This document summarizes various local anesthesia techniques used in dentistry. It describes the basic atraumatic injection technique in 19 steps and provides details on various local anesthesia techniques including topical anesthetics, local infiltration, field blocks, and nerve blocks. It also discusses newer trends in pain control during local anesthesia administration such as safety syringes, computerized delivery systems, and vibration devices. Complications of local anesthesia and contraindications are briefly covered as well.

1. LOCALANESTHESIA

2. CONTENTS
• TECHNIQUE
• ARMAMENTARIUM
• COMPLICATIONS
• REFERENCES
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3. Basic atraumatic injection technique
1. Use a sterilized sharp needle
2. Check the flow of anesthetic solution
3. Determine whether to warm the anesthetic cartridge or syringe
4. Position the patient
5. Dry the tissue
6. Apply topical antiseptic(optional)
7. A. Apply topical anesthetic
B. Communicate with the patient
8. Establish a firm hand rest
9. Make the tissue taut
10.Keep the syringe out of the patient's line of sight
11. A. Insert the needle into the mucosa
B. Watch and communicate with the patient
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4. 4
12.Inject several drops of local anesthetic solution(optional)
13. Slowly advance the needle toward the target
14. Deposit several drops of local anesthetic before touching the periosteum
15. Aspirate
16. A. Slowly deposit the local anesthetic solution
B. Communicate with the patient
17. Slowly withdraw the syringe
18. Observe the patient
19. Record the injection in the patient's dental chart

5. Various techniques are:
• Topical anaesthetics
• Local infiltration
• Field block
• Nerve block
Topical Anaesthetics :
They affect the free nerve endings. These are available in gel, liquid,
ointment and pressurized spray forms. Eg: Ethyl aminobenzoate,
Butacaine sulfate, Cocaine, Dyclonine, Lidocaine, and Tetracaine. -
Benzocaine offer a more rapid onset and longer duration of anesthesia
than other topical agents.
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6. 6
• Indications:
- reduce the slight discomfort that may be associated with the insertion
of the needle before the injection of the local anesthetic.
• Disadvantages:
- Disagreeable taste
- The additional time required to apply them may increase the child's
apprehension concerning the approaching procedure.
• Application:
Dry the mucosa with gauze at the site of the intended needle insertion
and a small amount of topical anesthetic agent is applied to the tissue with a
cotton swab. Topical anesthesia should be produced in approximately 30s.

7. • Local Infiltration :
Small terminal nerve endings in the area of the surgery are flooded
with L.A. solution rendering them insensitive to pain or preventing them
from becoming stimulated and creating an impulse.
Needle used: 1inch, 25 gauge needle
Amount of solution: 0.6-1.0mL buccally and just sufficient to cause
blanching palatally.
Examples: Supraperiosteal(infiltration),
Intraligamentary injection(0.2mL),
Intraseptal injection(0.1mL),
Intracrestal injection,
Intraosseous injection
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8. • Field block :
Depositing a suitable L.A. in the proximity to the large terminal nerve branches
so that the area to be anesthesized is circumscribed to prevent the central passage
of afferent impulses. Thus maxillary injections administered above the apex of the
tooth to be treated are properly termed field blocks.
• Nerve block :
Suitable L.A. is deposited within close proximity to a main nerve trunk, thus
preventing afferent impulses from travelling centrally beyond that point.
Needle used: 1 5/8-inch, 25guage needle
Amount of solution: 1.8-2.0mL
Examples: PSA, MSA, V2, Greater(anterior) palatine, Nasopalatine, Anterior
middle superior alveolar(AMSA), Palatal approach ASA(P-ASA) nerve block,
Inferior alveolar, Buccal, Mandibular, Mental, Incisive nerve block
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9. Inferior Alveolar Nerve Block ( Conventional Mandibular Block/ Halsted
approach)
Nerves anesthesized: Inferior alveolar, Incisive, Mental, Lingual
Areas Anesthesized: Mandibular teeth to the midline, Body of mandible, inferior
portion of ramus, buccal mucoperiosteum, anterior 2/3rd of tongue and floor of oral
cavity, lingual soft tissues and periosteum
Landmarks: a. Mucobuccal fold
b. Anterior border of ramus of mandible
c. External oblique ridge
d. Retromolar area
e. Internal oblique ridge
f. Buccal sucking pad of fat of tissue
g. Pterygomandibular raphe
h. Coronoid notch
i. Pterygomandibular space (deposited in this space)

10. Area of insertion: Mucous membrane on medial side of mandibular ramus at the
intersection of 2 lines: 1 horizontal line that represents the height of needle insertion
and 1 vertical that represents the AP plane of injection.
3 parameters to be considered during injection:
• Height of insertion: lies 6-10mm above the mandibular occlusal plane
• AP site of injection: at the intersection of 2 points. Point 1 falls along the
horizontal line from coronoid notch to deepest part of pterygomandibular raphe as
it ascends vertically toward the palate. Point 2 is on a vertical line through point 1
about 3-4ths of distance from anterior border of ramus. This determines AP site of
injection.
• Penetration depth: Bone should be contacted. Average depth of penetration to
bony contact in adult is 20-25mm( approx.2/3rd to 3/4th length of a long dental
needle).
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11. • Buccal nerve block :
Areas anesthesized : soft tissue and periosteum buccal to mandibular molar
teeth
Landmarks: Mandibular molars, Mucobuccal fold
Depth of penetration: 1-2mm,
Amount of deposition: 0.3mL over 10s
• Anterior Superior Alevolar Nerve Block (Infraorbital Nerve Block)
Nerves anesthesized : ASA, MSA, Infraorbital Target area: Infraorbital
foramen
Area of insertion: Height of mucobuccal fold directly over the first
Premolar Landmarks: Mucobuccal fold, Infraorbital notch, Infraorbital
foramen
Amount of solution: 0.9-1.2mL over 30-40s
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12. Posterior superior alveolar nerve block :
Nerves anesthesized: PSA and its branches
Area of insertion: height of mucobuccal fold above the maxillary 2nd
molars
Landmarks: mucobuccal fold, maxillary tuberosity, zygomatic process
of maxilla
Amount of solution: 0.9-1.8ml over 30-60s
Greater Palatine Nerve Block :
Areas anesthesized: posterior portion of hard palate and its overlying
soft tissues, anteriorly as far as the first premolar and medially to the
midline.
Area of insertion: soft tissue slightly anterior to the greater palatine
foramen
Landmarks: greater palatine foramen and junction of maxillary

13. Prevention of Toxicity
• Appropriate dosing
• Careful aspiration
• Giving test dose prior to full dose
• Giving the drug slowly(incremental
dose)
• Monitor side effects especially toxicity
CONTRAINDICATIONS
• There is no absolute contraindication
but precautions should be taken in the
• following conditions:
• - Very insane- mentally retarded
• - Chronic debilitating disease-
septicemia, diabetes, bacteremia
• - Bleeding disorder
• - Steroid therapy- Adrenal crisis
• - Anticoagulant therapy
• - Liver or renal disorders
• - Epilepsy
• - Radiation therapy
• - Hyperthyroidism
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14. RECENT TRENDS IN PAIN CONTROL
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15. Safety syringes
• Eg : Ultrasafe syringe, Ultra safety Plus XL syringe
• They minimize the risk of accidental needlestick injury occurring with the contaminated
needle. They possess a sheath that locks the needle when it is removed from the
patient's tissue.
• Advantages: disposable, single use, sterile, lightweight
• Disadvantages: more costly, different to first time users.
Computer Controlled Local Anesthetic Delivery System
• Introduced to dentistry in 1997. Also called as Wand system. Single use disposable
safety handpiece . This system administers L.A. solution at two specific rates: - slow
rate 0.5mL/min and fast rate 1.8mL/min
• Advantages: precise control of flow rate and pressure, increased tactile sensation,
nonthreatening, automatic aspiration
• Disadvantages: requires additional armamentarium and is costly.
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16. 20XX presentation title 16

17. Comfort Control Syringe :
Introduced after Wand. Electronic preprogrammed delivery device.
L.A. is deposited more slowly and consistently. It consists of 2 stage
delivery system.
- Local Anesthetics with New Additives Like Centbucridine,
Ropuvacaine ,Tetrodoxin
Eutectic Mixture of Local Anesthetic
It consists of 5%cream containing 25mg/g of lidocaine and 25mg/g of
prilocaine. It should be applied 1hour before procedure and the cream is
covered with an occlusive dressing. Numbing occurs 1hour after
application and lasts for 1-2hours after removal. But this may cause
transient and mild skin blanching and erythema.

18. 20XX presentation title 18
• Electronic Dental Anesthesia :
It provides pain control for administration of L.A. It provides
excellent soft tissue anesthesia. Effective for pain control in needle
phobics. EDA when applied at its low frequency setting for a period of
10-15mins removes a large volume of residual anesthetic solution and
thereby partially//totally reverses the anesthetic effect.
Advantages: no injection of drug and no residual anesthetic
effect at the end of the procedure.
• Vibraject
It is a small vibrating dental injection attachement device.
The device has a clip motor that gets easily attach to most kind of
dental injections. The clip bracket is autoclavable.

19. • Dental Vibe :
It is a cordless, rechargeable and hand-held device that delivers soothing, pulsed, and
percussive microoscillations to the site where an injection is being administered.
• Accupal
It is a cordless device that uses both vibration and pressure to precondition the oral
mucosa.
• Jet Injectors
This is based on the principle that small quantities of liquids forced through very small
openings under high pressure can penetrate mucous membrane or skin without causing
excessive tissue trauma. One jet injection device Syrijet MarkII holds a standard
1.8mL cartridge of L.A. It can be adjusted to expel 0.05-0.2mL of solution under
2000psi pressure.
Advantages: - produces surface anesthesia instanyly, is quick and painless
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20. Med-Jet H III
Injex :
This jet of anesthetic solution painlessly or by causing only slight pain can
penetrate the mucosal tissue. The degree of penetration in the tissue is a
function of volume of anesthetic being used and the nozzle pressure. The
shorter onset time also reduces the treatment induced stress for children.
- Devices for Intraosseous Anesthesia like: Satbident, Intraflow
Buzzy System:
Buzzy is a reusable 8*5*2.5cm plastic bee containing a battery powered
vibrating motor with an 18g solidly frozen ice pack underneath. It is shaped
like a bumblebee whose wings contain freezable gel packs, hence making it
fun for children while also distracting them from the pain. It is considered to
be an effective combination of coldness and vibration.

21. REFERENCES
• Handbook of Local Anesthesia, 7th edition, Stanley F.Malamed
• Textbook of Pediatric Dentistry, 4th edition, Nikhil Marwah
• Mcdonald and Avery's Dentistry for the Children and Adolescent,
Second
South Asia Edition
• Shobha Tandon Paediatric Dentistry, 3rd edition, Volume 2
• Principles and Practice of Pedodontics, Aarathi Rao
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