LOCAL ANAESTHESIA

LOCAL ANAESTHESIA

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com
www.indiandentalacademy.com
Contents
Contents
History
Armamentarium
Definition &Classification
Composition
Different Agents , Vasoconstrictors
Mechanism of Action
Bio ransformation
!ystemic Action
INTRODUCTION
INTRODUCTION
"#o pain no gain$
Ancient time % dental treatment associated with pain
&arliest pain relief % Coca shru' mood ele(ator

Incas
Cocoa shru' % foot hills of Andes
)ntroduced 'y &uropeans to !outh America
Cocaine
*+,, % -aedic.e e/tracted al.aloid &rythro/ylin
*+01 % Dr. !cher2er cocaine from this al.aloid
*+33 % 4rancis 5ynd 6Du'lin7

Acetate of morphine + Creosote

Skin incision TGN treatment

First time liquid used - intradermally

*++3 % mar.s 'irth of LA
!igmund 4reud Carl 8oller

Cocaine for eye operation

9illiam !teward Halsted

Cocaine for inferior dental nerve

*++0 % BD: 9illiam Alfred Hunt et al

Cocaine - dental anesthetic documented

*;1* % & Mayers

asoconstrictor + cocaine
*;1,

!" lives claimed # addiction

A $inhorn % $ &hlfelder'S(eden)

Synthesi*ed +rocaine hydrochloride

+rocaine sterili*a,le- non-additive- non-to.ic

*;3<

N /of0ren'S(eden)

Synthesi*ed Anilide called Lignocaine

Lignocaine amide linked synthetic derivative

*;30 % Lignocaine introduced Dental practice
*;3+ % Lignocaine = pu'lished in BD: % Lofgren
!weden % Birth place of newer LA agents

1upivacaine

2opivacaine
Pain and pain control
Pain and pain control
D&4)#))># ??

It is defined as an unpleasant emotional

e.perience usually initiated ,y a no.ious stimulus
and transmitted over a specific neural path(ay to
the central nervous system (here it is interpreted
as such3
Methods of pain control.
Methods of pain control.
Accupuncture Analgesia ??

4ri0inated-C5INA-,et(een6771C to 877A9
Hypnotism %

Still employed:suscepti,le patients-

Time consumin0- lasts for less time

Audio Analgesia %

!;<; Gardner and licklider

/oud noise used to produce anal0esia

&lectric analgesia ??

@eripheral ner(e? Direct electric current

$los-!-po(ered ,y !=v ,attery- Siemens

Never more than "7 ma

Analgesia 'y Cold air%

Ina,ility to conduct A+ at lo( tempr

Nondolar-French-67 lts>min-Cold air

9is adv-?ucosa dry- Cotton stick to mucosa-ulcers-if not

moistened3
Armamentarim
Armamentarim
!yringe?

1reech loadin0- metallic cartrid0e-aspiratin0

Ad!anta"e
Visi'le cartridge
Aspiration? * hand
Autocla(a'le
5ust resistance, Long lasting
Disad!anta"e
9eight
!i2e?oo 'ig
@ossi'ility of infection
@)!># 9)H
HA5@>>#
4)#-&5
-5)@
HAMB
5)#-
!B5)#-& BA55&L
#&&DL& ADA@>5
Breech loading plastic cartridge?aspirating
Ad!anta"e
Light weight
Cartridge (isi'le
5ust resistance, Long lasting
Low cost
Disad!anta"e
!i2e % oo 'ig C small
@ossi'ility of infection
5epeated autocla(ing % @lastic looses
its properties
@LA!)C 5&A!ABL& !B5)#-&
Breech loading metallic cartridge?!elf aspirating
Ad!anta"e
Cartridge (isi'le
Autocla(a'le
&asier to aspirate
@iston is scored % Dty 8nown
Disad!anta"e
9eight
@ossi'ility of infection
4inger has to 'e mo(ed from thum'
ring to disc?Aspiration
a.es time to accustom
!&L4 A!@)5A)#- !B5)#-&
@ressure syringe ??
Ad!anta"e
Measured dose
>(ercomes tissue resistance
#on threatening % Cartridge
protected
Disad!anta"e
Cost
)nEect too rapidly ?@ossi'ility
@5&!!A5&
!B5)#-&
9)LC>F? :&9& >BA#D&5
:et inEectors
Ad!anta"e
Does not reGuire % needle
Very small (olume % Deli(ered
opical anesthesia?effecti(e
Disad!anta"e
)nadeGuate % @ulpal C 5egional 'loc.
@atient distur'ed 'y Eolt of Eet.
Cost
@DL damage % common
:& )#:&C>5
Disposa'le syringe
Ad!anta"e
!ingle use
!terile?ill opened
Light weight
Disad!anta"e
Does not accept % Dental cartridge
Aspiration % Difficult % H hands
#eedle

Type # Stainless steel # 9isposa,le

+latinum
Iridium platinum
2uthenium platinum

+arts # 1evel
Shank
5u,-/eur lock- Friction 0rip3

-auge %H< 6)M7 % Length H< mm
H, 6D7 % Length <0CH0 mm ? I(e asprn
Blood % *11J
HK 6D7 % Length HK mm ? I(e asprn
Blood % +KJ
<1 6D7 % Length HH mm ? I(e asprn
Blood % H?,J
CartridgeL
Consists of ??

Cylindrical 0lass tu,e

Stopper

Aluminum cap

9iaphram
5u''er diaphragm
Aluminum cap
#&C8
-LA!! AB&
5ABB&5 @LA#-&5
Additional Armamentarium %

Topical antiseptic

Topical anesthetic

Cotton Gau0e

5emostat

Applicator Stick3
Definition of L.A ##
Definition of L.A ##
)t is defined as a transient loss of sensation to
a painful or potentially painful stimulus, resulting
from a re(ersi'le interruption of peripheral
conduction along a specific neural pathway to its
central integration and perception in the 'rain.
Classification##
Classification##
Based on composition %

A) Natural # e0 # cocaine3

1) synthetic nitro0enous compd #

para amino ,en*oic acid-procaine-
,en*ocaine3
acetanilide - li0nocaine
quinoline - cinchocoline

C) non Nitro0enous compounds -

,en*yl
alcohol

9) miscellaneous # clove oil - phenol 3

Based on intermediate group ??
Esters $
%en&oic acid Para Amino 'en&oic Acid
Butane Chloroprocaine
Cocaine @rocaine
Ben2ocaine @ropo/ycaine
He/ylcaine
etracaine
Amides $
Articaine
Bupi(acaine
Di'ucaine
Lignocaine
Mepi(acaine
@rilocaine
According to 'iological site and mode of actionL

Class A

Class 1

Class C

Class 9
Agents acting at receptor
site %e/ternal surface.
Agents acting at receptor
site? internal surface..
Agents acting at receptor
independent physico
chemical mechanism.
Agents acting in com'n
of receptor and
independent mechanism.
Bioto/in ?eg
tetrodoto/in
Duaternary amonium?
scorpion (enom
Ben2ocaine
Clinically useful
agents %Lignocaine etc
)nEecta'les ?? !urface ??

&ltra short actin0 *Solu,le - e0

@=7 min e0 /i0nocaine Cocaine
/i0nocaine

Short actin0 A<-<7 *Insolu,le- e0

?in 8B li0no (ith 1en*ocaine
!C! lakh C

?edium actin0 ;7-!<7

8B li0no (ith c or
AB prilocaine (ith !C8 epin

/on0 actin0 D !=7

<B 1upivacaine (ith !C8 epin

Composition##
Composition##
Local anesthetic drug %eg lignocaine .
Vasopressor drug ? eg adrenaline.
@reser(ati(e ? eg !odium meta 'i sulfide.
-ermicide % eg methyl para'en.
4or isotonicity % #ormal !aline .
Distilled water to eGual the desired amount .
Indi!idal A"ents ##
Indi!idal A"ents ##
Li"nocaine?? Classified under % Amide

8-diethylamino 8-6 aceto.ylidide hcl

!;A" # Nils /of0rens- intro !;A='dentistry)

?eta,olised- /iver ,y microsomal fi.ed function

o.idases to monoethyl 0lycerine and .ylidide

$.cretion -@!7B unchan0ed- D=7B-meta,

asodilaton -D+rocaine- @?epivacaine

+ka #E3; - ph'plain)-63<-ph'(ith c)< #<3<-4nset of

action 8-" min-Anesthetic half life !36hrs-topical
anesthetic -yes
#H.C>.CH
H
.#
CH
<
CH
<
C
H
H
,
C
H
H
,
LI(NOCAINE

Recommended dose # Em0>k0 notD<77m0 (ith C

A3Am0>k0 notD"77m0

For children (ith C "38 m0>k0

Council for dental therapeutics- A9A

A3Am0>k0

It is non aller0ic availa,le in three

formulations /i0no8B (ith out c
/i0no8B (ith C !C=7-777
/i0no8B (ith C !C!77-777

Adverse reactions- CNS stimulation then

9epression-4verdose causes unconsciousness and respiratory
arrest3

Bupivacaine #Classified under amide

!-,utyl 8-6 pipecolo.ylidide

To.icity @A times # /i0nocaine- ?epivacaine

?eta,olism #/iver ,y Amidases

$.cretion ,y kidney '!6B unchan0ed)

asodilation- relatively si0nificant

+ka-=3!-ph'plain)- A3<-6- ph'vc)- "-A3<

4nset of action #6-!7 min-Anesthetic half life-83Ehrs-9ose
!3"m0>k0 -?a.imum dose-not DA7m0-A,solute ma.imum dose-
notD ;7m0
#
#H.C>
C
3
H
;
CH
<
CH
<
BA@)VACA)#&

Availa,le as 73<B soln !C8-77-777 'vc)

Indicaton- pulpal anesthesia-D;7- min3

Full mouth recontruction3
$.tensive perio sur0ery3
mana0ement of post op pain3

9uration #+ulpal- ;7- !=7 min

Soft tissue-A-!8 hrs

Contra indication- ,urnin0 sensation at site of inFecton- in

children-anticipatin0 self trauma 3

Procaine- Classified under #$sters

89iethylamino ethyl Aamino,en*oate hcl

?eta,olised-in +lasma ,y plasma pseudocholine esterases

$.cretion D8Bunchan0ed- ;7B -+A1A-=B diethyl aminoethanol

in urine3

+ka-;3!-5i0h de0ree of vasodilation- 8B procaine !<-"7min soft

tissue /A
no pulpal anesthesia - D incidence aller0y- dru0 of choice for intra
arterial inFection and accidents3

Mepivacine- classified -amide type

! ?ethyl 8-6 pipecolo.ylidide hcl

?eta,olism-microsomal fi.ed funcn o.idasea in liver3

?a.imum dose A3A m0>k0 - a,solute ma. dose-"77m03

$.cretion-!-!7B unchan0ed urine3

+ka-E36-Anesthetic half life-;7min-

?ild vasodilator- "B mepivacaine used in patients (ith vc

contraindicaton3 /o( reported cases-aller0y3over dose CNS
stimulation follo(ed ,y depression3

Articaine- classified- Amide

8 Car,o.ymetho.y A methylthiophene hcl

?eta,olised- /iver

$.cretion # Gidney !7B - unchan0ed3

+ka E3=- Anesthetic half life-!38-8 hrs-

?a.imum dose # !m0>k0 - A,solute ma.imum dose #

<77m0

first /A A0ent (ith thiophene rin0-little potential to

diffuse throu0h soft tissue3

Adverse reaction-methymo0lo,inemia-2. ,y usin0

methylene ,lue !m0>k03

Etidocaine- classified #Amide

?eta,olism #/iver

$.cretion #urine- Gidney

+ka E3E -Anesthetic half life-<6 min3

?a.imum dose =m0 >k0- A,solute ma. dose A77 m0

$mployed mainly in epidural or caudal re0ional ,lock3

)A*OCON*TRICTOR*
)A*OCON*TRICTOR*
Added % to counteract (asodilation effect of
inEecta'le L.A

9ecreases rate of a,sorption

2educes the risk of overdose reaction

Increases duration of action

2educes ,leedin0 at the site

CLA**I+ICATION O+ ).C
CLA**I+ICATION O+ ).C
Catecholamines
$pinephrine
Nor epinephrine
9opamine
#on catecholamines
Amphetamine
?eta amphetamine
Based on chemical stc 6Catechol nucleus7
Based on mode of action
Direct acting
&pinephrine
#or epinephrine
)ndirect acting
Amphetamine
yramine
Mi/ed acting
&phedrine
@roprietary
name
Mode of
action
!ystemic
*7 CV!
&@)#&@H5)#&
Adrenaline
M*& N receptors
!ystolic &
Diastolic pressure
Heart rate
>/ygen consumption
!tro.e (olume
4&LB@5&!!)#
>ctopressin
Direct stimulation of
(asculature
#o direct effect on
Myocardium
#on?arrythmagenic
High doses % impaired
coronary flow
H7 C#!
<7 5!
37 Vasculature
,7Meta'olism
C#! stimulation
Bronchodilator
M* %
(asoconstriction
N H % (asodilation
o/ygen
consumption
'lood sugar le(el
Adrenergic ner(e % no
effect
Vasoconstriction %
coronary 'lood (essels
Anti?diuretic action
>/ytocin li.e action %
uterus
07 Clinical
application
K7 Ma/
dose
+7 !ide
effect
Allergy, hemostasis
1.H mg % healthy
1.13mg % CV! impaired
CV! & C#! symptoms
Cere'ral hemorrhage
As (aso?constrictor in
L.A
1.13mg
MEC,ANI*M O+ ACTION
MEC,ANI*M O+ ACTION
5esting mem'rane potential

$.citation of nerve

Stimulus # slo( depolari*ation # electric potential less ne0ative

increase in permea,ility to Na

$lectric potential # critical level # firin0 > threshold potential

2apid depolari*ation # reversal of electric potential

2eaches peak +"< mv - +A7 mv rapid depolari*ation

'73"msec)

2epolari*e to 2?+ -67 to #E7mv '73Emsec)

Conduction C propagation

9epolari*ation # !se0ment # local current affects

2?+ ne.t se0ment

Current flo( +ve #veH never ,ack(ards # prevented ,y

previous une.cita,le refractory se0m3
!pread

Sequential depolari*ation - non myelinated

Saltatory conduction # myelinated # faster % ener0y

efficient
5ate

Non-myelinated !38m>s

?yelinated !A3= # !87m>s

!ite of action

4uter ,imolecular lipoprotein layer in nerve mem,rane

MODE O+ ACTION
MODE O+ ACTION
Altering the 'asic 5M@ of ner(e
Altering the threshold potential
Decreasing the rate of depolari2ation
@rolonging rate of repolari2ation
T,EORIE* O+ ACTION O+ L.A
T,EORIE* O+ ACTION O+ L.A
AC&BLCH>L)#& H&>5BO

Involved in nerve conduction in addition to its role as a

neurotransmitter at nerve synapses

No such evidence
CALC)AM D)!@LAC&M&# H&>5BO

/3A causes nerve ,lock ,y displacement of Ca from some

mem,rane site that controls entry of Na

aryin0 conc3 4f Ca in nerve # not seen

!A54AC& CHA5-& H&>5BO

Action ,y ,indin0 to nerve mem,rane and chan0in0 its

electric potential3

Cationic molecules ali0ned at mem,rane (ater interface #

surface elec potn more positively char0ed - electric potn -
threshold potn3

9emerits- 2?+ not altered ,y /A3

/A act on nerve channel rather than surface #cannot
e.plain ho( unchar0ed /A molecule causes nerve
,locka0e3
Mem'rane e/pansion theory?

/A lipid solu,le # enters nerve mem,r and chan0es

confi0uration of mem,r3 There ,y reduced space for
sodium to enter and thus cause inhi,ition3

$.plains ho( non ionised dru0 causes- ,lockade- nerve

mem,rane do e.pand and ,ecome more fluid (hen e.posed to
/A 3

No evidence to tell that the (hole ,lockade is due to this

phenomenon3
!pecific receptor theoryL

/A act ,y ,indin0 to specific receptors- sodium channel-

on e.ternal> a.oplasmic surface3

4nce it ,inds there is no permea,ility of sodium- no

conduction3
/A molecule replace calcium molecule at calcium 0ate #
thus prevent sodium entry3
This is by far the most accepted theory3
Mechanism of action
Mechanism of action
.
.

All /A are availa,le as acid salt of (eak ,ases3

Ieak ,ase'1N545) com,ined (ith acid '5C/) to 0ive

acid salt'1N5C/)% (ater3

In mucosa 1N5C/ dissociates into 1N5 and C/ 3 Normal

tissue +5 E3A is necessary for conversion of acid salt to free ,ase3

1N5 (hich is hydrophilic further dissociates to 1N and

53 1N is no( lipophilic3

/ipophilic 1N diffuses throu0h nerve mem,rane 'lipid)3

Inside the nerve it com,ines (ith intrinsic 53 '5 in nerve
formed ,y ,ufferin0 action3)

Ne(ly formed ionised 1N5 displaces calcium from the

sodium channel receptor site to cause conduction
,lockade3
LA !olution .
%iotransformation.
%iotransformation.
&sters? eg? @rocaine?
hydroly2ed to pseudo cholinesterasePs
@ara amino 'en2oic acid Diethyl amino alcohol
&/creted unchanged urine further transformed?urine
Atypical cholinesterasePs ??? increase to/icity
Amide eg lidocaine ??
Mono ethyl /ylidide
-lycine /ylidide /ylidide
Fylidide
Hydro/y /ylidide. &/creted .idney .
!ignificant renal diseases % contra
indication.
*-stemic action.
*-stemic action.
C#! %
/o( levels # no action
To.ic dose # tonic clonic convulsions
1lood- 73<-A37 m0>ml-no complication
A3<-E37 m0>ml-pre sei*ure si0n>
symptom
DE3<m0>ml-tonic clonic sei*ures3
Anti convulsive property #
As it causes depression of CNS3
Sei*ure threshold- e.cita,ility nerve
CV!?

Action on 5eart

$lectrical e.cita,ility of myocardium 3

conduction rate

Tone of contraction3
clinically effective level-!3=-<m0>ml #anti arrhythmic
used in premature ventricular contractures - arrhythmias3

Action on vasculature-
normal value no chan0e3
over dose- hypo tension3' myocardial
contractility)
/ethal dose- cardio vascular collapse
' myocardial contractility- massive peripheral vaso
dilatation )
Action on 5espiratory system%

Normal levels- no over dose- ,ronchial muscles

rela.ation 3

4ver dose # 2espiratory arrest due to CNS depression3

.er-
.er-
Least to/ic LA? H chlorprocaine.
Most to/ic LA? tetracaine? for topical?dicyclomine
)f allergic to LA %diphenhydramine? anti histamine
I mild anesthetic
4or children ? H chlorprocaine
LA is added with 'i car'onate in infections
Allergy % delt in detail part ))
)deal reGuirements?

its action must ,e reversi,le

?ust ,e non irritant and not produce any secondary

irritation

/o( de0ree of systemic to.icity

?ust ,e potent enou0h

5ave sufficient penetratin0 properties

LOCAL ANAESTHESIA
LOCAL ANAESTHESIA

www.indiandentalacademy.com
Techni/es of In0ection
Techni/es of In0ection
Basic points?

&se a Sterile Sharp Needle

Check The flo( of Solution

9etermine Ihether to Iarm soln ,efore use or not3

+osition the patient

9ry the tissue> (ipe once3

Apply topical anesthetic

Topical antiseptic >optional

Communicate (ith patient apply firm hand rest

InFect fe( drops of soln- communicate (ith patient-

Advance to the tar0et slo(ly -aspirate - inFect

Iithdra( the needle slo(ly

4,serve the patient % check for anesthetic symptoms

Techni/e for Ma1illar- %loc2
Techni/e for Ma1illar- %loc2
!upra periosteal inEectionO

Anaestheti*e ,uccal soft tissue % hard tissue

Nerves anaestheti*ed # lar0e terminal ,ranches

Indication C

! or 8 teeth need to ,e anaestheti*ed > small area

Contra-indication C

Infection

9ense ,one coverin0

Tar0et area C

1ehind apices of tooth

/andmarks C

?uco-,uccal fold

Cro(n % root len0th

@osterior !uperior Al(eolar #er(e Bloc.

Area anaestheti*edC

?a.illary "
rd
- 8
nd
% !
st
molar 'e.cept mesio-,uccal root of !
st

molar

1one % periodontium over these

IndicationC

Treatment of 8 or more molars required

Supra-periosteal inFection # ineffective

Acute inflammation

Contra-indicationC

+t (ith ,leedin0 disorders

9isadvanta0eC

?ore of soft tissue landmarks used

8
nd
inFection for !
st
molar

/andmarksC

?uco,uccal fold

Jy0omatic process of ma.illa

Infratemporal surface of ma.illa

Anterior ,order and coronoid process of mandi,le

Tu,erosity of ma.illa

ComplicationsC

5ematoma #

Non visi,le - ptery0oid ple.us posteriorly

isi,le # ,uccal aspect

Accidental mandi,ular Anaesthesia

4r,ital contents # anaestheti*ed accidentally

Accidental - parotid 0land facial nerve affected

Anterior superior al(eolar ner(e 'loc.

Areas anaestheti*ed

+ulp of ma.illary C3Is # Canine

1uccal periodontium- lo(er eyelid- lateral aspect of nose

&pper lip

Indications

?ore than 8 anterior teeth

Contraindications

9iscreet treatment areas

5emostasis of locali*ed area # not adequately achieved

/andmarks

?uco,uccal fold- infra-or,ital notch- infra-or,ital foramen

H methodsO

Intra-oral

+remolar approach

Incisal approach

$.tra-oral
Palatal Anaesthesia
Palatal Anaesthesia
@ressure Anaesthesia

Slo( deposition

Small quantity

$ffect only a very small area

-reater palatine ner(e 'loc.

Areas anaestheti*ed

+alatal soft tissue # posterior aspect

+alatal hard tissue

Indication

Sur0ical procedures posterior portion of hard palate

+alatal Anaesthesia in conFunction (ith posterior superior

alveolar nerve ,lock3

/andmarks

Greater palatine foramen # Function of the ma.illary alveolar

process % palatine ,one

1et(een the 8
nd
% "
rd
molars # !-!3<cms a(ay from 0in0ival
mar0in
#asopalatine ner(e 'loc.

Areas anaestheti*ed

Anterior portion of 5ard palate and over lyin0 structures ,ack

to the ,icuspid area3

Indications

Anterior palatal procedures supplementin0 infraor,ital nerve

,locks

Anaesthesia of nasal septum

/andmarks

Central incisor % incisive papilla

Complications

5ematoma

Necrosis

Technique

Sin0le needle penetration

?ultiple needle penetration

&sually most discomfortin0 ,lock for patient # very painful
Ma/illary ner(e 'loc.

Areas anaestheti*ed

+ulpal Anaesthesia

?a.illary teeth # ! side

+eriodontium > soft tissue # ! side

Indications

$.tensive oral > periodontal > endodontal procedures

4ther re0ional nerve ,locks not possi,le

Therapeutic procedure to dia0nose neural0ias

Contra-indications

+ediatric patients

Infection > inflammation

5emorrha0e # anticipated

Greater palatine canal approach not possi,le # ,ony o,str3

/andmarks

?uco,uccal fold distal to ma.illary 8

nd
molar

?a.illary tu,erosity

Jy0omatic process

Greater palatine foramen

Complications

5ematoma

+enetration into or,it

olume # displaces or,ital structures- perior,ital s(ellin0-

proptosis- 6
th
nr ,lock # diplopia- transient loss of vision- optic
nerve ,locked- retro,ul,ar ,lock > hemorrha0e- opthalmople0ias
'common)

+enetration into nasal cavity

+atient complains # /A runnin0 do(n the throat # to prevent

keep mouth (ide open

Technique

5i0h tu,erosity approach

Greater palatine canal approach

Ma/illary ner(e 'loc. % &/tra >ral

Areas anaesthetised

Anterior temporal % *y0omatic re0ion

/o(er eyelid

Side of nose

Anterior cheek

&pper lip

?a.illary teeth > alveolar ,one % overlyin0 structures # !side

5ard % soft palate

Tonsils # parts of pharyn.

Nasal septum # floor of nose

Indications

$.tensive sur0ery # ! half of ma.illa

4thers ,locks not possi,le

Therapeutic purposes

Technique

mid point of *y0omatic process

Needle 0ently contact lateral ptery0oid plate

?a.imum len0th of A3<cms directed sli0htly up(ard % for(ard

NoteC

In final position # internal ma.illary artery # inferior to needle

Temporal vessels on either sides

+osteriorly foramen ovale (ith mandi,ular nerve % foramen

spinosum (ith middle menin0eal artery

Anteriorly ptery0oma.illary fissure

Mandi'lar Ner!e %loc2s
Mandi'lar Ner!e %loc2s
)nferior al(eolar ner(e 'loc.

Areas anaesthetised

?andi,ular teeth upto midline

1ody of mandi,le

Inferior portion of ramus

1uccal periosteum % mucous mem,rane

/in0ual soft tissue

Anterior 8>"
rd
of ton0ue

Indications

?ultiple mandi,ular teeth # procedures

1uccal > /in0ual soft tissue anaesthesia

Contraindications

Infection > acute inflammation

Koun0 children > mentally handicapped

/andmarks

Coronoid notch

+tery0omandi,ular raphe

4cclusal plane of posterior mandi,ular teeth

Complication

5ematoma

Trismus

Transient facial paralysis 'parotid 0land)

Anatomical structures - final position

Superiorly #

Inferior alveolar nerves % vessels

Insertion of medial ptery0oid

?ylohyoid nerves % vessels

Anteriorly #

9eep part of parotid 0land

/aterally #

/in0ual nerve

Internal ptery0oid

Spehnomandi,ular li0ament

?edially- ramus of mandi,le3

Closed mouthC A.inosis technGL

Area anestheti*ed

one half of mandi,le upto mid line includin0 lin0ual tissue3

/and mark-

occludin0 plane of the teeth3

?uco 0in0ival Function ma.illary teeth3

Antr ,order of ramus3

?ore popular no(

/and marks easy

4ne prick # mandi,ular- ,uccal- lin0ual n anesthetised3

+atient more comforta,le3

-ow gates techniGue% *;K<.

deposit soln at neck of condyle

Area #all mandi,ular hard and soft tissue &pto mid line3

/and marks-

antr ,order of ramus- tendon of temporalis- corner of mouth-

inter tra0ic notch of ear and e.ter nal ear3

Final position needle is Fust inferior to condyle3and

insertion of lateral ptery0oid3
Gained popularity # sin0le needle penetration- relies on
soft tissue landmarks # differ from patient to patient
Lingual ner(e 'loc. %

Area anaesthetised #

Anterior 8>"
rd
ton0ue- floor of mouth- lin0ual mucoperiosteum
4nly used sin0ly to operate on ton0ue- floor of mouth
Buccinator C long 'uccal ner(e 'loc.

Area anaesthetised #

1uccal mucosa % mandi,ular molar # mucoperiosteum

/and marks

$.ternal o,lique rid0e- retromolar trian0le

Mental ner(e 'loc.

Areas anaesthetised

/o(er lip- mucous mem,rane # anterior to mental foramen

/andmarks

?andi,ular ,icuspids

Indications

Sur0ery of lo(er lip or mucous mem,rane

E1tra Oral Techni/e
E1tra Oral Techni/e
Mandi'ular ner(e

Area anaesthetised

Temporal re0ion (ith auricle of ear % e.ternal auditory

meatus

T?L- salivary 0lands

Anterior 8>"
rd
of ton0ue

?andi,le # hard % soft tissue # midline

/andmarks

mid point of *y0omatic arch

Jy0omatic notch

Cornoid process of mandi,le

/ateral ptery0oid plate

Indications

Ihen need to anaesthetise entire mandi,ular nerve

Infection > trauma # makes terminal anaestheisa not possi,le

9ia0nostic > therapeutic

The needle is pointed posteriorly % to a 0reater depth of
< cms
Mental & )ncisi(e ner(e 'loc.

Area anaesthetised

?andi,ular hard % soft tissue # la,ial aspect (ith lo(er lip

/andmarks

1icuspid teeth- lo(er rid0e of ,ody of mandi,le

Supra % infra or,ital notch

+upil of the eye

8 inch 88 0au0e needle used % introduced sli0htly
anteriorly % do(n(ards
Complications
Complications
Definition

An anaesthetic complication may ,e defined as any

deviation from the normal e.pected pattern durin0 or
after securin0 re0ional anaesthesia

8 types

/ocal

Systemic
L>CAL C>M@L)CA)>#!

Needle ,reaka0e

+ain on inFection

1urnin0 on inFection

+ersistent anaesthesia or paresthesia

Trismus

5ematoma

Slou0hin0 of the tissue > soft tissue inFury

Facial nerve paralysis

!B!&M)C C>M@L)CA)>#!

To.icity

Idiosyncracy

Aller0y

Anaphylactoid reaction

Syncope
Classification

+rimary > secondary

+rimary # caused % manifested at time of anaesthesia

Secondary # manifested later

?ild > severe

?ild # e.hi,it sli0ht chan0e from normal e.pected pattern

- reverses itself (ithout treatment

Severe # manifests itself # pronounced deviation

- requires specific treatment

Transient > permanent

Transient # is one that is severe at occurrence # no residual

effects

+ermanent # residual effectH lasts for a life time even thou0h it

is mild
Complications could ,e a com,ination of any of the a,ove
mentioned types
?aFority are either +rimary ?ild % Transient or Secondary ?ild
% Transient
Complications

Attri,uted to solutions # to.icity- aller0y- idiosyncrasy-

anaphylactoid reaction- local irritation

Attri,uted to technique > needle # syncope- muscle

trismus- pain- edema- hematoma
Needle 'rea2a"e
Needle 'rea2a"e
Cause %

&ne.pected movement # patient 'if patient movement is

opposite to path of needle insertion)

&sually at 5u, # ?a0ill forceps # hemostat used

If needle has penetrated soft tissue # not usually more

than fe( mms deep # encased in scar tissue in fe( (eeks
# removed later on if necessary

?ultiple used needle

@re(ention

Correct 0au0e # 8< 0au0e

/on0 needles # prevent penetration till hu,

Not to redirect (hen in tissue

Management

+atient # not to move # hand in the mouth # mouth open

Fra0ment visi,le # remove it

Fra0ment not visi,le # inform patient # not necessary for

intervention immediately # 2adio0raph su00ested
@recautions

Avoid ,ony contact

Avoid heavy pressure

Avoid movement of needle and patient

Pain on in0ection
Pain on in0ection
Causes %

Careless inFection technique

?ultiple used needle

2apid deposition
@ro'lems %

+ain # patient an.iety # une.pected movements

@re(ention %

+roper technique # sharp needles

$nter topical anaesthetics

InFect slo(ly # solution sterili*ed

Check temperature of solution

%rnin" on in0ection
%rnin" on in0ection
Causes

9ue to p5 of solution < '/A) # " '/A+C)

2apid inFection

Contamination

Iarm solution
@ro'lems

p5 disappears upon /A action # no residual

sensitivity

Contaminated solution other complications # trismus-

edema- paraesthesia
@re(ention

Slo( inFection # !ml > minute

Cartrid0e stored at room temperature # a(ay from

containers (ith alcohol > other a0ents
Persistent anaesthesia 3 paresthesia
Persistent anaesthesia 3 paresthesia
Causes

9irect trauma to nerve # ,evel of needle

/A solution containin0 neuroto.ic su,stance # alcohol

InFection of (ron0 solution

5emorrha0e > infection # near to nerve

@ro'lem

+ersistent anaesthesia # usually rare

1itin0 > thermal > chemical insult # (ithout patient

a(areness

Ihen lin0ual nerve is involved # taste impaired

@re(ention

+roper care % handlin0 of dental cartrid0e

Adherence to inFection protocol

Management

&sually resolve in = (eeks

+eriodic recall % check up of patients

+ersistence # consult neurosur0eon

/A # not to ,e inFected in the same re0ion

Trisms
Trisms
Definition

Mdifficulty in openin0 the Fa(s due to muscle spasmN

Causes

Trauma # muscle > ,lood vessel

Irritatin0 solution # hemorrha0e

/A have ,een kno(n to have sli0ht myoto.icity

$.cessive volume # distension of tissues

@ro'lems

+ain > hypomo,ility

@re(ention

&se of sharp- sterile- disposa,le needle

Aseptic technique

+ractice atraumatic methods

Avoid repeated inFections

&se minimum volume

Management

5eat therapy

Iarm saline rinses- moist hot packs

Anal0esics

Aspirin- Codeine '"7-67m0)

Initial physiotherapy

Thrice a day

Anti,iotic re0ime

+ossi,ility of infection
,ematoma
,ematoma
Causes

Arterial % venous puncture # common in +SA % Inf Alv

nerve ,locks
@ro'lem

1ruise # may > may not ,e visi,le e.traorally

Complications # pain % trismus

S(ellin0 % discolouration
@re(ention

Gno(led0e of normal anatomy # proper technique

Shorter needle # +SA- minimise the num,er of

penetration
Management

Immediate # apply firm pressure <-!7minutes

Inf Alv Nr3 1lock # medial aspect of ramus

Infra or,ital- ?ental- Incisive ,lock # directly over foramen

+SA # pressure on soft tissue (ith fin0er as posteriorly as

tolerated ,y patient # medial superior direction
+atient to ,e revie(ed after 8A hours- advice anal0esics- cold
application upto A-6 hours- heat application ne.t day
Infection
Infection
Compariti(ely rare complication
)nstrument needle solution to 'e as aseptic as
possi'le
Area & operati(e hands % cleaned
A(oid passing needle through infected area
Edema
Edema
Causes

Trauma durin0 inFection

Infection- hemorrha0e

Aller0y 'An0ioedema)

InFection of irritatin0 solution

@ro'lems

+ain % dysfunction

Air(ay o,struction
@re(ention

+roper care % handlin0 of armamentarium

Atraumatic inFection technique

Complete medical evaluation prior to inFection

Management

Trauma # resolve in fe( days (ithout therapy

5emorrha0e # resolve slo(ly E-!A days

Aller0y # life threatenin0- air(ay impairment # ,asic life support-

call medical help- $pinephrine # 73"m0- Antihistamine-
Corticosteroids

Total air(ay o,struction # Tracheostomy > Cricothyroidectomy

*lo"hin" of tisse
*lo"hin" of tisse
Causes

$pithelial desquamation # topical anaesthesia # lon0

time- hei0htened sensitivity to /A

Sterile a,scess # secondary to prolon0ed ischemia # C

in /A site # hard palate
@ro'lems

+ain % infection
@re(ention

Topical # for not more than !-8 minutes

C # minimal concentration in solution

Management

Symptomatic # pain # anal0esia

$pithelial desquamation # resolve fe( days

Sterile a,scess resolve E-!7 days

*oft tisse in0r-
*oft tisse in0r-
Causes

Trauma occurs # frequently mentally > physically

challen0ed children

+rimary cause # si0nificantly lon0er duration of action

@ro'lem

+ain % s(ellin0

Infection of soft tissue

@re(ention

Cotton roll ,et(een lip % teeth

+atient # 0uarded a0ainst eatin0 > drinkin0

+acial ner!e paral-sis
+acial ner!e paral-sis
Cause

/A solution into parotid 0land # usually (hile 0ivin0 Inf

Alv Nr3 1lock- Akinosis technique
@ro'lem

Ipsilateral loss of motor control # 1uccinator muscle

Ina,ility to raise the corner of ?outh- close $ye lid

@re(ention

Needle tip to contact ,one- redirection of needle to ,e

done only after complete (ithdra(l
Management

2eassure the patient

$ye patches to the affected # eye drops

Contact lenses if any # removed

!ome post anaesthetic e/tra oral lesions % recurrent apthous
stomatitis, herpes simple/ seen in suscepti'le patient
Mi/ture of Diphenhydramine, mil. of magnesia % relief
against ulcers
*-stemic complications
*-stemic complications
o/icity C to/ic o(erdose

Caused ,y overdose reaction # increased conc3 In ,lood

+redisposin0 factors

A0e # any a0e

Iei0ht # 0reater the ,ody (ei0ht 0reater is the amount of dose

tolerated ,efore overdose reaction

Se. # durin0 pre0nancy # renal function distur,ed # females

more affected at this time

9iseases # hepatic % renal dysfunction reduced ,reakdo(n

Con0estive heart failure # less liver perfusion

Genetics # pseudocholinesterase deficient # to.icity - $ster /A

?ental attitude and environment # pyscholo0ical attitude

affects response to various stimuli # lar0er dose /A needed

Fearful patients # lo(er sei*ure threshold for /A

9ru0 factors # asoactivity # vasodilation # increase in ,lood

Concentration # 0reater concentration # 0reater risk

9ose smaller dose should al(ays ,e preferred

2oute of Administration # Intravascular # increased to.icity

2ate of inFection # slo(er rate preferred

ascularity of inFection site # more vascular # 0reater

a,sorption

+resence of asoconstrictor # (ith C less a,sorption

Causes of to.icity #

1iotransformation usually slo(

9ru0 # slo(ly eliminated ,y kidney

Too lar0e a total dose

A,sorption from inFection site - rapid

Accidental intra-vascular inFection

Symptoms #

CNS # cere,ral cortical stimulation # talkative- restless-

apprehensiveness- convulsions

Cere,ral cortical depression # lethar0y- sleepiness-

unconsciousness

?edullary stimulation # increased 13+- +ulse rate- 2espiration

?edullary depression # mild fall in 13+# severe cases

drops to 7 - +ulse - 2espiration # similar effect
reatment

?ild overdose reaction # slo( onset reaction # D < mins

administer 4.y0en 'prevent acidosis)- monitor vital
si0ns- in case of convulsions # anti-convulsants

Slo(er onset - D!< mins # same procedure

Severe overdose reaction # rapid onset # ! minute #

unconsciousness (ith or (ithout convulsion- patient in
supine position- convulsions # protect hand- le0- ton0ue-
1/S- administer anti-convulsant ----------- post sei*ure #
CNS depression usually present
Idios-ncras-
Idios-ncras-
Any reaction neither to/ic nor allergic
Common cause % some underlying pathology C
psychological
@yschotherapy may 'e helpful
reatment % symptomatic
*-ncope
*-ncope
An/iety % increased 'lood supply to muscles, sitting
position Hmm Hg, less pressure % cere'ral arteries
Clinically light headedness, di22iness, tachycardia
& palpitation % may further lead to Anconsciousness
reatment % discontinue procedure, supine position,
deep 'reathing, BL!
Aller"-
Aller"-
* J of all reaction in, LA is allergy
@redisposing factors

5yper sensitivity to ester more common-procaine

?ost of patients aller0ic to methyl para,en

2ecently aller0y to sodium meta ,i sulfide is also

increasin0
+recautions---
5o of aller0y to ,e recorded
5o any asthmatic attack to ,e noted3
Al(ays ,etter to test the patient for aller0y ,efore
treatment3

Consultation and aller0y testin0

2efer dou,tful cases for aller0ic skin test # su, cutaneous test
most sensitive3

Informed consent that includes cardiac arest end death to ,e

included3

Si0ns and symptoms of aller0y3

9ermatolo0ical------ urticaria #(heal and smooth elevated

patch seen- ------an0io oedema:localised s(ellin0 # face
hands- common

2espiratory# ,roncho spasm- respiratory distress-

dysnea- (hee*in0- flushin0- tachycardia etc3

/aryn0eal edema # type of an0io neurotic oedema- life

threatin03

$dema upper air (ay # laryn0eal edema

/o(er air (ay affect ,roncioles- small3

?ana0ement

Oskin reactions-

9elayed # non life threatenin0 - oral histramine ,lockers- <7 m0

diphenhidramine

Immediate reaction:(ith conFunctivites rhinitis- vi0erous

mana0emennt3

73" m0 epinephrine3 I?

<7 m0 diphenhydramine Im

medical help summoned3

4,serve patient for minimum of 67 min

4ral histamine ,lockers for < days3

2espiratory reaction #

patient in comforta,le position3

administer - o.y0en

Admn epinephrine- ,ronchodilator

4,serve for 67 min - advise anti histamines to prevent relapse3

/aryn0eal edema-

+atient position -o.y0en- ,roncho dilator- oral anti histamines3

If condition not improvin0 cricothyrotomy - achieve patent air

(ay if necessary 0ive artificial ventilation3
@atient with confirmed allergy status?

if patient aller0ic to any one type of anesthetic ester >

amide use the other3

&se histamine ,locker like diphenhydramine as

anesthetic3

General anesthesia

alternative method of pain control #

electric anesthesia > hypnosis3

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