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Local Anesthesia in Endodontics

Dr. Soliman Kamha

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The dentist has many techniques available for controlling pain: topical anesthesia, local anesthesia, regional anesthesia or nerve blocks, and of supplemental forms anesthesia.
Dr. Soliman Kamha 2

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TOPICAL ANESTHESIA
It is the topical application of anesthetics for various reasons. The principal means by which topical anesthesia is administered are liquids, troches, gels, sprays, and cooling. This type of anesthesia is indicated for desensitizing the mucosa to needle pricks, which would be necessary for local infiltration.
Dr. Soliman Kamha 3

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Dr. Soliman Kamha

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LOCAL INFILTRATION
Local infiltration may be defined as a technique by which an anesthetic solution is deposited within the treatment area. This technique permits rapid, effective anesthesia for: - all the maxillary teeth and - mandibular incisors.
Dr. Soliman Kamha 5

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To anesthetize the nerve fibers that innervate the palatal root of the upper molars or premolars, or any other tooth that has a palatal root, it is advisable to perform a palatal infiltration after the vestibular infiltration. The palatal root is usually closer to the palatal than vestibular cortical bone; thus, a buccal infiltration alone may not suffice.
Dr. Soliman Kamha 6

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Palatal infiltration is quite painful. Therefore, it should be performed slowly by steadily depositing a small amount of anesthetic (0.5 ml) under adequate pressure.

Dr. Soliman Kamha

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REGIONAL ANESTHESIA OR NERVE BLOCKS


Regional anesthesia or nerve block involves a larger area than infilteration; however, it more precisely anesthetizes the entire distribution of a specific nerve. It is achieved by depositing the local anesthetic near the trunk of a major nerve, thus blocking the afferent impulses from travelling proximal to that point.
Dr. Soliman Kamha 8

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The success of this method depends on the dentists precision in depositing the anesthetic solution at a pre-selected anatomical point. The anesthetic diffuses from this point in sufficient amounts and concentrations to produce the desired effect.
Dr. Soliman Kamha 9

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Inferior alveolar nerve block


This is usually called mandibular nerve block. It serves to anesthetize all the mandibular nerves of the same quadrant. However, because the lower central incisors may be innervated by the controlateral hemiarch, it is preferable to anesthetize them by a vestibular infiltration to obtain more certain results.
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Adequate anesthesia is indicated by tingling and numbness of the lower lip and, when the lingual nerve is affected, the tip of the tongue. This technique does not achieve anesthesia of the vestibular mucosa or periostium associated with the molars, which are innervated by the buccinator nerve.
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Mental nerve block


Anesthesia of the canine and lower first premolar can be achieved at the level of the mental foramen, rather than mandibular spine. This has the advantage of taking effect sooner and avoiding anesthesia of the tongue, thus sparing the patient pointless paresthesiae.
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It is performed by depositing the anesthetic solution near the mandibular canal, at the level of the mental foramen. The needle is inserted in the alveolar mucosa between the two premolars, about 1 cm external to the vestibular surface of the mandible.
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Dr. Soliman Kamha

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Particular attention must be paid to not injuring the mental nerve with the point of the needle. It must not be introduced in the mental foramen.

Dr. Soliman Kamha

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Nasopalatine nerve block


The innervation of the soft tissues of the anterior one third of the palate arises from the nasopalatine nerve, which emerges from the incisive foramen. Course of the nasopalatine nerve after its emergence from the incisive foramen. In the region of the canine, terminal branches of this nerve are superimposed on terminal branches of the anterior palatine nerve.
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Anesthesia is achieved by introducing the needle into the palatine surface, next to the incisive papilla, and injecting the anesthetic under pressure. This procedure may be quite painful. However, it is usually necessary in the case of extractions or other surgical procedures in this area.
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Anterior palatine nerve block


The innervation of the soft tissues of the posterior two-thirds of the hard palate arises from the anterior palatine nerve. This nerve emerges from the greater palatine foramen, which lies between the second and third molars, half-way between the alveolar crest and midline of the palate.
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Course of the anterior palatine nerve after its emergence from the greater palatine foramen Anesthesia is achieved by introducing the needle near the point of emergence of the nerve from the foramen.
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This procedure is also quite painful and is used for extractions or surgical procedures, when anesthesia of the soft tissues of the hard palate from the tuberosity to the region of the canine or from the midline of the hard palate to the gingival margin is required.
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SUPPLEMENTAL ANESTHETIC TECHNIQUES Lingual infiltration It is useful in lower first molars with pulpitis. Holding the syringe parallel to the occlusal plane, the needle is introduced into the lingual gingiva about halfway between the gingival margin and the base of the fornix.
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The development of a whitish area of ischemia assures that the technique is correct. If, instead, a bubble-like collection of anesthetic forms in the lingual fornix, the technique is incorrect. The approach must be repeated by inserting the needle more occlusally.
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Intraseptal injection This is accomplished at the level of the bony septum by introducing the needle into the dental papilla and injecting a minimum amount (0,2-0,4 ml), distally to the tooth to be anesthetized.

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Because this type of anesthesia must be performed directly within the cancellous bone, the dentist must overcome high pressures with the injection. For this reason, the use of an appropriate pressure syringe, such as Peripress, is recommended, together with a 27-gauge short needle.
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As for all the intraosseous injections, it is advisable to use an anesthetic solution without vasoconstrictor, in order to avoid systemic effects. This anesthesia is indicated when the periodontal involvement precludes the use of the intraligamental injection.
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The advantages of the intraseptal anesthesia are several: only a minimum volume of solution is required, there is no lip and tongue anesthesia, immediate onset of action (less than 30 seconds) and presents very few postoperative complications. The pulpal anesthesia has a short duration, and this has to be into consideration during endodontic treatment.
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Intraligamental infiltration Injection into the space of the periodontal ligament is most effective when the local anesthesia achieved with traditional techniques is incomplete.
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This type of anesthesia is performed with the appropriate syringe, such as Peripress, Citoject , or Ligmaject, by introducing the small needle (27-gauge) into the space of the periodontal ligament, making sure that the needles bevel faces the bone of the alveolar crest, according to some authors,or, according to others, the root of the tooth so as not to damage the radicular cementum.
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The needle must be forced to the point of maximal penetration, and the anesthetic must be injected under high pressure. In multirooted teeth, the anesthesia must be repeated for each root, The indroduction of the needle should always be in the interproximal areas, never on the buccal.
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The anesthetic effect is immediate and prolonged. The size of the needle has little relation to the anesthetic effect. The manufacturers of pressure syringes recommend very thin needles (0.30 mm in diameter), but these tend to bend easily. Better results are obtained with short, 25/27-gauge needles.
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Contraindications to the intraligamental injection include infection or severe inflammation at the injection site and primary teeth. Brannstrom et al. reported the development of enamel hypoplasia in permanent teeth, following the administration of the periodontal ligament injection.
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In contrast to intrapulpal anesthesia, which is always painful for the patient, intraligamental anesthesia is painless if done after standard anesthesia. Other advantages of intraligamental anesthesia are that it does not require special equipment. It may be done with a pressure syringe, but may also be done with the same syringe and needle used for the standard injection
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Nevertheless, the use of appropriate syringes is recommended, since they may attain pressures more than twice as high as regular syringes. Furthermore, since the vial is sheathed in a metallic or Teflon container, they better protect the patient against accidental rupture of the glass vial, which can occur as a result of the high pressure generated.
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If it becomes necessary to use this type of anesthesia when the rubber dam is already in position, it is not necessary to remove or lift it. The opening of the rubber dam may be stretched slightly to identify the space into which to insert the needle.
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If the need arises, intraligamental anesthesia may also be performed with the rubber dam in place. There is no need to remove the rubber sheet; it needs only be stretched aside Regarding the anesthetic solutions distribution tissues, in the intraligamental anesthesia must be considered all effects an to intraosseous anestesia.
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The injected solutions are rapidly absorbed by the systemic circulation For this reason, the use of anesthetics containing catecholamines for intraligamental anesthesia is inadvisable in patients with ischemic heart disease or hypertension.
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In conclusion, the preferred supplemental technique to obtain profound pulpal anesthesia if the standard block or infiltration injection is not effective, at this time is the periodontal ligament injection. If even the periodontal ligament injection does not effect profound pulpal anesthesia, the intrapulpal injection is the next option
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Intrapulpal infiltration The intrapulpal injection assures certain results in 100% of cases. It requires the injection of anesthetic through as small an opening as possible in the roof of the pulp chamber.
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It is important that the chamber opening be small and that the needle be well engaged. This assures good pressure within the chamber itself. The pressure thus transmitted to the pulp tissue causes instantaneous, profound anesthesia, even for very prolonged endodontic procedures.
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In multi-rooted teeth, however, it may be necessary to repeat this type of anesthesia in the individual canals. The anesthesia may be painful, but the sensitivity will last for only a few seconds. It suffices to inject a few drops of anesthetic under pressure to obtain the desired effect.
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Intra-osseous anesthesia
It is a supplemental technique where the solution is deposited directly into cancellous bone adjacent to the affected tooth.

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The technique involves three simple steps: 1. anesthesia of the attached gingiva 2. cortical bone perforation 3. deposition of anesthetic solution into cancellous bone.
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A special perforator is used to penetrate though bone, then a guide sleeve is left through which the needle is inserted and the solution deposited slowly.

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Since it is directly inside bone, the vasoconstrictor will enter the circulation and cause palpitations that will resolve in few minuites.

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The duration of anesthesia in ALL SUPPLEMENTAL injections is shorter than with standard infiltration or nerve block. The duration ranges between 15 to 30 minutes which is quite sufficient to remove pulpal tissue.
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