon emergency medical assistance.
• Continue Basic life support (BLS).
• Vasopressor and IV fluid is recommended for
management of hypotension.

◦ Hypersensitive state, acquired through exposure to a
particular allergen.
◦ Allergic reactions cover a broad spectrum of clinical
manifestations ranging from mild and delayed response
occurring as long as 48 hours after exposure to allergen, to
immediate and threatening reaction develop within secondsof
exposure.
Allergy

◦ Sodium Bisulfite:
Antioxidant invasoconstrictor local
anesthesia.
◦ Topical Anesthesia:
Mostly ester.
Preservatives containing such as
methylparaben, ethylparaben, or
propylparaben.
Predisposing Factors

Clinical Manifestation
Dermatological reaction
Generalized anaphylaxis
Respiratory reactions

◦ Dermatological reaction:
Urticaria
Angioedema
Clinical Manifestation

• Clinical Manifestation
Respiratory reactions:
• Bronchospasm:
• Respiratory distress
• Dyspnea
• Wheezing
• Flushing
• Cyanosis
• Perspiration
• Tachycardia
• Anxiety
• Laryngeal edema:
• Extension of edemato the larynx
• Life threatening emergency.
malamed 6th edition

• Generalized Anaphylaxis:
• Skin reactions
• Smooth muscle spasmof gastrointestinal andgenitourinary tracts and
bronchospasm.
• Respiratory distress.
• Cardiovascularcollapse.
• Treatmentof the entirereaction maybe terminatedrapidly,but hypotension
andlaryngealedema maypersist forhours to days.
malamed 6th edition

• Skin reaction:
• Delayed reaction:
• Oral histamine blocker 50 mg diphenhydramine or 10 mg
chlorpheniramine
• Observation for 1hour.
• Medical consultation.
• If patient isdrowsiness,
not allowed to leave the clinic.

• Skin reaction:
• immediate reaction:
• Epinpherine 0.3 mg IM.
• IM histamine blocker 50 mg diphenhydramine (25mgfor
children)or 10 mg(5mg for children ) chlorpheniramine.
• Medical consultation
• Prescribe Oral histamine blocker3days.

• Respiratory reaction:
• Bronchospasm :
• P-C-A-B
• Administer oxygen atflow 5-6 litersmin.
• Epinpherine 0.3 IM (0.15 mg children ) or Bronchodilator
“albuterol” , dose repeated 10-15 min. if needed.
• IM histamine blocker 50 mg (25 mg child )
diphenhydramine or10mg (5 mg child )
chlorpheniramine.
• Medical consultation
• Prescribe Oral histamine blocker3days.

• Respiratory reaction:
Laryngeal Edema : “unconsciouspatient”
• P-C-A-B
• Epinpherine 0.3 IM, dose repeated 10-15min.if
needed.
• Activate Emergency Medical Services.
• IM histamine blocker 50 mg diphenhydramine or 10 mg
chlorpheniramine. Corticosteroid IM or IV (100 mg
Hydrocortisone sodium succinate to inhibit and decrease
edema.
• Perform cricothyrotomy.

• Generalized Anaphylaxis :
• Signs of allergy present : “unconscious patient”
• P-C-A-B
• Summon medical assistance.
• Epinpherine 0.3 IM, dose repeated 10-15min
• Administer oxygen.
• Monitor vital signs, recorded every 5 min.
• IM histamine blocker and Corticosteroid IM or IV “If
clinical improvementnoted increasedblood pressure,
decreased bronchospasm”

• Generalized Anaphylaxis :
• No signs of allergy present : “unconscious patient”
• P-C-A-B
• Summon medical assistance.
• Administer oxygen.
• Monitor vital signs, recorded every 5 min.
• Addition management, on arrival of the emergency
medical personnel depend on the cause of the loss of
consciousness.

EMLA – Eutectic Mixtureof Local Anesthetics
• Used as topical anesthetic able to provide surface anesthesia for intact skin
• Composed of lidocaine 2.5% and prilocaine 2.5%
• Supplied as a 5g or 30g tube or as an EMLA anesthetic disc.
• EMLA anesthetic disc is packaged in protective laminate foil surrounded
by adhesive tape.

Indication
▪ As topical anesthetic in pediatric patient and needle phobic patient
▪ Venipuncture
▪ Circumcision and gynecologic procedure
▪ During leg ulcer debridement
▪ Note: should be applied 1 hr before the procedure.
RECENT ADVANCES IN LOCAL ANESTHESIA – A REVIEW.Ananthi Christopher, International Journal of Recent Scientific Research
Research, October, 2016

Contraindicated
• Patient with congenital or idiopathic methemoglobinemia
• Infants younger than 12 month who are receiving treatment with
methemoglobine inducing agent
• Known sensitivity to amide type LA

Lidocaine and prilocaine periodontal gel
2.5%/2.5% (Oraqix)
• Eutectic mixture of local anesthetics
• Solution at room temperature; gel at body temperature
• First topical anesthetic specifically designed for scaling and root planing

Oraqix cartridge contents
➢ Lidocaine/prilocaine 2.5%/2.5%
➢ HCl for pH adjustment
➢ Purified water
➢ pH7.5-8.0

Electronic Dental Anesthesia
• Principle of Transcutaneous Electrical Nerve
Stimulation (TENS) which has been used for the relief of pain.
• Some limitations are increased salivary flow and inability to use metal
instruments freely.
• It is powered by a battery ,two small sponges are placed in the patients mouth or on
the face, which are attached to the control box that the patient uses to select the
depth of anesthesia

Indication
▪ Patient having needle phobia
▪ Ineffective LA
▪ Instances where LA cannot be administered
▪ TMJ(chronic pain)
▪ Nonsurgical periodontal pain
▪ Restorative dentistry
▪ Fixed prosthodontic procedure
RECENT ADVANCES IN LOCAL ANESTHESIA – A REVIEW.Ananthi Christopher, International Journal of Recent
Scientific Research Research, October, 2016

Advantages
• No need of needle
• No need for injections of drugs
• Patient is in control of the anesthesia
• No residual anesthetic effect at the end of procedure
• Residual analgesic effect remains for several hours

Disadvantages
• Cost of the unit
• Training
• ‘Learning curve‘ initial success may be low but increases with experience
• Intraoral electrode:weak link in the entire system
• It is contraindicated in severalconditions such as heart disease,
seizures,neurological disorders, brain tumors, patients wearing pacemakers
and cochlear implants

Dentipatch
• a patch that contains 10-20% lidocaine is placed on the dried mucosa for 15
minutes.
• Hersh et al (1996) studied the efficacy of this patch and recommended it for
use in achieving topical anesthesia for both maxilla and mandible.
RECENT ADVANCES IN LOCAL ANESTHESIA – A REVIEW.Ananthi Christopher, International Journal of Recent
Scientific Research Research, October, 2016

Jet Injection
• Jet-injection technology is based on the principle of using a mechanical energy source to
create a release of pressure sufficient to push a dose of liquid medication through a very
small orifice.
• creating a thin column of fluid with enough force that it can penetrate soft tissue into the
subcutaneous tissue without a needle

Newer Local Anaesthetic Drugs and Delivery Systems in
Dentistry – An Update by sharma et al JDMS,2012

• advantages over traditional needle injectors by being fast and
easy to use, with little or no pain,less tissue damage ,faster
drug absorption at the injection site
• This technique is particularly effective for palatal injections
• Marketed as Syrijet and MED-JET H III

Iontophoresis
• Iontophoresis is non-invasive transdermal drug delivery
• This technique is a suitable alternative for application of drug in achieving surface
anesthesia.
• It is a painless modality of administrating anesthesia.

• a fast and effective way to apply a local anesthetic without needles or pain. The
method is faster and penetrates deeper than topical anesthetic creams and is an ideal
alternative for numbing the skin before injections and biopsies.
• After just 10 minutes, the skin is as numb as after 60 minutes of traditional treatment
with creams.
• Eg, Xylocaine topical anesthetic solution, 40 mg/ml.
• Xylocaine has a positive charge, so connect the anode (red clamp) to the drug
delivery electrode

CCLAD Systems (Computer Controlled Local Anesthesia Delivery
System)
• Introduced the first CCLAD system in 1997 and was termed the “WAND” and
the subsequent versions were renamed as “WAND PLUS” and“COMPUDENT”.
In 2001, DENTSPLY International introduced the
“Comfort Control Syringe – CCS” and similar devices originating outside USA
were; “Quick Sleeper, Sleeper
Ananthi Christopher., Shankar, P and Rohini, G.2016, Recent Advances in Local Anesthesia – A Review. Int J Recent Sci Res.
7(10), pp. 13576-13581.

• Wand” has 3 components: Base unit, Foot pedal and Disposable Handpiece
assembly
• Base unit consists of a microprocessor and connects to the foot pedal
and Handpiece assembly that accepts the LA cartridge.
• LA solution from the cartridge passes through the microbore tubing in the
Handpiece assembly and needle into the target tissue
7(10), pp. 13576-13581.

• Rate of Injection: foot pedal controls the rate of injection and if aspiration
feature is enabled, it prevents inadvertent intravascular injections.
• 1. Slow: 0.005ml/s – needle insertion, PDL injection, Palatal
administration
• 2. Fast: 0.03ml/s – buccal infiltrations,nerve block
• 3. Turbo: 0.06ml/s
7(10), pp. 13576-13581.
Gibson et all concluded in his study that that wand was an effective
technique in reducing the fear and anxiety levels in children as compared
to conventional technique.

“Single Tooth Anesthesia System – STA System” was introduced by Milestone
Scientific in 2007.
• Its advantages include „Dynamic Pressure Sensing – DPS‟
• which provides continuous feedback to the user about
the pressure at the needle tip to identify the ideal needle placement for PDL
injections.
Ananthi Christopher., Shankar, P and Rohini, G.2016, Recent Advances in Local Anesthesia – A Review. Int J Recent Sci Res. 7(10),
pp. 13576-13581.

Ananthi Christopher., Shankar, P and Rohini, G.2016, Recent Advances in Local Anesthesia – A Review. Int J Recent Sci Res.7(10),
pp. 13576-13581.
• Rate of Injection: 3 modes to control the rate of injection
• STA mode: Single, slow rate of injection
• Normal mode: emulates the Compudent device
• Turbo mode: faster rate of injection – 0.06ml/s

Comfort Control Syringes
• Consists of two components; base unit and syringe.
• The most important functions of the unit (injection and aspiration) can be
controlled directly from the syringe.
• Rate of injection: Five different basic injection rate settings for specific
applications: block, infiltration,PDL, IO and Palatal regions.
• The unit uses two stage delivery rates for every injection.
• It initially expresses the LA solution at an extremely low rate and after 10
seconds the rate slowly increases to the pre-programed value for the
selected injection technique.

Advantages of CCLADs
1) Ability to administer small quantities of LA solution continuously during
needle insertion, which anesthetizes the tissue immediately ahead of the
advancing needle.
2) Steady infusion of the anesthetic solution at the target site reduces the
discomfort associated with less controlled injections.
3) More accurate needleinsertion
4) Less pain oninjection
5) Less fear ofinjection
6) More controlled insertion of theneedle

7) Ability to rotate the Handpiece back and forth during needle insertion to avoid
needle deflections & reduced force for insertion leading to more comfort for patients
8) Ability to perform newer techniques such as
a.AMSA – anterior middle superior alveolarblock
b. PDL – periodontal ligamentinfiltration
c.P-ASA – palatal approach to anteriorsuperior alveolar block.
pp. 13576-13581.

• Because of these attributes the CCLAD devices are better tolerated by patients
and produce less disruptive behavior can be used successfully for
• restorations,
• pulpal therapies &
• extractions in pediatric dentistry
pp. 13576-13581.
•Bernardin et all in 2017 said that Wand system may provide a less painful
injection when compared to the conventional local anesthesia and it seemed
to be better tolerated with respect to a traditional syringe.

Intra-Osseous Anesthesia
• The use of motor driven perforator to penetrate the buccal gingiva and
bone can be considered as the first modern technique of IO anesthesia.
• The devices used for this technique, inject the solution into the cancellous
bone adjacent to the root apex.
• Commonly used devices are:
i. Stabident
ii. X –Tip
iii. Intraflow
pp. 13576-13581.

(i)Stabident:
• It includes a solid 27 gauge perforator needle with a beveled tip and a plastic
base which fits a latch type slow speed contra-angle handpiece.
• This perforator creates a small tunnel through attached gingiva,periosteum
and alveolar bone.
• The insertion point of the perforator is in the attached gingiva, 2mm
below the facial gingival margin and midway between the tooth of intent
and immediately adjacent (distal) tooth.

• The angle of perforation is usually directed apically in the mandibular incisor
region whereas a more perpendicular angle is advantageous in the molar region
to avoid bending the perforator against the dense cortical bone.
• Later a 27 gauge ultra-short needle is used to deposit the local anesthetic
solution
pp. 13576-13581.

(ii)X-tip
• X – Tip: this system consists of three parts; the drill,perforator,
25 gauge guide sleeve
• The advantage of this system over Stabident
• the ease with which the perforation could be located for inserting the needle.
• The drill leads the guide sleeve through the cortical
plate into the cancellous bone.
• The drill portion is removed, leaving the guide sleeve in place, which directs
the needle into the cancellous bone to deposit the LA solution. Later the
guide sleeve is removed with a hemostat

(iii)Intraflow
• the Intraflow Anesthesia Delivery System is an “all in one” system that
allows the operator to perforate the bone and deposit the anesthetic
solution in a single step.
• The device is a dental handpiece equipped with an injection system built
into its body. A 24 gauge hollow perforator is used to penetrate the bone
and infuse the LA solution.

Vibrotactile devices
• aimed at easing the fear of the needle take advantage of the gate control theory of
pain management, which suggests that pain can be reduced by simultaneous
activation of nerve fibers through the use of vibration
• Devices are :vibrajet,dentvibe and accupal
pp. 13576-13581.

VibraJet
• It is a small battery-operated attachment that snaps on to the standard dental
syringe. It delivers a high-frequency vibration to the needle that is strong
enough for the patient to feel.

DentalVibe
▪ It is a cordless, rechargeable, hand held device that delivers soothing, pulsed, percussive
micro-oscillations to the site where an injection is being administered.
▪ Its U-shaped vibrating tip attached to a microprocessor-controlled Vibra-Pulse motor
gently stimulates the sensory receptors at the injection site, effectively closing the
neural pain gate, blocking the painful sensation of injections.

Accupal
• A cordless device that uses both vibration and pressure to precondition the
oral mucosa.
• Accupal provides pressure and vibrates the injection
site 360° proximal to the needle penetration, which shuts the “pain gate,” according to
the manufacturer.
• Applying moderate pressure, the unit light up the area and begins to vibrate. The
needle is placed through a hole in the head of the disposable tip, which is
attached to the motor.

• Jayanthi et all in 2015 investigated the effects of vibration stimuli on pain
experienced during local anesthetic injections in Thirty patients aged 6-12 years
old of both the genders and suggested that vibration can be used as an effective
method to decrease pain during dental local anesthetic administration.
• CCLAD systems to be very promising in achieving painless injections especially
with the AMSA, PASA, PDL injections. Vibrotactile devices also are useful in
achieving patient satisfaction during injection.
Effectiveness of new vibration delivery system on pain associated with injection of local anesthesia in children
Journal of Indian Society of Pedodontics and Preventive Dentistry, Vol. 33, No. 3, July-September, 2015, pp. 173-
Mungara Jayanthi

• Ujaoney S. et all in 2013 designed a Camouflage Syringe with a toy-like appearance
that veils the conventional syringe to permit topical application and injection of
local anaesthesia and ensure more involvement of the patient in the treatment
process.
• He concluded that Camouflage Syringe is highly efficacious in dental procedures
requiring a fear-controlled delivery of topical or local anaesthesia.
Efficacy trial of Camouflage Syringe to reduce dental fear and anxiety, Ujaoney S. European
Journal of Paediatric Dentistry vol. 14/4-2013

Local anesthesia in pediatric dentistry

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