‫بسم الله الرحمن الرحيم‬

Our lecture today will be about local anesthesia, we will start by talking
about pain & control methods of pain.
Pain is a highly personalized state accompanying tissue damage. So there
should be a stimulus that causes the damage, this stimulus could be real like
skin laceration, bruise or inflammation, or it could be apparent such as a
person has a pain in the abdominal area because of the distention, the pain
is not as a result of real tissue damage, it is as a result of pressure.
Another definition of pain is unpleasant sensory & emotional experience
(that is why different people express their pain in different ways, the threshold is
different from one person to another & that is all because of psychological &
emotional aspects of pain.)it is localized to a part of the body & associated with
actual or potential tissue damage.

Types of pain:
1)acute pain: is usually sharp , localized , more severe , &stops if the
stimulus is removed.
2)chronic pain: is dull, long term pain , the area is not as localized as in
acute pain & there is not apparent site of injury .

Types of stimuli that resulting in pain sensation:

1)mechanical stimuli such as pressure, bruising , laceration & trauma
2)chemical stimuli like acids.
3)thermal stimuli
4)electrical stimuli

In the body there are special receptors that receive pain sensation are called
the Nociceptors. so they are nerve endings response to stimuli that actually
or potentially produce tissue damage.
These nociceptors are two types :
1)A Delta fibers: they are high threshold mechanoreceptors.
2)C fibers :they are polymodal fibers
These are the major fibers that we concern about as they associate with the
pulp & craniofacial area.
Both of them are innervated by small diameter fibers.

1
The non- nociceptors are low threshold mechanoreceptors fibers &
innervated by large diameter fibers.
To know the differences between the nociceptors & the non- nociceptors
look at this example:
Thermal nociceptors respond to high skin temperature which is the burning
temperature (high threshold)
But the non-nociceptors respond to lower skin temperature described as
cold or warm temperature (low threshold).
Now if we want to compare between A-delta &C fibers
A-delta fibers are the fast conducting fiber as they are myelinated & they
respond to mechanical stimulation while the C fibers can respond to more
than one stimulus.
The pain that results from their stimulation is usually localized stinging
pricking pain which is acute type of pain while the C fibers can be
agonizing
Burning diffuse intolerable pain.
The A-delta fibers cover a larger area than C fibers.
The A-delta fibers have the property of sensitization which means if you
do a brief or slight stimulation then you apply something a bit stronger &
then something a bit stronger & so on , you can affect the threshold of the
nerve & make it lower & the fiber becomes active & the pain becomes
continuous. & this what happened in case of infection & inflammation
this phenomena is responsible of hyperalgesia or hypersensitivity that
happens in damaged tissue.
This is what usually happenes in an inflamed pulp or wound ,continuous
stimulation will lower the threshold while the pain is continuous & this is a
unique quality of the nociceptors.

Now…in the craniofacial region we have a trigeminal nociceptors in the

dental pulp , some of A-delta pulpal fibers respond to the mechanical
stimulation of the dentin such as drilling or when you blow air or water or
the temperature of the water you blow or throbbing . other fibers can
respond to thermal stimuli.

2
The c fibers also respond to thermal stimuli.
Pathway of pain means how you can feel pain from its origin until it
reaches the cranial region .
The sensory nerves which are cranial nerves number V(trigeminal)
,VII(facial), IX(nasopharyngeal) ,&X(vagus) ,these are equivalent to the
dorsal roots of the spinal nerves which are responsible about the sensation
in different parts of the body, the cell bodies of them are found in the
ganglia of these nerves.

These pain pathways are two types:

1)the first pathway for the receptors that respond to pain , temperature ,
simple touch & pressure that we will call it a sensory pathway.

2)the second pathway are mechanoreceptors for the propriception .

Propriceptors are responsible to pressure sensation & they are found in the
periodontal ligament & the tendons of the muscles.

In each of these pathways there are three steps & three principles neurons :
First ,second ,& third order neurons

Now.. you have to remember the anatomy of the trigeminal nerve

The trigeminal nerve is attached to the lateral part of the pones & it gives
three nuclei :
1)a sensory nucleus
2)a small motor nucleus(it is not entirely motor& join only to the mandibular
division later to move some muscles in the mandible.
3)the msencephalic nucleus.

The sensory roots (the dorsal divisions of the spinal nerves) is continuous
with the trigeminal ganglia & it is located in the trigeminal cave in the
middle cranial fossa ,the whole nerve actually located in the middle cranial
fossa.,

3
The divisions of the nerve which are the ophthalmic , the maxillary & the
mandibular descend directly from the ganglion & go directly to different
parts.

The motor roots (the ventral divisions of the spinal nerves) pass beneath the
ganglion to join the motor nucleus later on.

The ascending pathways: the first, second & third order neurons, they
ascend from the site of pain to the brain.
There are many ascending pathways in the body, but the one that we are
concerned about is trigeminothalamic tract .
The first order neuron is the neuron that transmit the action potential from
the receptors to the nucleus ,so in this tract the first order neurons carry the
action potential from the nociceptors to the sensory nucleus, & from the
propriceptors to the mesencephalic nucleus & from the motor receptors in
the muscles to the motor nucleus.
From these nuclei the action potential go through a higher neuron which is
the second order neuron, the mesencephalic nucleus & the sensory nucleus
will transmit their action potentials to the thalamus, then the thalamus sends
them through the third order neurons to the cortex where every thing is
memorized so it can tell you the type of the sensation.

In case of motor nucleus it will take the action potential through a reflex
arch because it will induce movement of the muscles , so if you put your
hand on something hot , the reflex arch will cause you to remove your
hand.

One of the theories of pain is the gate control theory:

It says that there are various gates that control the level of the stimuli that
you feel or the small fibers input to the spinal cord ,these small fibers are
the nociceptors which actually transmit the pain sensation to the dorsal
nuclei of the spinal nerves & this can be modulated by the larger fibers
which will stop the pain or inhibit the pain sensation or by higher CNS
input.

4
Sometimes you do not feel things as painful as they seem. So you get some
input from small fibers to the spinal cord & then the large fibers will
transmit something else to stop pain or actually to reduce it & sometimes
the CNS produce some chemicals like endorphin & encephalin to reduce
the action potential & stop the pain.
So, what is the meaning of gates control theory?
If the number of the action potentials of the small fibers exceeds those from
the large fibers then you will feel the pain.
For example if a child bruised himself then the father or the mother start
rubbing the area ,they are causing another sensation ,the first sensation is
the pain because of the fall or the bruise & the second sensation is the
rubbing, if this rubbing sensation exceeds the painful sensation then the
pain will be reduced . It may also cause distraction.
If the rubbing is not enough ,so the input of small fibers exceeds that of the
large fibers & the patient will feel pain.
So we can apply this in dentistry ,the shaking the lip during insertion of the
needle, so if we are going to give an ID block you can shake the lip so you
can distract the child & the mechanoreceptors will transmit the sensation
of shaking or vibration or touch or the temperature of your hand ,all of
these sensations will be felt by the patient & transmitted by the large fibers
.if these sensations are strong enough it will inhibit some of the pain that
caused by insertion of the needle.

So what are the pain control methods that are available today:
1)general anesthesia which will work on the CNS.
2)relative analgesia which affect the CNS in someway, such as nitric oxide
sfdation.
3)local anesthesia
4)analgesic drugs
(this order is from strongest to weakest)
A question from a student: what is the nitric oxide??
It is the laughing gas ,it makes muscles relaxation ,so if the patient is
extremely anxious it relaxes him.& it is also used in patient with gage

5
reflex during taking the impression. It has many applications in medicine &
dentistry.
The analgesics are two types:
1)the narcotics: they actually interact with the opoid receptors in the CNS
They result in analgesia, sedation ,& cough suppression so they are added
to cough medications.
They are used for severe pain . the draw back is the sedation so if the
patient takes them advise him not to drive & not to go work that day.
&they cause respiratory depression & dependence & abuse. Different
examples: morphine, codeine, & other types.

2)the non-narcotics: are used for mild-moderate pain which is 90% of

dental pain. so we need them more than narcotics. they exert their effect on
the peripheral nervous endings.
Examples: aspirin & acetaminophen & non-steroidal (you have to read about
them from the slides, the doctor said that we have to know the dosage)

Local anesthesia:
They work on the sodium channels in the nerve membrane ,they lock these
channels .as you know in order for action potential to happen,the sodium
ions must enter from extracellular fluid to the intracellular fluid through
these channels & cause a gradient in the charges.
When the local anesthesia is applied , it closes these channels & the sodium
can not enter so you do not so you do not feel pain.
Types of local anesthesia:
1)the amide: the most of the types that we use are amides such as
lidocaine, bupivicaine, prilocaine & articaine

2)the esters : such as procaine & topical anesthetic agent(benzocaine)

What is the difference between amide & ester?

6
Both amide & ester have the same groups the lipophilic & the carbon chain
which also joins to hydrophilic group the type of junction between them is
only the different.
The onset & duration of local anesthesia depend on:
1)PH & pka of the tissues: these are the most important factors &the pka is
more important than PH.
PH drops during infection & this will lead to a delayed onset of pain .
Pka is the point at which the drug is ionized into the positively charged &
the negatively charged parts. So it is the PH at which the ionized & non-
ionized forms are present in equivalent concentrations.
You get an effective anesthesia if you have the uncharged part which is
lipophilic & the charged part which is hydrophilic.
So you get the effective anesthesia when you have the ionized form.
Why we need the two forms which are lipophilic & hydrophilic?
Because the cell membrane is lipophilic so the uncharged part which is the
lipophilic part will diffuse through the membrane , but the intracellular
fluid is hydrophilic that is why we need the hydrophilic part to diffuse
through it. So that is why the pka is the most important factor.

2)proximity: if you want to give anesthesia to a tooth, you should be as

closest as possible to that tooth.
3)nerve morphology :the thinner the fiber the easier the anesthesia .
4)higher concentration & greater lipid solubility improve the onset to a
small degree.

5)Duration of action:
Because local anesthetic agents usually causes vasodilatation of the blood
vessels we need something to help it to stay in the area & have a longer
duration , that is why we add vasoconstrictors.
In general the block effect is longer than infiltration, & tissue anesthesia
stays longer than pulpal anesthesia .
So if you look at the formulation of the drug & the duration of action..
You have to memorize the ones that have shortest & the longest duration,
you do not have to memorize the numbers.

7
So bupivicaine with epinephrine will have the longest action in case of soft
tissues & pulpal tissues in the mandible & in case of block & soft tissues in
the maxilla.
In case of lidocaine you have to know the numbers , you have to know the
durations. Because the patient will go home & he wants to know how long
the anesthesia will last.
So if we got about one hour in case of maxillary infiltration , so if you
anesthetized the patient & the procedure take half an hour, then tell your
patient that the effect of anesthesia will last another half an hour.
If you give an ID block, the effect of anesthesia will last for85 to 90
minutes, so in this case the effect will last an hour after the procedure (if
you do it in half an hour)
But the soft tissues will numb more than that, it lasts about two hours.
In case of mepivicaine which does not contain any vasoconstrictor ,it has
the shortest duration.
In case of pulpal infiltration we have articaine with epinephrine has the
longest duration & prilocaine has the shortest duration.

The metabolism of local anesthesia is how the body gets rid of this drug .in
case of amides ,they are metabolized in the liver, so if you have a patient
with a problem in the liver you have to be careful & adjust the dose.
Lidocaine is an amide but it is metabolized in the plasma & the kidney.
Once it is metabolized , it may cause methmoglobinemia which affects the
hemoglobin .
The esters are metabolized by cholinesterase in the plasma or pseudo-
cholinesrase.

In the carpule we have:

1)the local anesthetic agent
2)the vasoconstrictor
3)the preservative such as methylparaben which keep it until the expiration.
4)organic solute

8
Methmoglobemia can occur with lidocaine or prilocaine , & it associates
with the drug induced globinemia ,it causes oxidation of the iron atom in
the hemoglobin & produces something called methmoglobin.
So when the iron atom becomes ionized ,the hemoglobin changes into
methmoglobin.
So the RBCs can not carry oxygen & this causes cyanosis. & if you
measure the level of methmoglobin in the blood ,it will be 10-20%,so you
have cyanosis.
If it is higher than that present there will be dyspnoea & tachycardia.
Because more blood cells are attached & reduce the level of blood &
reaches the heart, that is why we get tachycardia & dyspnoea .
Risk factors: it occurs in people who are very old or very young( extremes
of age), patient who have anemia, patient who have respiratory diseases or
patient who have G6PD deficiency or who have methmoglobin reductase
deficiency. This an enzyme to get rid of the methmoglobin.

After you give local anesthesia ,sometimes you get some complications
,you want to be aware of these complications:
1)psychogenic factor: it is caused by anxiety , the patient creates the
problem with himself .The apprehension ,the tiredness, & the pain he feels
will cause the some sort of psychogenic reactions .
Sometimes he might faint because of the fear. so they are anxiety induced
&manifested by syncope , the patient might be hyperventilated , or there
might be shaking or might be some nausea, & alteration in his blood
pressure & in some very severe cases it might be as an allergic reaction.
2)allergy: it is rare in amide local anesthesia ,but in case of esters there
may be an increased risk for allergy.
Any allergy to one ester will role out the use of another ester. But allergy
to one amide does not role out the use of another amide.
Para-amino benzoic acid is one of the allergic component.
Allergy to epinephrine is physiologically impossible.
Metabisulphate is present with epinephrine & the methylparaben also are
allergen.
In some patient with latex allergy you have to be aware with the rubber
stopper in the carpool that the rubber may diffuse through the local

9
anesthesia & cause allergic reaction in his body( it is rare, but it is better to
know it)
Types of allergic reactions:
1)type I which is the immediate type.
2)type II
3)type III
4)type IV which is the delayed type.
Types I&IV are the most types that are associated with the local anesthesia.

Treatment of allergy:
1)avoid the allergens.
2)anti-histamine for mild skin reaction.
3)rapid rate of onset of reaction should be alert not to have anaphylactic
reaction.
The signs could be dyspnoea & nausea.
You have to give IM or SC epinephrine & call for medical help & take the
patient to the hospital.

The prevention of allergy: you should know the medical history very
well.

Toxic effect of the local anesthesia:

Toxicity means you have taken an increased does & it is different from
allergy .
The signs of toxicity are usually neurologic:
1)mild toxicity :headache ,drowsy ,high blood pressure.
2)moderate toxicity: tremor, epilepsy ,muscles contraction
3)severe toxicity :coma & respiratory depression.
Always tonic clonic convulsion will alert you to toxicity reactions.

The treatment of toxicity:

Drugs to convulsions & respiratory depressions, so you monitoring the vital
signs & protect the patient from injuring himself.
Place him in a supine position & call for medical help or take him to the
hospital.

10
If you have oxygen , give him oxygen.
You should have diazepam in your clinic, 5 mg / 5min until the
convulsions go away.
prevention of toxicity:
1)You have to know the toxic doses especially for lidocaine , if you give it
with epinephrine you have to give it 7mg/kg .If it is plain( without
vasoconstrictor) ,you have to give less amount which is 4.4 mg/kg.

In case of epinephrine especially with cardiac patient, you know the effect
epinephrine on α,β1,& β2 receptors ,there is accommodation of dose of
epinephrine not to be more than0.2 mg of epinephrine for the non-cardiac
patients & no more than 0.04 mg for patient with cardiac diseases.
Some people say these recommendations are arbitrary & you don’t have to
stick to them.
2) you have to know the medical history very well.

Treatment of epinephrine toxicity:

1)monitor the vital signs
2)place your patient in supine position
3)call for medical help
4)if there is a lot of rise in the blood pressure, give him sublingual
nitroglycerin

Prevention epinephrine toxicity:

1)slow injection
2)adhere to the toxic amount
3)take the medical history especially with cardiac patients.

You should know to calculate the toxic level , for example in the clinic we
use cartridges which contain 1.8 ml of the local anesthesia ,2% lidocaine,
1:100,000 epinephrine.
So 2% is actually 20 mg/ml
20*1.8=36mg of lidocaine in the cartridge., so for 10 kg child(about one
year of age) he can not receive more than 70 mg of lidocaine, so:
70/36 will equal about 2 carpules as a maximum.

11
You have to know if the patient get cyanosis give him methylene blue
which will reverse the cyanosis.

Parasthsia :a case in which the analgesia will last for a bit longer & this
happen in minor oral surgery when they do extraction of an impacted
wisdom tooth, they injure the lingual nerve & the anesthesia of the tongue
will last longer.
Reassure the patient ,it will resolved within 8 weeks.
You should give time to patient after anesthesia for efficiency, do not start
the work immediately after the injection.
Anatomical variations: some people differ from others ,as they have
accessory nerves especially the mandibular nerves, or the contra-lateral
innervations of anterior teeth sometimes the inferior dental nerve cross the
midline & innervate the other side, so you give anesthesia to one & the
patient still feels pain.

(the dr said that you have to be an expert in giving LA & very confident to
say that the patient feels pain because of anatomical variation)
Topical anesthesia:
it is a cream or jelly that comes in different flavours, such as mango,
strawberry or banana or mint ( mint not for children ,only for adult).
& only have the basic type which is benzocaine, there is no amla (another
type of topical anesthesia which is a mixture of different types)
If you want them to be effective ,dry the tissues & then apply them for at
least one minute up to five minutes so an average of two to three minutes.
Saftey issues for giving LA:
1)use aspirating syringe , so if you go into a blood vessel, it will aspirate
blood.
2)be strict not to touch the nerve, sometime the dentist touches the ID nerve
so the patient feels an electric shock.
3)syncope because of extreme fear.
4)reduce hepatic function: this is due to toxic dose, not due long duration
of action of local anesthetic
Behavior management :

12
(you can read them alone)
If you have to give a LA for a child, there are some techniques to make it
comfortable.
**counter irritation: during giving the LA, start make rubbing or
mechanical irritation there.
Distract him by talking to him about the movies that you watch yesterday.
**duration: always try to give you injection over times, not at once time, so
first when you break the tissue give a very little amount , then a little bit ,
then a little bit, so give it in one shoot.
Because the patient does not feel discomfort due to breaking the tissues, he
feels that because of fluid pressure. So do it very slowly & the patient will
feel more comfortable.
**always have good control on the patient’s head ,don’t let him to move
his head during giving the LA.
If his hands are in your way, let the nurse to help you , so she can put her
hands gently on his hands , to prevent any sudden movement which will
affect the procedure & harm the child.
**put topical anesthesia.
**The gauge of the needle represents the diameter of the needle, we have
27 or 30 ,the higher the gauge the smaller the diameter, the better the
needle.
**the length of the needle:
In children we only use the ultra short for infiltration & we use the short
type for the ID block, so we don’t use the long needle in the pedo clinic.
**the duration : give the injection slowly.
**the depth of the insertion: you will not give it superficially ,you have to
reach bone.
(you have to read about the techniques of the infiltration & the ID block &
the anatomy of pterygomandibular)

Now… if you give an ID block or an infiltration very well but it doesn’t

work , you can give what is called the supplementary anasthesia
Types of the supplementary anasthesia
1)intraligamentary technique

13
Here you are going to inject in the periodontal ligament, in the lower teeth
we usually apply it to the mesiobuccal & distobuccal area (at the corners),
put your needle in 45 degree between the gingival margin & the tooth , You
have to feel some pressure during giving it, suddenly the patient will not
feel anything & the anesthesia will resolved quickly ,lasts only for 15
minutes.
2)intrabony technique
You give the injection in the cancellous bone, sometimes you have to drill
some bone to give the injection.
3)intrapulpal for pulpatomy ,so if you are doing pulpatomy & after you
have entered the pulp chamber , the patient felt pain or sensetivity, you can
give him some anesthesia in the pulp directly.
Advantages of the supplementary anesthesia:
1)immediate onset
2)no collateral analgesia, so if you have to do the E on the left & the D on
the right & you don’t want to give two ID blocks then you can give
intraligemintary on both teeth & start your work.
3)needs less amount of anesthetic solution.
4)good for abscessed tooth ,because it has low PH so it is sometimes hard
to have good analgesia
Disadvantages of the supplementary anesthesia:
1)post-operative pain
2)rapid decrease in the blood flow (you can benefit from that when you do
class V cavity preparation, this give you good isolation)
3)it may increase the periodontal diseases & the pocket , so avoid it in case
of periodontal diseases
4)the need for many injections in multi-rooted
5)there is pressure &the duration is variable.
6)if the tooth is too far posteriorly then there is difficulty in the access.
7)it can induce bactereamia , so avoid it in patient with infective
endocarditis or hemophilia.

At the end of the lecture , I want to say hi for my best friends HEBBO &
AAYA
Done by :S7r .S. Rabab3h

14