Local Anesthesia (Part1)
Dr. Gao Yin, MDS
Oral and Maxillofacial Surgery Department
The Affiliated Stomotological Hospital
Wenzhou Medical University
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Objectives
Contraindications to Local
Armamentarium of local Selection of a Local
Neurophysiology Review Anatomy Review Anesthetics: Absolute and
anesthesia Anesthetic Agent
Relative Contraindications
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Neurophysiology Review
What is Local anesthesia?
Some methods of
A loss of sensation in a inducing local anesthesia
circumscribed area of the body,
caused by Mechanical trauma
A depression of excitation in Low temperature
nerve endings
Or an inhibition of the Anoxia
conduction process in Chemical irritants
peripheral nerves Neurolytic agents such as
Compared to general anesthesia, alcohol and phenol
local anesthesia produces a loss
Chemical agents such as local
of sensation without inducing a
loss of consciousness anesthetics
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Neurophysiology Review
Systemic Toxicity
All injectable and most topical local
anesthetics are eventually absorbed from
their site of administration into the
cardiovascular system
The potential for drug toxicity is an
important factor in its selection for use as a
local anesthetic
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Neurophysiology Review
Nerve Impulse Generation and Transmission
How Do Local Anesthetics Work?
By preventing both the generation and
the conduction of a nerve impulse
This is equivalent to creating a chemical
roadblock between the source of the
impulse and the brain
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Neurophysiology Review
Nerve Impulse Generation and Transmission
Nerve Anatomy
Neuron
The nerve cell which transmits information
between the CNS and all parts of the body
There are two types of neurons
Sensory or afferent
Motor or efferent
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Neurophysiology Review
Nerve Impulse Generation and Transmission
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The Syringe
There are seven types
of syringes
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Breech-Loading means that the cartridge is
inserted into the syringe from the side
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Ultracaine (articaine)
is available in Canada
and Europe
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Most often used for intramuscular and intravenous drug
administration
May also be used for intraoral injections
Aspiration requires using both hands
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Syringe Problems
Leakage during injection
Broken cartridge
Bent harpoon
Disengagement of the harpoon from the plunger during aspiration:
Use a sharp harpoon and gentle force when aspirating
Surface deposits: Clean all debris, saliva, and other deposits from
syringes
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The Needle
Standard needle lengths are long (40 mm), and short (25 mm)
Always use a long needle when penetrating significant thicknesses of
soft tissue
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Gauge refers to the diameter the needle lumen
The smaller the number, the larger the diameter of the needle
lumen
A 30-gauge needle has a smaller internal diameter than a 25-
gauge needle
The 25-gauge long needle is recommended
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Needle Problems
Pain on insertion: Avoid Pain on withdrawal: Avoid
by using sharp, new, situations that create
disposable needles, and fishhook barbs on
topical anesthetic at the needles
insertion site
Injury to the patient or
Breakage: Avoid bending administrator: Be
needles unnecessarily. attentive, and anticipate
The hub is the weakest sudden patient
part of the needle movement. Keep needles
sheathed when not in use
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The Cartridge or Carpule
USA: 1.8 ml
Europe: 2.2 ml
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Cartridge Contents
Local anesthetic Sodium
drug Chloride
Distilled water
Vasopressor
drug and a
preservative
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Calculations of Milligrams Anesthetic or
Vasoconstrictor for Different Concentrations
The number of milligrams of The number of milligrams of
anesthetic is calculated by vasoconstrictor is calculated
multiplying the percentage by by multiplying the volume of
the volume of solution in the solution in the cartridge (1.8
cartridge (1.8 ml or 2.2 ml) ml or 2.2 ml)
For a 1:100, 000 (1 g/100,
For a 2% solution: 000 ml) vasoconstrictor:
20 mg/ml x 1.8 ml = 36 mg 0.01 mg/ml x 1.8 ml = 0. 018
per cartridge mg vasoconstrictor per
cartridge
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Cartridge Problems
Bubble in the cartridge Corroded cap
Rust on the cap
Extruded stopper
Leakage during
Burning on injection
injection
Sticky stopper Broken cartridge
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Cartridge Recommendations
Never use a cartridge in Do not use cartridges
more than one patient beyond their
expiration date
Store cartridges at room
temperature Carefully check
cartridges for cracks,
chips, and the integrity
It is unnecessary to of the stopper and cap
warm cartridges prior to prior to use
use
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Additional Armamentarium
Topical antiseptic Cotton gauze (2 x
2 inches)
Topical anesthetic
Hemostat
Applicator sticks
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Additional Armamentarium
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Preparation of the Armamentarium
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Preparation of the Armamentarium
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Preparation of the Armamentarium
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Preparation of the Armamentarium
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Preparation of the Armamentarium
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Preparation of the Armamentarium
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Preparation of the Armamentarium
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Preparation of the Armamentarium
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Preparation of the Armamentarium
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Anatomy Review
Posterior superior alveolar nerve Inferior alveolar nerve
(PSA)
Middle superior alveolar nerve (MSA) Lingual nerve
Anterior superior Alveolar nerve Long buccal nerve
(ASA)
Greater palatine nerve
Mental nerve
Nasopalatine nerve
Incisive nerve
Lesser palatine nerve
Maxillary infiltration Mandibular infiltration
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Long Buccal
Nerve
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Selection of a Local Anesthetic Agent
Examples of Local anesthetics Amides
Esters Articaine
Esters of benzoic acid
Butacaine
Bupivacaine
Cocaine Dibucaine
Ethyl aminobenzoate (benzocaine) Etidocaine
Hexylicaine Lidocaine
Piperocaine
Mepivacaine
Tetracaine
Esters of para-aminobenzoic acid Prilocaine
Chloroprocaine
Propoxycaine
Quinoline
Procaine Centbucridine
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Selection of a Local Anesthetic Agent
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Selection of a Local Anesthetic Agent
Lidocaine is the most commonly chosen local anesthetic
Lidocaine 2% with epinephrine 1:100,000 provides good
anesthesia for healthy patients
Lidocaine 2% with epinephrine 1:50,000 is used for
hemostasis
It should be used sparingly because of the rebound effect of
increased bleeding once the anesthetic wears off
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Selection of a Local Anesthetic Agent
3% Mepivacaine without a vasoconstrictor is used as an
anesthetic for patients who cannot take a vasoconstrictor or for
short procedures
It is appropriate for pedodontics and for use on geriatric
patients
2% Mepivacaine with vasoconstrictor provides pulpal
anesthesia that is similar to lidocaine with epinephrine, but
hemostasis is not as intense
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Selection of a Local Anesthetic Agent
The action of prilocaine plain varies with the area injected
(longer with a nerve block), but usually provides anesthesia
similar to lidocaine and mepivacaine with vasoconstrictor
Prilocaine with vasoconstrictor
gives good anesthetic effect
with a 1:200,000 concentration
of epinephrine
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Selection of a Local Anesthetic Agent
Bupivacaine is used when pulpal anesthesia is desired for longer
appointments and when postoperative pain is anticipated
Nonsteroidal anti-inflammatory agents may be prescribed
prior to the appointment
An intermediate duration anesthetic is used for the
procedure
Inject bupivacaine just prior to the patient's dismissal, and
direct the patient to take an oral analgesic for a certain
number of days following the procedure
Bupivacaine is not recommended for children or
handicapped patients because of the increased risk of
postoperative injury (chewing on a numb lip)
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Selection of a Local Anesthetic Agent
Articaine is a newer anesthetic typically given in a 4% solution
with 1:100,000 epinephrine
Articaine reportedly is more potent than Lidocaine and
requires less volume to achieve a similar state of anesthesia
Practitioners reported rarely missing an inferior alveolar
nerve block with Articaine
However, concern has arisen about its potential for tissue
necrosis and persistent nerve parasthesia
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