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Local Anaesthesia / Analgesia

Rohana Kumara De Silva

Associate Professor/Oral and Maxillofacial Surgeon
Department of Oral Diagnostics and Surgical Science
University of Otago
New Zealand
Local anaesthetic agents work by blocking the sodium
channels in the nerve cell membrane
Available as a water soluble salt which need to be
dissociated to the active base to enter the cell
vasoconstrictor properties) MEPIVICAINE

Metabolised in the liver
Hydrolysed in the plasma by pseudo
cholinesterase to para
Prilocaine also
metabolise in lungs
This can leads to allergic reactions
What is in the local anesthetic solutionn
Local anaesthetic agent


Adrenaline, Felypressin

Preservative for Vasoconstrictor

Sodium metabisulphite or Sodium sulphite

pH regulator

Sodium Hydroxide, Hydrochloric acid

Other excipients

Sodium chloride and water for injection

Concentration of topical local anaesthetics is considerably higher than
that used for injection to facilitate the diffusion through the mucous
Available as a spray, cream or gel
Allow painless needle penetration of mucous membrane
Beware of the total dose of the anesthetic
Topical Benzocaine does not raise blood levels but in high doses it
can produce Methaemoglobinaemia
Counteract vasodilating action of local anaesthetic and keep it around
the nerve for longer period
Minimise bleeding at site of injection and therefore give a clear
surgical field (Not Felypressin

Side effects - CNS stimulation; increasing fear, anxiety, tension,
restlessness. throbbing headaches, tremor, weakness, dizziness,
pallor, respiratory difficulties and palpitation
Maximum dose 0.2 mg (200g) - 10 cartridges of 1:100000 for
healthy patients; 0.04 mg (40g) 2 cartridges in ASA III and IV

More effective on venous microcirculation than arteriolar therefore
not as good a haemostatic agent
Systemic actions are minimal but has antidiuretic and oxytocic

Breech-loading, metallic,
cartridge syringes
Aspirating, self-
self-aspirating or
Periodontal ligament injection
Intra bony injection systems
Jet injector Syrijet
Computer controlled injection
systems CompuDent
Disposable plastic syringes
Periodontal intra-
Provides pulpal anaesthesia for one
isolated tooth
Injection need to be placed in the
buccal and lingual(or mesial and
distal) side of each root
Bevel of the needle should be
towards the root surface and
slightly rotate before injection
Most of the solution diffuse to the
bone marrow
Contraindicated in the patients who
are prone to bacterial endocarditis
Patients may experience tenderness of
the tooth later
Peripress,, Ligmaject etc.
Computer controlled - STA
Sensory supply to oro facial region
Innervation of the
Maxillary teeth

Posterior superior
alveolar nerve

Middle superior alveolar


Anterior superior alveolar

Innervation of the soft tissue of the
All superior alveolar nerves

Infraorbital nerve

Greater palatine nerve

Nasopalatine (Incisal
Incisal)) nerve

Lesser palatine nerve

Innervation of the Mandibular teeth
Inferior alveolar nerve
Incisor nerve

Innervation of soft tissues of the lower teeth

Long buccal nerve
Mental nerve
Lingual nerve

Accessory innervations
Greater auricular nerve
Nerve to mylohyoid
Local anaesthesia techniques
Block local anaesthesia
Anaesthetise larger nerve trunk that supply a wider area
Anaesthetic solution deposit near the nerve bundle

Infiltration local anaesthesia

Injection of local anaesthesia immediately adjacent to the
treatment site (Field block)

Block the nerve fibers closer to their end

Depend on the diffusion of solution through the tissue

Inferior alveolar nerve block

Land marks

Coronoid notch

Pterygomandibular raphe

Mandibular premolar teeth on

opposite side

Mandibular occlusal plane

Inferior alveolar nerve block

Patient preparation

Patient supine or semi supine

Mouth wide open

Visualise the pterygomandibular raphe

Apply topical anesthetics and wait

about a minute
Inferior alveolar nerve block
Thumb on the coronoid notch

Other fingers on the posterior ramus

Visualise the deepest part of the

pterygomandibular raphe

Imagine a line between two places

This line is usually 6 - 10 mm. above

and parallel to lower occlusal plane
Inferior alveolar nerve block
Syringe direction from the opposite
lower premolar teeth

Insert the needle three fourth

posteriorly in this line

Pierce through mucosa and buccinator


Bone contact at the mid ramus in about

25 mm. depth
Inferior alveolar nerve block
Withdraw the needle 2 mm. from bone

Aspirate and slowly deposit about half of

the cartridge (Inferior alveolar nerve)

Withdraw the needle about 1cm and move

the syringe to the same side and deposit
half of the remaining (Lingual nerve)

Inject the rest near the coronoid notch or to

the distal buccal sulcus (Long buccal
Inferior alveolar nerve block
Patient will feel tingling sensation of the lower lip and
tongue in about two minutes (Subjective testing)

Objective testing in three to five minutes

Objective testing method For lower molar teeth

Press with a blunt instrument at:

l Buccal gingiva at lower molar region

l Buccal gingiva between or anterior to premolar teeth

l Lingual gingiva
Inferior alveolar nerve block
Important points to remember
Explain the procedure and what to expect
Position the patient and mouth fully open
Visualise and feel the guidelines
Topical anaesthesia and time lapse
Needle penetration
Withdraw and aspirate when bone contacted
Slowly inject sufficient solution
Time lapse
Subjective and objective testing
Inferior alveolar nerve block
Possible Difficulties

Interfere with the tongue

Early bone contact

Bone cannot be contacted

Positive aspiration of blood

Electric shock like feeling

Mandibular nerve block
Gaw--Gates technique
In this method all the branches of
the mandibular nerve blocked in
one injection
Wide open mouth
Insert needle behind upper second
molar tooth at the level of the
mesio--palatal cusp and direct to the
neck of the condyle
External landmarks Angle of the
mouth and inter-
inter-tragal notch
Deposit solution at neck of the
Supine or semi supine, mouth
Bevel of the needle towards
Needle at the level of
mucogingival junction at upper
2nd or 3rd molar tooth, parallel
to upper occlusal plane
Advance the needle 25-
25-30 mm,
aspirate and inject 1.5 to 1.8ml.
Infiltration Local Anaesthesia
Supraperiosteal (Paraperiosteal
Anaesthesia Technique

- axis of the tooth

- mucobuccal / labial fold

Stretch the lip outward and

Supraperiosteal (Paraperiosteal
Paraperiosteal)) Anaesthesia

Bevel of the needle towards bone

Insert the needle at mucobuccal fold

related to the tooth about 45
45 to the outer
If bone contacted, withdraw 1-
aspirate and inject about 1.5ml of solution
Intrabony injection technique

Radiograph to ensure that there is enough cancellous bone

Anaesthetise the soft tissue by infiltration of LA into the

buccal fold near the area to be perforated

Perforate into the cancellous space on the attached gingiva

with the instruments provided or with a small round bur
about 1 mm to 2 mm coronally to the mucogingival line
Slowly inject 0.9 mL of LA into the cancellous space
This volume provides pulpal anaesthesia for the teeth on
either side of the perforation
Injection should be done slowly, over about 45 seconds
per 0.9 ml, to avoid palpitations

Stabident system X tip system

Failure to achieve anaesthesia

Local complications

Complications due to overdose



Reactions unrelated to local anaesthesia

Psychomotor responses

Sympathetic stimulation

Spread of infections

Idiosyncratic and allergic reactions

Failure to achieve anaesthesia
Operator dependent
Inaccurate placement, Needle deflection
Follow the land marks to perform injections
Intra vascular injection
Always aspirate before injections
Insufficient solution
Infiltration 1.0ml,
Regional block injection 1.5ml,
Buccal and palatal blocks 0.2-- 0.5ml
Insufficient time lapse
Give enough time to work
Wrong solution
Careless mistake, Expired solution
Failure to achieve anaesthesia
Patient dependent - Anatomical variations
Barriers to local anaesthetic diffusion
Thick buccal cortex eg
eg.. Zygomatic buttress at upper molar region
(Articaine may diffuse through thicker bone)
Number of perforations in the cribriform plate of lower anterior region
Variations in the position of the foramina
Position of the tooth in the jaw
Lower anterior teeth difficult to anaesthetise with IDB alone
Accessory nerve supply
Nerve to mylohyoid
mylohyoid,, Grater auricular nerve, Auriculo temporal nerve
Cross over supply form opposite site in the anterior teeth

Combination of block and Infiltration on both side of the tooth

Use high blocks (Gaw

(Gaw Gates technique)

Intra ligamentary injections

ligamentary,, intra osseous, intra pulpal injections
Failure to achieve anaesthesia
Pathological reasons - Infection and inflammation
Alteration of the tissue pH
Increase vascularity to the site
Loss of the solution through the sinuses
Dilution of the LA solution in pus or cyst fluid
Hyperalgesia of the nerve due to inflammation
Use higher concentration of the drug if available
This may cause ?? permanent damage to the nerve
Use more local anaesthetic solution
Most effective solution but do not overdose
Use a different injection method
Regional blocks, intraligamentary , intrabony
intrabony,, intrapulpal

Psychological reasons
Reassure the patient or use conscious sedation methods
M Needle breakage
M Burning on injection NEVER Needle break
M Pain on injection BUY Bruising
M Persistent anaesthesia or PINK Pain
parasthesia PILLS Paraesthesia
M Facial nerve paralysis FROM Facial
M Trismus paralysis
M Haematoma formation
TURBAN Trismus
M Spread of infection
HEADED Haematoma
M Lip chewing formation
M Sloughing of tissues Infection
I !!!!!!
M Oedema LIQUOR Lip biting
M Post--anaesthetic intraoral
Post SHOP Sloughing
lesions, blanching OWNERS Oedema
M Temporary blindness or
blurred vision
Needle breakage
Usually cause by sudden unexpected movement of the
Previously bent needles and needles of smaller gauges are
more likely to break
Needles within the tissues are rapidly encased in scar
tissue and infection is extremely rare
Surgical removal can be extensive with major post-
operative complications
Refer to a Oral and Maxillofacial Surgeon
Use larger gauge needle for injections requiring deeper
tissue penetration ie
ie.. 25-
25-gauge needle
Do not insert needle to the hub
Do not bend the needle when performing regional blocks
Pain at local anesthesia
Nerve damage at penetration
Nerve stimulation due to pressure
Expansion of the tissue
Change of temperature
Chemical irritation - ??? Low pH
Needle contact with the nerve bundle
Periosteal contact or penetration
Subperiosteal injection
How to provide pain less anaesthesia
Explain the procedure and reassure the
Use topical anaesthetics and sharp needles
Stretch the mucosa and perpendicular
penetration of the needle
For palatal injections - Pressure at or behind
the site or it can be given through inter-
papilla after labial / buccal anaesthesia
Inject a drop of LA after mucosal penetration
and inject slowly outside the periosteum
Use of TENS, vibrating devices or computer
controlled devices
Persistent anaesthesia /paraesthesia
Mostly involve the lingual nerve

Trauma to the nerve sheath can be produced by the needle;

Patient reports an electric shock during injection

Barbed needles can damage the nerve directly

Injection of contaminated local anaesthetic solution

Oedema around the nerve can lead to paraesthesia

More cases seen after use of Articaine

Articaine in USA

Proper injection technique can help to prevent paraesthesia

Usually resolve within 8 weeks but rarely longer

Trauma to the blood vessels or muscles in the pterygomandibular
space - Multiple needle insertions , injection into the muscle
Contaminated local anaesthetic or excessive volumes
Low--grade infection
Use sharp, sterile, disposable needles. - Avoid repeat insertions
Do not use contaminated needles in the gingival crevice for inferior
dental block injections
Some patients may report difficulty in opening the mouth on the day
following LA and for a few days after surgical treatment
Reassure the patient, mouth opening exercises and advice to use
sugar free chewing gum; Antibiotics when required
If no improvement, refer to an Oral and Maxillofacial Surgeon
Haematoma formation
Inadvertent damage of blood vessels (vein or artery) during injection
eg.. Pterygoid venous plexus
Frequently seen in patients with haemostatic disorders or on blood
thinning medications
Possible trismus and pain
Inconvenience to patient
and embarrassment
to dentist

Prevention and Management

Use sharp needles
Know the anatomy and minimise number of needle insertions
Direct pressure and ice if swelling evident immediately
Advise regarding trismus and discomfort
Apply heat from the next day if not contraindicated
Rarely follows administration of local anaesthetic since
the advent of single use needles and cartridges
Major cause is needle contamination
Do not use the needle for IDB if used in the gingival
Application of topical anaesthetic for a prolonged period
heightened tissue sensitivity
Local tissue injury due to pressure of the injection
Example High pressure, high volume injection to palate
Avoid rubbing of topical anaesthetic for a long period
Do not inject rapidly and / or large volume into the palate
Trauma during injection
Allergy; angio oedema
Angio oedema
Injection of irritating solutions

Seldom intense enough to produce airway obstruction but
can be life threatening
Analgesics for discomfort
Oedema produced by infection may require antibiotics
Degree and position of the oedema is highly significant
Lip Chewing
Trauma to the lips and tongue is caused by
chewing whilst still anaesthetised
Usually in children or mentally handicapped
Analgesics and antibiotics if infected
Lukewarm salt water / antiseptic rinses
Lubricant to minimise irritation (Vaseline)
Instructions to watch closely, use a short
acting LA or LA technique
Keep a cotton wool roll between lip and
teeth in the lower jaw if necessary
Facial Paralysis
Unilateral paralysis of the muscles of
facial expression
Local anaesthetic deposited in the parotid
gland during inferior dental block injection
Loss of motor function is transitory for
one to two hours
No treatment other than to protect the eye
and reassurance eye patch
Advice to remove contact lenses

Prevention by correct technique

DO NOT INJECT !!! If bone cannot
be contacted when injecting for
inferior dental nerve block
Ulcers at the injection site
Occasionally about 2 days
later ulcers develop at the
injection site
? Recurrent aphthous

stomatitis or Viral infection

No means of prevention

Not bacterial infection

Blanching of the facial skin

Usually due to injection into a
Patient may complain burning
sensation of the face
Transient problem and
resuscitate when required
Temporary blindness, Blurred vision
and loss of power in accommodation
Intra arterial injection
Injection close to the infra
orbital fissure
Abnormal vascular

Remember to aspirate
before injections
Fainting and other psychogenic problems
Toxicity due to overdose
methaemoglobinemia due to Prilocaine
Prilocaine,, Benzocaine (or Articaine)
Do not use on patients with congenital methaemoglobinemia
Prilocaine dose in excess of 400mg is needed to produce significant
methaemoglobin levels (20%) in the blood

Patients present with cyanosis of the lips, mucous membranes, nail beds and
infrequently respiratory and circulatory distress

It is rapidly reversed by 1-
1-2mg/kg body weight of 1% Methylene Blue
administered intravenously over 5 minutes

Hypersensitivity very rare

Local Anaesthetic Overdose
Signs and symptoms
Tinnitus, circumoral paraesthesia
Light--headedness, metallic taste
Nausea, vomiting, double vision
Nystagmus,, slurred speech, hallucinations
Muscle twitching, convulsions
Loss of consciousness
Respiratory arrest, cardiovascular collapse
Prilocaine overdose may produce Methemoglobinemia
Safe total dose of Local Anaesthetic agents
Lignocaine 2% with adrenaline
2.2 ml cartridge contains 44mg Lignocaine
Safe total dose 4.4mg per kg. body weight (limit 300 mg)
Articaine 4% with adrenaline
2.2 ml cartridge contains 88mg Articaine
Safe total dose 7mg per kg. Body weight (limit 500 mg)
Mepivacaine 2% with adrenaline
2.2 ml cartridge contains 44mg Mepivacaine
Safe total dose 4.4mg per kg. Body weight (limit 300 mg)
Prilocaine 3% with Felypressin
2.2 ml cartridge contains 66 mg Prilocaine
Safe total dose 6mg per kg. Body weight (limit 400 mg)
Bupivacaine 0.5% with adrenaline (Marcain
2.2 ml cartridge contains 11mg Bupivacaine
Safe total dose 1.3mg per kg. Body weight (limit 90 mg)
Thank you