LOCAL ANESTHESIA

ASHA REDDY

 DEFINATION FUNDAMENTALS OF IMPULSE GENERATION AND TRANSMISSION THEORIES OF MECHANISM OF ACTION OF LOCAL ANESTHESIA Acetyl choline theory Calciu Di!"lace ent Theory Sur#ace char$e theory e %rane E&"an!ion theory S"eci#ic Rece"tor theory LOCAL ANESTHESIA Characteri!tic! Hi!tory Co "o!ition TYPES OF ANESTHETICS USED FACTORS EFFECTING LA E'UILI(RIUM TOPICAL ANESTHETICS PHARMACO)INETICS OF LOCAL ANESTHESIA ARMAMENTARIUM TECHNI'UES OF LOCAL ANESTHESIA Ma&illary Man*i%ular Su""le ental In+ection techni,ue! COMPLICATIONS OF LOCAL ANESTHESIA Local Sy!te ic

CONTENTS

Anaesthesia
-hat i! local ane!the!ia. / Local ane!the!ia0 lo!! o# !en!ation in a !"eci#ic area o# the %o*y 1ithout the lo!! o# con!ciou!ne!! DEFINATION

/ Local ane!the!ia i! *e#ine* a! a lo!! o# !en!ation in a circu !cri%e* area o# the %o*y cau!e* %y a *e"re!!ion o# e&citation in ner2e en*in$! or an inhi%ition o# the con*uction "roce!! in "eri"heral ner2e!3 STANLEY F. MALAMED / Local ane!the!ia i! *e#ine* a! a re2er!i%le te "orary ce!!ation
o# "ain#ul i "ul!e! #ro a "articular re$ion o# the %o*y3 )OCH FUNDAMENTALS OF IMPULSE GENERATION AND TRANSMISSION / The conce"t %ehin* action o# local anae!thetic! i! !i "le3 They "re2ent %oth $eneration an* con*uction o# a ner2e i "ul!e3 They create a che ical roa*%loc4 %et1een !ource o# i "ul!e an* the %rain3

/ The a%orte* i "ul!e 5 "re2ente* #ro reachin$ the %rain i! not inter"rete* a! "ain %y the "atient

/ Neuron or ner2e cell6 i! the !tructural unit o# the ner2ou! !y!te / T1o ty"e!0 !en!ory 7a##erent8 9 otor 7e##erent83 / !en!ory neuron! 0 con*uct i "ul!e! #ro "eri"hery to CNS / Motor neuron! 0 con*uct i "ul!e! #ro CNS to the "eri"hery

/ /

Ner2e e %rane 0i! :;6<; An$!tro unit3 it i! a #le&i%le non!tretcha%le !tructure con!i!tin$ o# t1o layer! o# li"i* olecule! / The li"i*! are oriente* 1ith their hy*ro"hilic en*! #acin$ the outer !ur#ace an* hy*ro"ho%ic en*! "ro+ectin$ to the i**le o# the e %rane

/ /

So e ner2e! are yelinate* 72erte%rate!8 1hile !o e are not3 Myelinate* ner2e #i%re! are enclo!e* in !"irally 1ra""e* layer! o# li"o"rotein3 / The outer o!tlayer o# yelin con!i!t! o# !ch1ann cell cyto"la! an* it! nucleu! / There are con!tiction! at re$ular inter2al! alon$ the yelinate* ner2e #i%er 7no*e! o# Ran2ier8 / At the!e no*e! the ner2e e %rane i! e&"o!e* *irectly to the e&tracellular e*iu 3

Electrophysiology of nerve conduction

/
Ner2e con*uction Re!tin$ !ta$e De"olari!ation Re"olari!ation Re!tin$ !tate = "olari>e* !tate / Electric e %rane "otential i! ? @; MA Greater no3 o# anion! B6C in!i*e cell out!i*e cell e %rane / 4+ in!i*e an* Na+ 5 Cl- out!i*e
/

e %rane an* cation! BDC

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Due to relati2e "er ea%ility to 4+ an* i "er ea%ility to Na+

/ /

Maintaiance %y Na+ - Ka+ pump De"olari>ation !ta$e

Re"olari>ation !ta$e

Re!tin$ !tate0the ner2e e %rane i! Sli$htly "er ea%le to !o*iu ion! 7NaD8 i$rate! in1ar*ly %eco! o# the conc $ra*ient 7E ou!i*e8 #a2or! !uch i$ration3 Re!tin$ ner2e e %rane i! relati2ely i "er ea%le to !o*iu / Freely "er ea%le to "ota!!iu ion!7)D836 )D ion! re ain 1ithin the a&o"la! *e!"ite it! a%ility to *i##u!e #reely %eco! the ne$ati2e char$e o# ner2e e %rane re!train! the "o!iti2ely char$e* ion! %y electro!tatic attraction3 / Freely "er ea%le to chlori*e ion! 7cl68 re ain! out!i*e the ner2e e %rane %eco! the o""o!in$ 5 nearly e,ual electro!tatic in#luence #orce! out1ar* i$ration3
/ /

Membrane channels:
Di!crete a,eou! "ore! 7!o*iu channel!8 are olecular !tructure! that e*iate it! it! "er ea%ility "re!ence o# the!e channel! hel" e %rane "er ea%ility or i "er ea%ility to certain ion! 7 $atin$ the ion! 8 Na ion! 7 hy*rate* 8 are too lar$e to "a!! thro the channel! at re!t *urin$ *e"olari>ation they "a!! ea!ily *ue to 1i*enin$ o# the!e channel!

Relea!e o# the %oun* calciu ion! #ro the ion channel rece"tor !ite ay %e the "ri ary #actor re!"on!i%le #or inc !o*iu "er ea%ility

Theories of mechanism of action of Local Anesthetics

/ / / / /
ACETYL CHOLINE THEORY 0 CALCIUM DISPLACEMENT THEORY SURFACE CHARGE THEORY MEM(RANE EFPANSION THEORY SPECIFIC RECEPTOR THEORY

MEM(RANE EFPANSION THEORY

/ LA *i##u!e to hy*ro"ho%ic re$ion! o# e&cita%le e %rane!5 e&"an*in$ critical re$ion! in the e %rane an* "re2entin$ an inc in the "er ea%ility to !o*iu ion! SPECIFIC RECEPTOR THEORY

/ Mo!t #a2oure* theory / They %in* to the !"3 Rece"tor !ite in the !o*iu channel / LA are cla!!i#ie* %y their a%ility to react 1ith !" rece"tor !ite! in the !o*iu channel

L !AL ANE"T#E"$A
De!ira%le characteri!tic! o# local ane!the!ia / Not %e irritatin$ to ti!!ue! / Not cau!e any "er anent alteration! o# ner2e !tructure / Lo1 !y!te ic to&icity / E##ecti2e0 in+ecte* or a""lie* on MM / Ti e o# on!et0 !hort / Duration o# action0 lon$ / Free #ro aller$ic reaction! / Ra"i* %iotran!#or ation in %o*y

Ho1 local ane!the!ia 1or4.

/ / / /
Pro*uce con*uction %loc4 to *ecrea!e "er ea%ility o# ion channel! to !o*iu ion! Se,uence o# action Di!"lace ent o# calciu ion! #ro !o*iu channel rece"tor !ite (in*in$ o# local anae!thetic to rece"tor !ite

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/ /

(loc4a*e o# !o*iu channel Decrea!e in !o*iu con*uctance De"re!! rate o# *e"olari!ation Coca lea2e! #ro the $enu! Erythro&ylu Erythro&ylu contain! hi$h concentration o# al4aloi* u" to ;3:6

Hi!tory
G3<H Al4aloi* ha! natural nitro$en %a!e! #oun* in the coca lea2e!5 al!o 4no1n a! cocaine / Genu! Erythro&ylu *i!co2ere* in South A erica5 Aene>uela5 (oli2ia5 an* Peru !ince "re6Colu %ian "erio*! / Earlie!t culti2ation an* u!e o# the coca lea# 1ent %ac4 to a%out :;; (C in (oli2ia an* An*e! re$ion! / Ne1 *i!co2erie! !ho1e* hu an! u!e* coca ore than I5;;; year! a$o in Ecua*or
/

De2elo" ent o# $eneral an* local ane!the!ia

/ Too4 "lace in -e!tern Euro"e #ro G:I; to G<I; / Che i!t! an* "hy!ician! collecte* !a "le o# coca lea2e! #or e&"eri ent! / I!olate* acti2e "rinci"le o# coca lea#5 !ynthe!i>e* to a *ru$ #or "atient! to #eel ore relie# o# "ain 1hen ta4in$ !ur$erie! / In G<J;5 Ger an che i!t Al%ert Nie ann !ucce!!#ully

i!olate the acti2e "rinci"le o# coca lea#K he na e* it cocaine

/ In G<JI5 -illhel Lo!!en *eter ine the correct olecular #or ula o# cocaine BCG:HLGNOMC / Nie ann *i!co2ere* the e##ect o# nu %ne!! o# the ton$ue! cau!e* %y al4aloi* in G<J; / (a!e* on Nie annN! *i!co2ery5 Ru!!ian "hy!ician (a!il Aon Anre" *i* e&"eri ent! on ani al!5 !uch a! rat!5 *o$!5 an* cat!3 / He in+ecte* ! all ,uantity o# GH !olution to hi! ton$ueK ton$ue %eca e in!en!iti2e / He conclu*e* cocaine i! a $oo* *ru$ #or !ur$ical ane!thetic / -illia Ste1ar* Hal!te* an* Richar* Oohn Hall

*e2elo"e* the in#erior *ental ner2e %loc4 techni,ue! #or *enti!try

Procaine re"lace* cocaine in later year! %ut it ha* any *ra1 %ac4! / Nitrou! o&i*e $a! 1a! ore co only u!e* than "rocaine Nitrou! o&i*e

! M% "$T$ N
/ / / / / / /
/ / / / / / / LOCAL ANESTHETIC AASOCONSTRICTOR ANTIOFIDANT PRESERAATIAE FUNGICIDE SALT AEHICLE Local ane!thetic0 ay %e an a i*e or e!ter 7li*ocaine LH8 Aa!ocon!trictor0 E"ine"hrine It cau!e! 2a!ocon!triction an* "re2ent! ra"i* a%!or"tion o# L3A into %loo* !trea there%y re*ucin$ their to&icity Increa!e! *uration o# action o# local ane!thetic! an* al!o their "otency Cau!e! he o!ta!i! in the local area into 1hich it i! in+ecte* an* hel"! in creatin$ %loo* #ree #iel*

E"ine"hrine conc ? G0G;;5;;;7nor ally u!e*8

Antio&i*ant 0 !o*iu eta%i!ul"hite "re2ent! ra"i* o&i*ation o# the 2c 9 "rolon$! !hel# li#e o# the !oln / Pre!er2ati2e 0 Methyl "ara%en / Salt0 (icar%onate i! a**e* to a4e !oln i!otonic3 LA 9 AS ha! a "h o# M6I 1hich cau!e %urnin$ !en!ation in "t3 !o %icar%onate i! a**e* to a4e !oln i!otonic / Rin$er! lactate= *i!tille* 1ater ? to *i!!ol2e all content! an* a4e it in+ecta%le "ro2i*in$ a**nl 2ol3 #or in+ection 1ithout increa!in$ total *o!e a* ini!tere*

Local Ane!thetic

A Drug that, when injected into tissue, has little or no irritating effects and when absorbed into the nerve will temporarily interrupt its conduction.

Cla!!i#ication o# local ane!thetic a$ent! / ESTERS / E!ter! o# %en>oic aci* / Cocaine / Procaine / (en>ocaine / (utacaine / E!ter! o# PA(A / Chlor"rocaine / Pro"o&ycaine / Tetracaine / AMIDES / Atricaine / (u"i2acaine / Di%ucaine / Eti*ocaine / Li*ocaine / Me"i2acaine / Prilocaine / Ro"i2acaine / 'UINOLONE / Cent%ucri*ine CLINICAL CLASSIFICATION Short *uration / li*ocaine HCL LH / Me"i2acaine HCL PH / Prilocaine HCL MH B (y in#iltration C Inter e*iate *uration / Articaine HCL MH D e"ine"hrine G0G;;;;; / Articaine HCL MH D e"ine"hrine G0L;;;;; / li*ocaine HCL LH D e"ine"hrine G0I;;;; / li*ocaine HCL LHD e"ine"hrine G0G;;;;; / Prilocaine HCL MH B (y ner2e %loc4 only C / Me"i2acaine HCL LH D le2onor*e#rin G0L;;;;; / Me"i2acaine HCL LH D e"ine"hrine G0G;;;;; Lon$ *uration / (u"i2acaine HCL ;3IH D e"ine"hrine G0 L;;;;; Cla!!i#ication %a!e* on %iolo$ical !ite an* o*e o# action

Cla!! A 0 E&ternal !ur#ace o# rece"tor (IOTOFINS / Cla!! ( 0 Internal !ur#ace o# Rece"tor! SCORPION AENOM 'UARTERNARY AMMONIUM ANALOGUES OF LIDOCAINE / Cla!! C 0 Rece"tor in*e"en*ent (ENQOCAINE / Cla!! D 0 Rece"tor an* rece"tor in*e"en*ent MOST CLINICALLY USED AGENTS

Structure! o# A i*e! an* E!ter!

The a ine en* i! hy*ro"hilic B!olu%le in 1aterC5 ane!thetic olecule *i!!ol2e in 1ater in 1hich it i! *eli2ere* #ro the *enti!tN! !yrin$e into the "atientN! ti!!ue3 ItN! al!o re!"on!i%le #or the !olution to re ain on either !i*e o# the ner2e e %rane3 / The aro atic en* i! li"o"hilic B!olu%le in li"i*!C3 (ecau!e ner2e cell i! a*e o# li"i* %ilayer it i! "o!!i%le #or ane!thetic olecule to "enetrate throu$h the ner2e e %rane3 / The tric4 the ane!thetic olecule u!t "lay i! $ettin$ #ro one !i*e o# the e %rane to the other Di##erence! o# E!ter! an* A i*e! / All local ane!thetic! are 1ea4 %a!e!3 Che ical !tructure o# local ane!thetic! ha2e an a ine $rou" on one en* connect to an aro atic rin$ on the other an* an a ine $rou" on the ri$ht !i*e3 The a ine en* i! hy*ro"hilic B!olu%le in 1aterC5 an* the aro atic en* i! li"o"hilic B!olu%le in li"i*!C / T1o cla!!e! o# local ane!thetic! are a ino a i*e! an* a ino e!ter!3 A i*e!0 E!ter!0 66A i*e lin4 %=t inter e*iate 66E!ter lin4 %=t aro atic rin$ inter e*iate chain
/

66Meta%oli>e* in li2er an* 2ery !olution "la! a 66Cau!e aller$ic reaction!

an* aro atic rin$ 66Meta%oli>e* in !ta%le in the

E!ter ty"e local ane!thetic! are no lon$er a2aila%le in cartri*$e #or ! %ut %en>ocaine an* tetracaine are !till u!e* a! to"ical ane!thetic a$ent! LIDOCAINE / The o!t "o"ular contain! e"ine"hrine G0G;;5;;; an* "ro2i*e! $oo* ane!the!ia #or healthy "atient!3

Li*ocaine 1ith e"ine"hrine G0I;5;;; i! u!e* #or he o!ta!i!5 %ut %ecau!e o# the rebound effect note* earlier5 it !houl* %e u!e* !"arin$ly
/

/ In G@M;5 the #ir!t o*ern local ane!thetic a$ent 1a! li*ocaine5 tra*e na e FylocaineR / It *e2elo"e* a! a *eri2ati2e o# &yli*ine / Li*ocaine relie2e! "ain *urin$ the *ental !ur$erie! / (elon$! to the a i*e cla!!5 cau!e little aller$enic reactionK itN! hy"oaller$enic / Set! on ,uic4ly an* "ro*uce! a *e!ire* ane!the!ia

e##ect #or !e2eral hour!

/ / /

Li*ocaine Hcl Pre"are* %y Nil! Lo#$ren5G@MP

G!t a i*e to %e ar4ete*3 U!e* a! !tan*ar* #or co "ari!on / On!et o# action i! L6P in! / E##ecti2e *ental conc i! LH / Hal# li#e i! G3J hr! 7@; in! 8 / To"ical ane!thetic action 0 in IH conc / Ma& reco en*e* *o!e 7MRD8 LH Li*ocaine 1ith e"ine"hrine6P3L $=l% or : $=4$ %o*y 1t 7not to e&cee* I;; $87!a e #or chil*ren8 / LH li*ocaine 1ithout e"ine"hrine6 L $=l% or M3M $=4$ 7not to e&cee* P;; $8 / Aa!ocon!trictor 7a*renaline8 ? ;3L $ or L;; u$ 7healthy "t!8 / ;3;M $ or M; u$ ? c2 *i!ea!e
/

ARTICAINE / Articaine i! a ne1er ane!thetic ty"ically $i2en in a MH !olution 1ith G0G;;5;;; e"ine"hrine3 / Practitioner! re"orte* rarely missing a in#erior al2eolar ner2e %loc4 1ith Articaine3 / Ho1e2er5 concern ha! ari!en a%out it! "otential #or tissue necrosis an* "er!i!tent nerve parasthesia3 / Hi$h "enetratin$ MEPIAACAINE / PH Me"i2acaine 1ithout a 2a!ocon!trictor i! u!e* a! ane!thetic #or "atient! 1ho cannot take a vasoconstrictor or #or !hort "roce*ure!3 / It i! a""ro"riate #or "e*o*ontic! an* #or u!e on $eriatric "atient!3 / LH Me"i2acaine 1ith 2a!ocon!trictor "ro2i*e! "ul"al ane!the!ia that i! !i ilar to li*ocaine 1ith e"ine"hrine5 %ut he o!ta!i! i! not a! inten!e PRILOCAINE / The action o# "rilocaine "lain 2arie! 1ith the area in+ecte* Blon$er 1ith a ner2e %loc4C3 / Prilocaine 1ith 2a!ocon!trictor $i2e! $oo* ane!thetic e##ect an* u!e! a G0L;;5;;; concentration o# e"ine"hrine (UPIAACAINE / (u"i2acaine i! u!e* 1hen "ul"al ane!the!ia i! *e!ire* #or lon$er a""oint ent! an* 1hen "o!to"erati2e "ain i! antici"ate*3 / (u"i2acaine i! not reco en*e* #or chil*ren or han*ica""e* "atient! %ecau!e o# the increa!e* ri!4 o# "o!to"erati2e in+ury Bche1in$ on a nu % li"C3 CENT(UCRIDINE / It *oe! not e##ect the CNS or CAS a*2er!ely e&ce"t 1hen a* ini!tere* in 2ery lar$e *o!e!3 / U!e* in ;3IH concentration! TAMED (IOTOFINS / Tetra*oto&in an* Sa&ito&in / (loc4 a&onal *e"olari>ation %y %loc4in$ tran! e %rane in1ar* !o*iu current3

The *i##u!ion an* "enetratin$ a%ilitie! are 2ery "oor5 can not cro!! the e"ineuriu 3 / Sy!te ic to&icity to %rain 5 heart an* u!cle i! al!o o# concern
/

HYALURONIDASE / An en>y e that %rea4! *o1n intracellular ce ent3 / A*2ocate* a! an a**iti2e to local ane!thetic! a! it "er it! in+ecte* !olution! to !"rea* an* "enetrate ti!!ue! / A2aila%le a! Wydase in a lyo"hili>e* "o1*er an* a !ta%ili>e* !olution3 / A**e* to the cartri*$e +u!t %e#ore a* ini!tration %y re o2in$ a""ro&i ately G=<th o# !olution3 / Aller$ic reaction! ha2e %een *e on!trate*

PH ALTERATIONS
/
-hen a local anae!thetic i! in+ecte* into ti!!ue5 t1o "article! are in e,uili%riu 0 a li"o"hilic neutral "article an* a "o!iti2ely char$e* hy*ro"hilic "article Three #actor! can a##ect thi! e,uili%riu 0 / The ")a o# the local anae!thetic5 / The "H o# the local anae!thetic / The "H o# the ti!!ue in 1hich the anae!thetic i! %ein$ *e"o!ite*3 ")a o# local ane!thetic! / The ")a o# a local anae!thetic i! *e#ine* a! the "H at 1hich hal# o# the local anae!thetic "article! in e,uili%riu are neutral BRNC an* hal# are char$e* BRNHD C / Mo!t local anae!thetic! ha2e ")a E :3M RNHD RN D HD "H o# local ane!thetic! / Mo!t local ane!thetic! ha2e a "H %et1een I3I an* : 1ith out 2a!ocon!trictor an* le!! than I3I 1ith 2a!ocon!trictor The a**ition o# !u%!tance! to the ane!thetic that al4alini>e! the !olution !houl* a4e the *ru$N! a* ini!tration ore co #orta%le3

Hi$her the "H

ore ra"i* i! the on!et o# action an* $reater "otency3

Car%onate* local ane!thetic! / Ner2e! internal "H i! lea!t a##ecte* %y e&ternal "H #luctuation!3 / Ga!e! *i##u!e rea*ily acro!! the ner2e e %rane! Co& CO& + H& H&CO' + # + #! ' D RNH RN D HD (loc4 con*uction SODIUM (ICAR(ONATE A**e* i e*iately %e#ore in+ection al4alini>e! the !olution increa!in$ the nu %er o# unchar$e* %a!e olecule! NaHCO' RNHD Na+ + #! RN D HD
'

HLCOP Di!a*2anta$e! o# al4alini>ation / I# "h i! too hi$h local ane!thetic ay "reci"itate out a! the *ru$ %a!e / Sta%ility o# local ane!thetic *ecrea!e! a! "h increa!e! hence !hel# li#e i! *ecrea!e*

TOPICAL ANESTHETICS

I "ortant co "onent #or atrau atic a* n o# intraoral local ane!the!ia / Do not contain 2a!ocon!trictor! / E##ecti2e only on !ur#ace ti!!ue! / (en>ocaine an* Li*ocaine are o!t co only u!e* / E##ecti2e only on a%ra*e* !4in

INTRAORAL TOPICAL ANESTHETIC DELIAERY G3 A! 1ater !olu%le !alt! L3 Di!!ol2e* in or$anic !ol2ent! P3 A! oil?1ater emulsions M3 A! eutectic i&ture! I3 Incor"orate* into patches an* controlle* relea!e *e2ice! J3 U!in$ iontophoresis an* phonophoresis :3 Incor"orate* into liposome's

E(TE!T$! M$)T(*E

+ L !AL ANE"T#E"$A ,EMLA

E(TE!T$!-Melts at a temperature lo.er than either of its crystalline constituents / /0 of la +1&0 of .ater+ inert stabili2er / Local anesthetic agent oil is emulsified .ith .ater / &3/0 lidocaine and &3/0 prilocaine / Agent is made to form a cream .ith ph of 1 .ell above the p4a of either local anesthetic agents3 / Hi$h "h en!ure! @;H or ore o# the local ane!thetic
/

a$ent i! in *i##u!i%le unchar$e* #ree %a!e #or

/ / /

$ntact s4in is barrier to diffusion EMLA should be applied 5 hour before the procedure

Sati!#actory nu %in$ occur! G hour a#ter a""lication an* reache! a&i u at L to P hour! an* la!t! #or G to L hour! a#ter re o2al
/ "upplied in a / g or '6 g tube or as an EMLA anesthetic disc3 / $t is .hite round7 cellulose disc preloaded .ith EMLA pac4aged in a protective laminate foil surrounded .ith adhesive tape3

L$8 !A$NE %AT!#

/ /

It i! an a*he!i2e containin$ MJ3G $ o# li*ocaine3 The li*ocaine i! a%!or%e* %y the uco!a5 an* they clai ane!thetic on!et 1ithin L3I inute! o# a""lication3

/ The "atch i! le#t in "lace u" to GI inute! an* the ane!thetic e##ect can la!t u" to P; inute! a#ter re o2al / le2el! o# li*ocaine #ollo1in$ a""lication are le!! than ;3G S$= L3 / Unli4e con2entional ane!thetic oint ent! an* $el! 5"atche!
"ro*uce a #air a ount o# "erio!teal ane!the!ia 1hen a""lie* to intact %uccal uco!a

$ontophoresis
Ionto"hore!i! i! a ean! o# *eli2erin$ local ane!thetic! to *ee"er ti!!ue a#ter to"ical a""lication 3
/

%e

Po!iti2ely char$e* *ru$! !uch a! li$nocaine an* a*renaline can encoura$e* to "enetrate

the ti!!ue un*er the in#luence o# electrical char$e

%# N %# *E"$"

/ Phono"hore!i! i! the u!e o# hi$h #re,uency ra*io 1a2e! to *ri2e *ru$! into ti!!ue! an* ha! %een !u$$e!te* a! a "o!!i%le etho* o# increa!in$ the e##icacy o# to"ical a""lication! / 3

L$% " ME" / Carrier 2ehicle! co "o!e* o# naturally occurrin$ li"i* an*
chole!terol 5 !i ilar in co "o!ition to %iolo$ical e %rane!3 / The relati2ely lar$e !i>e o# the li"o!o eT! a!!ure! that they re ain at the !ite o# a* ini!tration #or a "rolon$e* "erio* o# ti e3

ELE!T* N$! 8ENTAL ANE"T#E"$A

-HAT IS THE MECHANISM OF ACTION OF EDA. / CHRONIC PAIN / ACUTE PAIN Chronic "ain / At lo1 #re,uency !ettin$ "ro*uce! ea!ura%le chan$e! in %loo* le2el! o# !tryptophan, "eratonin, and beta endorphins. / L try"to"han Seratonin / Seratonin Analgesic actions

#levates the pain threshold level (eta en*or"hin! an* en4e"halin! Potent anal$e!ic!

ACUTE DENTAL PAIN / Mel>ac4 an* 1all! $ate control theory o# "ain "ro2i*e! a*e,uate e&"lanation #or "re2ention o# acute "ain "ro2i*e* %y EDA / At hi$h #re,uency EGL; h>! 5 Patient e&"erience! !en!ation *e!cri%e* a! 2i%ratory 5 thro%%in$ 5 "ul!in$ 5 t1itchin$

In2ol2e! !ti ulation o# lar$e *ia eter A *elta #i%er! 3 / I# ini u thre!hol* inten!ity o# lar$e *ia eter a *elta #i%er! i! aintaine* "ain i "ul!e! %rou$ht a%out %y ! aller a *elta an* c #i%er! 1ill co e on a clo!e* $ate to %e una%le to reach the %rain3 / The lar$e #i%er in"ut i! !ai* to inhi%it central tran! i!!ion o# the
o2erall e##ect! o# ! all #i%er in"ut3

/ (loo* le2el! o# !eratonin an* en*or"hin! li4e1i!e are al!o ele2ate* *urin$ hi$h #re,uency !ti ulation / Pro*uce! ele2ate* %loo* le2el! o# !eratonin an* en*or"hin!3 / Increa!e* le2el! "er!i!t #or !e2eral hour! a#ter ter ination o#
TENS3

/ Hel" to %loc4 the "ain cycle 1hich i! re!"on!i%le #or chronicity o# "ain / -hen EDA i! utili>e*5 electro*e! initially are "lace* in the
re$ion o# the a&illa= an*i%le 1here Uane!the!iaU i! *e!ire*3

/ A#ter e!ta%li!hin$ a %a!eline co #ort >one o# electrical i "ul!e!5 the "atient a*+u!t! the electronic !ti ulation to !uit hi! or her co #ort le2el3
/ Patient! 1ho ha2e recei2e* %oth local ane!the!ia an* EDA re"ort i&e* re!ult! 1ith re$ar* to the e##ecti2ene!! o# EDA in "ain control an* #DA alone does not mitigate the possibility that a dental local anesthetic may be nee*e*3 EDA i! u!e* o!t a""ro"riately in routine o"erati2e "roce*ure! an* !i "le "e*iatric e&traction!3 It! u!e#ulne!! ay %e ,ue!tione*5 ho1e2er5 1hen ca2ity "re"aration! ore clo!ely a""ro&i ate the "ul"3

PHARMACOKINETICS

A9" *%T$ N 8$"T*$9(T$ N META9 L$"M :9$ T*AN"+ *MAT$ N; E)!*ET$ N

A%!or"tion0
/ / /
AASOACTIAITY 0 All the LA are 2a!o*ilator!3 ESTER LA are "otent 2a!o*ilator! COCAINE i! the only LA 1hich cau!e! "er!i!tent 2a!ocon!triction3 B%co> it inhi%it! u"ta4e o# catechola ine! into ti!!ue %in*in$ !ite!3C / PROCAINE i! "ro%a%ly the o!t "otent 2a!o*ilator A(SORPTION / ORAL ROUTE 0 All LA are "oorly a%!or%e*3 / Mo!t LA un*er$o HEPATIC #ir!t "a!! e##ect #ollo1in$ oral a* ini!tration3 / TOPICAL 0 A%!or%e* at *i##erent rate!3 6tracheal ?#a!t a! IA 6 "haryn$eal ? !lo1er 6e!o"ha$eal=%la**er6 e2en !lo1er -hen no intact layer o# !4in 6 it act!3B!un%urn re e*ie! A(SORPTION / In+ection 0 The rate o# u"ta4e a#ter in+ection B!u%cutaneou!5 intra u!cular5 IA C *e"en*! on the 2a!cularity o# the in+ection !ite an* the 2a!oacti2ity o# the *ru$3

IA6 Mo!t ra"i* inta4e an* i! u!e* #or the treat ent o# 2entricular *y!rhyth ia!

DISTRIBUTION
Di!tri%ution to %o*y or$an! 0
53 9rain7 liver spleen7head74idney :because they are highly perfused; <initially high levels of LA3

L3S)ELETAL MUSCLE 0 Greate!t "ercenta$e %ecau!e it a4e! lar$e!t a!! o# ti!!ue in the %o*y

/ /

LA can readily cross the blood-brain barrier3 LA can also cross the placenta and can enter the circulating system of the developing fetus3

META9 L$"M
Esters < #ydrolysis in the plasma by the en2yme %seudo cholinesterase Amides < Metaboli2ed in the liver via a Multi step path.ay by Microsomal mi=ed function =idase system :cytochrome p>/6;3

EXCRETION
The 4idneys are the primary e=cretory organ for both local anesthetic groups3 E"TE*" appear only in very small ?uantities in the urine as the parent compound3

A i*e! %co> o# co "le& "roce!! o# %iotran!#or ation ? a""ear in $reater "ercenta$e than the e!ter!

A*MAMENTA*$(M
/ E,ui" ent nece!!ary #or LA a* ini!tration

/ Syrin$e! / Nee*le! / to"ical ane!thetic! / Ane!thetic! / Mouth "ro"! Ty"e! o# !yrin$e! / Non*i!"o!a%le

%reech loa*in$5 etallic cartri*$e ty"e a!"iratin$ %reech loa*in$5 "la!tic cartri*$e ty"e a!"iratin$

%reech loa*in$

etallic cartri*$e ty"e !el# a!"iratin$

Pre!!ure !yrin$e #or "erio*ontal li$a ent in+ection

/ / / /

Oet in+ector Di!"o!a%le !yrin$e! Sa#ety !yrin$e! Co "uter controlle* local ane!thetic *eli2ery !y!te !

/ /

(reech loa*in$ 5 etallic5catri*$e6ty"e a!"iratin$ Pre!!ure !yrin$e!6u!e* #or Intra li$a entary in+ection!

OET INOECTOR

/ / /

Fi$$e an* Scherer G@M: nee*le le!! in+ection

Mar$eti! et al G@I< in *enti!try

Oet in+ector6%a!e* on "rinci"le that li,ui*! #orce* throu$h 2ery ! all o"enin$!5calle* +et!5 at 2ery hi$h "re!!ure can "enetrate intact !4in or ucou! e %rane DISADAANTAGES / Co!t / Potential to #ri$hten "atient! 1ith the !u**en noi!e

/ Pre!!ure !en!ation that occur on *eli2ery o# the ane!thetic / Intru!i2e a""earance o# the *e2ice / "o!!i%ility o# ! all Re!i*ual he ato a! / Lea4a$e o# ane!thetic / 'ue!tiona%le e##icacy #or "ul"al ane!the!ia SAFETY SYRINGES / Mini i>e! acci*ental nee*le !tic4 in+ury3 / Syrin$e! "o!!e! a sheath that loc4! o2er the nee*le 1hen it i! re o2e* #ro the "atient ti!!ue!3

/ /

Sa#ety !yrin$e! are *e!i$ne* to %e #or !in$le u!e ite !3 Reloa*in$ the !yrin$e 1ith a !econ* ane!thetic catri*$e an* rein+ectin$ 1ith the !a e !yrin$e i! *i!coura$e* %ecau!e thi! o%2iate! the i "ortant !a#ety a!"ect o# the *e2ice

!!LA8

/ / /

-an*=co "u*ent Co #ort control !yrin$e

Hal!tea* "er#or e* the #ir!t ane!thetic ner2e %loc4 a century a$o an* i*enti#ie* an a""ro"riate *ru$ *eli2ery !y!te ?the !yrin$e an* hollo1 %ore nee*le3 / S"inello 5later in G@@:*e2elo"e* an inno2ati2e *ental *e2ice5 1hich 1a! co ercially a2aila%le a! -an* BMile!tone Scienti#ic

-hat *oe! 1an* *o. / Pro2i*e! increa!e* tactile control an* er$ono ic! 5 "reci!e nee*le control *urin$ the in+ection3 / A2aila%le flow rates o# local ane!thetic *eli2ery are co "uter controlle* an* re ain! consistent #ro one in+ection to the ne&t3 / controlle* #lo1 o# ane!thetic i! thou$ht to re*uce "ain an* thu! "atient! #ear an* an&iety3 FEATURES OF -AND / -ith tra*itional !yrin$e the !tatic "o!ition o# the nee*le relati2e to the %e2ele* en* cau!e! *e#lection 5 re!ult! in i!!e* %loc4 or *elaye* on!et o# re!ult3 / Pen li4e $ra!" ha! the a*2anta$e o# allo1in$ the o"erator to rotate the han* "iece *urin$ "enetration an* in!ertion / A! the nee*le i! in!erte* ane!thetic i! *eli2ere* in a con!tant co "uter controlle* anner re$ar*le!! o# ti!!ue *en!ity3 / The *e2ice "ro2i*e! a %etter alternati2e to tra*itional reca""in$

A!"iration te!t can %e acti2ate* at any ti e %y !i "ly relea!in$ the "re!!ure on #oot control rheo!tat !tartin$ a M3I !econ* a!"iration cycle3 / Deli2er! a controlle* rate o# #lo1 an* control! "re!!ure *e2elo"in$ 1ith in the ti!!ue / A* ini!ter! local ane!thetic a$ent at L !"eci#ic rate! o# *eli2ery COMFORT CONTROL SYRINGE / CCS ha! L !ta$e *eli2ery !y!te in+ection %e$in! at an e&tre ely !lo1 rate to "re2ent "ain a!!ociate* 1ith ,uic4 *eli2ery3 / A#ter G; !econ*! CCS auto atically increa!e! !"ee* to the "re"ro$ra e* in+ection rate3

NEEDLES0 lon$5 e*iu 5!hort (IROTATIONAL INSERTION TECHNI'UE B(RIT / Mini i>in$ nee*le *e#lection -hy nee*le *e#lect!

Durin$ in!ertion a #orce "er"en*icular to the #or1ar* *irectional o2e ent act! on the !ur#ace o# nee*le3 / Thi! cau!e! the nee*le to %en* or *e#lect in a *irection o""o!ite to 1hich the %e2el #ace!3 NEEDLE FACTORS INFLUENCING DEFLECTION / Lon$er the nee*le len$th ore i! the *e#lection5 %ecau!e the nee*le ha! to tra2el $reater *i!tance alon$ the *e#lectin$ "ath3 / S aller the *ia eter o# nee*le ore e&a$$erate* i! the %en*in$ or *e#lection3 / S all $au$e i! le!! ca"a%le o# re!i!tin$ the *e#lection3 (RIT AND TRADITIONAL SYRINGE / Tra*itional !yrin$e i! ty"ically hel* 1ith a "al an* thu % $ra!" an* *oe! not "er it !uch a techni,ue e##ecti2ely3 / The 1an* co "u*ent e "loy! a li$ht 1ei$ht han* "iece that i! hel* 1ith a "en li4e or *art $ra!" that i! ea!ily rotate*3 *e#lection i! eli inate* or neutrali>e* #ro the con!tant chan$in$ o# %e2el orientation a! it i! rotate* DISADAANTAGES / Co!t / Potential to #ri$hten "atient! 1ith the !u**en noi!e / Pre!!ure !en!ation that occur on *eli2ery o# the ane!thetic / Intru!i2e a""earance o# the *e2ice / "o!!i%ility o# ! all Re!i*ual he ato a! / Lea4a$e o# ane!thetic / 'ue!tiona%le e##icacy #or "ul"al ane!the!ia SAFETY SYRINGES

/ /

Sa#ety !yrin$e! are *e!i$ne* to %e #or !in$le u!e ite !3 Reloa*in$ the !yrin$e 1ith a !econ* ane!thetic catri*$e an* rein+ectin$ 1ith the !a e !yrin$e i! *i!coura$e* %ecau!e thi! o%2iate! the i "ortant !a#ety a!"ect o# the *e2ice ADDITIONAL ARMAMENTARIUM / To"ical anti!e"tic / To"ical ane!thetic / A""licator !tic4! / Cotton $au$e

He o!tat

NE*@E 9L !K TE!#N$A(E"
/ For *ental anae!the!ia5 the neuroanato ical #ocu! i! the #i#th cranial ner2e5 al!o 4no1n a! the tri$e inal ner2e3

/ Thi! ner2e ha! three *i2i!ion! 6 the o"hthal ic *i2i!ion BAGC5 the a&illary *i2i!ion BALC an* the an*i%ular *i2i!ion BAPC3 / The a&illary *entition recei2e! inner2ation #ro AL5 an* the an*i%ular *entition recei2e! inner2ation #ro AP3 THE MAFILLARY NERAE / The a&illary ner2e enter! the "tery$o"alatine #o!!a an* %ranche! into three a+or !ection!0 the $an$lionic %ranche!5 the >y$o atic ner2e an* the "o!terior !u"erior al2eolar ner2e3 / The $an$lionic %ranche! tra2el to the "tery$o"alatine

$an$lion5 1hich in turn !en*! !en!ory5 "ara!y "athetic an* !y "athetic #i%re! %ac4 to the a&illary ner2e / The >y$o atic ner2e enter! the or%it an* tra2el! alon$ the
lateral 1all3 It %i#urcate! into t1o ter inal %ranche!5 the >y$o atico#acial ner2e5 1hich !u""lie! !en!ation to the chee45 an*

the >y$o aticote "oral ner2e5 1hich !u""lie! !en!ation to the te "le area

/
$lan*

There i! al!o a "ara!y "athetic co "onent to the lacri al

The "o!terior !u"erior al2eolar ner2e tra2el! in#eriorly on the in#rate "oral !ur#ace o# the a&illa5 enterin$ the a&illary !inu! an* e2entually ter inatin$ in !en!ory %ranche! #or the a&illary olar! an* their !urroun*in$ %uccal $in$i2a5 1ith the "o!!i%le e&ce"tion o# the e!io%uccal root o# the #ir!t olar / Ho1e2er5the i**le !u"erior al2eolar ner2e i! not "re!ent in all "eo"leK i# the ner2e i! a%!ent5 the!e area! are inner2ate* %y the "o!terior an* anterior !u"erior al2eolar ner2e! / The ain area! o# !en!ory inner2ation #or the anterior !u"erior al2eolar ner2e are the cu!"i*5 an* central an* lateral inci!or! an* the %uccal $in$i2a in that area3

/ The in#raor%ital ner2e continue! an* e2entually "a!!e! throu$h the in#raor%ital #ora en onto the #ace5 !u""lyin$ the lo1er eyeli*5 the !i*e o# the no!e an* the u""er li" / L !AL $N+$LT*AT$ N0

/ S all ter inal ner2e en*in$! in the area o# *ental treat ent are #loo*e* 1ith local anae!thetic !olution3Treat ent i! *one in the !a e area o# in 1hich !olution ha! %een *e"o!ite*3

+$EL8 9L !K0

Local anae!thetic !olution i! *e"o!ite* near the lar$er ter inal %ranch5 !o the anae!theti>e* area 1ill %e circu !cri%e* to "re2ent the "a!!a$e o# i "ul!e #ro the tooth to CNS3Treat ent i! *one in an area a1ay #ro the !ite o# in+ection NE*@E 9L !K0

LA *e"o!ite* clo!e to the ain ner2e trun4 u!ually at a *i!tance #ro the !ite o# o"erati2e inter2ention3 Eg0 "o!terior !u"erior al2eolar ner2e %loc43 In#erior al2eolar ner2e %loc4 MA)$LLA*B $NCE!T$ N TE!#N$A(E" SUPRA PERIOSTEAL INOECTION0 B Local In#iltration C INDICATIONS0 / Pul"al anae!the!ia o# a&illary teeth 1hen treat ent i! li ite* to one or t1o tooth 3 / So#t ti!!ue anae!the!ia #or !ur$ical "roce*ure in a circu !cri%e* area ! NT*A$N8$!AT$ N0 / In#ection or acute in#la ation in the area o# in+ection3

8$"A8@ANTADE" 0 / Nee* #or ulti"le nee*le in!ertion!3 / Nece!!ary to a* ini!ter lar$e 2olu e o# !olution3

TECHNI'UE0

AM (NT T

9E 8E% "$TE86 ;3J l o2er L; !ec3

POSTERIOR SUPERIOR ALAEOLAR NERAE (LOC) / One o# the #re,uently u!e* ner2e %loc4! in *enti!try3

/ The ane!thetic !olution i! *e"o!ite* %ehin* the tu%ero!ity 5 near the "o!terior !u"erior al2eolar ner2e %e#ore it enter! the a&illary !inu!
The "o!terior !u"erior al2eolar BPSAC ner2e %loc45 other1i!e 4no1n a! the tu%ero!ity %loc4 or the >y$o atic %loc45 i! u!e* to achie2e ane!the!ia o# the a&illary olar teeth u" to the G!t olar 1ith the e&ce"tion o# it! e!io%uccal root in !o e ca!e!3 / One o# the "otential co "lication! o# thi! techni,ue i! the ri!4 o# he ato a #or ation #ro in+ection o# ane!thetic into the "tery$oi* "le&u! o# 2ein! or acci*ental "uncture o# the a&illary artery3 A!"iration "rior to in+ection i! in*icate* 1hen the PSA %loc4 i! $i2en / The in*ication! #or thi! techni,ue are the nee* to ane!theti>e ulti"le olar teeth / In in*i2i*ual! 1ith coa$ulation *i!or*er!5 care u!t %e ta4en to a2oi* in+ection into the "tery$oi* "le&u! or "uncture o# the a&illary artery3 LI6 or L:6$au$e !hort nee*le i! "re#erre* #or thi! techni,ue3
/

Technique

I*enti#y the hei$ht o# the Thi! 1ill %e the in+ection !ite3

/ /

uco%uccal #ol* o2er the Ln*

olar3

The ri$ht han*e* o"erator !houl* !tan* at the nine oNcloc4 to ten oNcloc4 "o!ition 1herea! the le#t han*e* o"erator !houl* !tan* at the t1o oNcloc4 to three oNcloc4 "o!ition3 Retract the li" 1ith a retraction in!tru en
/ /

Hol* the !yrin$e 1ith the %e2el to1ar* the %one3

In!ert the nee*le at the hei$ht o# the uco%uccal #ol* a%o2e the a&illary Ln* olar at a MI *e$ree an$le *irecte* !u"eriorly5 e*ially5 an* "o!teriorly Bone continuou!

o2e entC3 A*2ance the nee*le to a *e"th o# three ,uarter! o# it! total len$th
No re!i!tance !houl* %e #elt 1hile a*2ancin$ the nee*le throu$h the !o#t ti!!ue3 / I# %one i! contacte*5 the e*ial an$ulation i! too $reat3 Slo1ly retract the nee*le B1ithout re o2in$ itC an* %rin$ the !yrin$e %arrel to1ar* the occlu!al "lane3 Thi! 1ill allo1 the nee*le to %e an$ulate* !li$htly ore lateral to the "o!terior a!"ect o# the a&illa3 / Prior to in+ectin$5 one !houl* a!"irate in t1o "lane! to a2oi* acci*ental in+ection into the "tery$oi* "le&u!3 A#ter the #ir!t a!"iration5 the nee*le !houl* %e rotate* one ,uarter turn3 The o"erator !houl* then rea!"irate3 / I# "o!iti2e a!"iration occur!5 !lo1ly retract the nee*le one to t1o illi eter! an* rea!"irate in t1o "lane!3 / Succe!!#ul in+ection techni,ue 1ill re!ult in ane!the!ia o# the a&illary olar! B1ith the e&ce"tion o# the e!io%uccal root o# the #ir!t olar in !o e ca!e!C5 an* a!!ociate* !o#t ti!!ue on the %uccal a!"ect3
/

!omplications
HEMATOMA

Thi! i! co only "ro*uce* %y in!ertin$ the nee*le too #or "o!teriorly into the "tery$oi* "le&u! o# 2ein! 3 / In a**ition a&illary artery ay %e "er#orate*3 / U!e o# !hort nee*le ini i!e! the ri!4 o# "tery$oi* "le&u! "uncture

Middle "uperior Alveolar Nerve 9loc4

The i**le !u"erior al2eolar ner2e %loc4 i! u!e#ul #or "roce*ure! 1here the a&illary "re olar teeth or the e!io%uccal root o# the G!t olar re,uire ane!the!ia3 / Althou$h not al1ay! "re!ent5 it i! u!e#ul i# the "o!terior or anterior !u"erior al2eolar ner2e %loc4! or !u"ra"erio!teal in#iltration #ail! to achie2e a*e,uate ane!the!ia / In*i2i*ual! in 1ho the MSA ner2e i! a%!ent5 the PSA an* ASA ner2e! "ro2i*e inner2ation to the a&illary "re olar teeth an* the e!io%uccal root o# the G!t olar / Contrain*ication! inclu*e acute in#la ation an* in#ection in the area o# in+ection or a "roce*ure in2ol2in$ one tooth 1here local
/

in#iltration 1ill %e !u##icient3 A LI6 or L:6$au$e !hort nee*le i! "re#erre* #or thi! techni,ue3 Technique

I*enti#y the hei$ht o# the uco%uccal #ol* a%o2e the a&illary Ln* "re olar3 Thi! 1ill %e the in+ection !ite3 / The ri$ht han*e* o"erator !houl* !tan* at the nine oNcloc4 to ten oNcloc4 "o!ition 1herea! the le#t han*e* o"erator !houl* !tan* at the t1o oNcloc4 to three oNcloc4 "o!ition3 / Retract the li" 1ith a retraction in!tru ent an* in!ert the nee*le until the ti" i! a%o2e the a"e& o# the Ln* "re olar tooth 3 / A!"irate an* in+ect ane!thetic !olution !lo1ly o2er the cour!e o# one inute3 Succe!!#ul e&ecution o# thi! techni,ue "ro2i*e! ane!the!ia to the "ul"5 !urroun*in$ !o#t ti!!ue an* %one o# the G!t an* Ln* "re olar teeth an* e!io%uccal root o# the G!t olar3G Contrain*ication! / In#ection or in#la ation in the area o# in+ection or nee*le in!ertion or *ru$ *e"o!ition Anterior Su"erior Al2eolar Ner2e (loc4= In#raor%ital Ner2e (loc4
/

The anterior !u"erior al2eolar BASAC ner2e %loc4 or in#raor%ital ner2e %loc4 i! a u!e#ul techni,ue #or achie2in$ ane!the!ia o# the a&illary central an* lateral inci!or! an* canine a! 1ell a! the !urroun*in$ !o#t ti!!ue on the %uccal a!"ect3 / In "atient! that *o not ha2e an MSA ner2e5 the ASA ner2e ay al!o inner2ate the "re olar teeth an* e!io%uccal root o# the G!t olar3 In*ication! #or the u!e o# thi! techni,ue inclu*e "roce*ure!
/

in2ol2in$ ulti"le teeth an* ina*e,uate ane!the!ia #ro the !u"ra"erio!teal techni,ue3 A LI $au$e lon$ nee*le i! "re#erre* #or thi! techni,ue Technique / Place the "atient in the !u"ine "o!ition3 I*enti#y the hei$ht o# the uco%uccal #ol* a%o2e the a&illary G!t "re olar3 / Thi! 1ill %e the in+ection !ite3 / The ri$ht han*e* o"erator !houl* !tan* at the ten oNcloc4 "o!ition 1herea! the le#t han*e* o"erator !houl* !tan* at the t1o oNcloc4 "o!ition3 / I*enti#y the in#raor%ital notch on the in#erior or%ital ri 3 / The in#raor%ital #ora en lie! +u!t in#erior to the notch u!ually in line 1ith the !econ* "re olar3

Sli$ht *i!co #ort i! #elt %y the "atient 1hen *i$ital "re!!ure i! "lace* on the #ora en3 It i! hel"#ul %ut not nece!!ary to ar4 the "o!ition o# the in#raor%ital #ora en
/

Retract the li" 1ith a retraction in!tru ent 1hile notin$ the location o# the #ora en / Orient the %e2el o# the nee*le to1ar* %one an* in!ert the nee*le at the hei$ht o# the uco%uccal #ol* a%o2e the G!t "re olar / The !yrin$e !houl* %e an$le* to1ar* the in#raor%ital #ora en an* 4e"t "arallel 1ith the lon$ a&i! o# the G!t "re olar to a2oi* hittin$ the a&illary %one "re aturely3 / The nee*le i! a*2ance* into the !o#t ti!!ue until the %one o2er the roo# o# the #ora en i! contacte*3 A#ter a!"iration5 ane!thetic cartri*$e i! *e"o!ite* !lo1ly o2er the cour!e o# one inute3 / It i! reco en*e* that "re!!ure %e 4e"t o2er the !ite o# in+ection to #acilitate the *i##u!ion o# ane!thetic !olution into the #ora en3 / Succe!!#ul e&ecution o# thi! techni,ue re!ult! in ae!the!ia o# the lo1er eyeli*5 lateral a!"ect o# the no!e5 an* the u""er li"3
/

Pul"al ane!the!ia o# the a&illary central an* lateral inci!or!5 canine5 %uccal !o#t ti!!ue5 an* %one i! al!o achie2e*3 In a certain "ercenta$e o# "eo"le5 the "re olar teeth an* the e!io%uccal root o# the G!t olar i! al!o ane!theti>e*3 / The !econ* *irection o# in!ertion %i!ect! the cro1n o# the
/

central inci!or #ro

the

e!io inci!al an$le to the *i!to$in$i2al an$le

The nee*le i! in!erte* a%out I an* $ui*e* into "o!ition %y the thu % in#raor%ital #ora en Dreater %alatine Nerve 9loc4

#ro the uco%uccal #ol* ar4in$ the location o#

The $reater "alatine ner2e %loc4 i! u!e#ul 1hen treat ent i! nece!!ary on the "alatal a!"ect o# the a&illary "re olar an* olar *entition / Al!o calle* a! Anterior "alatine ner2e %loc43 / Thi! techni,ue tar$et! the area +u!t anterior to the $reater "alatine canal3 The $reater "alatine ner2e e&it! the canal an* tra2el! #or1ar* %et1een the %one an* !o#t ti!!ue o# the "alate3
/

Contrain*ication! to thi! techni,ue are acute in#la ation an* in#ection at the in+ection !ite3 A LI6 or L:6 $au$e lon$ nee*le i! "re#erre* #or thi! techni,ue
/

Technique / The "atient !houl* %e in the !u"ine "o!ition 1ith the chin tilte* u"1ar* #or 2i!i%ility o# the area to %e ane!theti>e*3 The ri$ht han*e* o"erator !houl* !tan* at the ei$ht oNcloc4 "o!ition 1herea! the le#t han*e* o"erator !houl* !tan* at the #our oNcloc4 "o!ition3 / U!in$ a cotton !1a%5 locate the $reater "alatine

#ora en %y "lacin$ it on the "alatal ti!!ue a""ro&i ately one centi eter e*ial to the +unction o# the Ln* an* Pr* olar
/ -hile thi! i! the u!ual "o!ition #or the #ora en5 it ay %e locate* !li$htly anterior or "o!terior to thi! location3 / Gently "re!! the !1a% into the ti!!ue until the *e"re!!ion create* %y the #ora en i! #elt3 The area a""ro&i ately one to t1o illi eter! anterior to the #ora en i! the tar$et in+ection !ite3 / U!in$ the cotton !1a%5 a""ly "re!!ure to the area o# the #ora en until the ti!!ue %lanche!3

Ai the !yrin$e "er"en*icular to the in+ection !ite 1hich i! one to t1o illi eter! anterior to the #ora en3
/
/

-hile 4ee"in$ "re!!ure on the #ora en5 in+ect ! all 2olu e! o# ane!thetic !olution a! the nee*le i! a*2ance* throu$h the ti!!ue until %one i! contacte*3 / The ti!!ue 1ill %lanch in the area !urroun*in$ the in+ection !ite3 / De"th o# "enetration i! u!ually #e1 illi eter!3 / Once %one i! contacte*5 a!"irate an* in+ect ane!thetic !olution3 / Re!i!tance to *e"o!ition o# ane!thetic !olution i! nor ally #elt %y the o"erator3 / Thi! techni,ue "ro2i*e! ane!the!ia to the "alatal uco!a an* har* "alate #ro the G!t "re olar anteriorly to the "o!terior a!"ect o# the har* "alate an* to the i*line e*ially Nasopalatine Nerve 9loc4

The na!o"alatine ner2e %loc45 other1i!e 4no1n a! the inci!i2e ner2e %loc4 an* !"heno"alatine ner2e %loc45 ane!theti>e! the na!o"alatine ner2e! %ilaterally3 / In thi! techni,ue ane!thetic !olution i! *e"o!ite* in the area o# the inci!i2e #ora en3 / Thi! techni,ue i! in*icate* 1hen treat ent re,uire! ane!the!ia o# the lin$ual a!"ect o# ulti"le anterior teeth3 A LI6 or L:6$au$e !hort nee*le i! "re#erre* #or thi! techni,ue3
/

Technique / The "atient !houl* %e in the !u"ine "o!ition 1ith the chin tilte* u"1ar* #or 2i!i%ility o# the area to %e ane!theti>e*3 / The ri$ht han*e* o"erator !houl* %e at the nine oNcloc4 "o!ition 1herea! the le#t han*e* o"erator !houl* %e at the three oNcloc4 "o!ition3 / I*enti#y the inci!i2e "a"illae3

The area *irectly lateral to the inci!i2e "a"illa i! the in+ection !ite3
/
/

-ith a cotton !1a%5 hol* "re!!ure o2er the inci!i2e "a"illa3 / In!ert the nee*le +u!t lateral to the "a"illa 1ith the %e2el a$ain!t the ti!!ue / A*2ance the nee*le !lo1ly to1ar* the inci!i2e #ora en 1hile *e"o!itin$ ! all 2olu e! o# ane!thetic an* aintainin$ "re!!ure on the "a"illa3 / Once %one i! contacte*5 retract the nee*le a""ro&i ately one illi eter5 a!"irate5 an* in+ect ane!thetic !olution o2er the cour!e o# thirty !econ*!3

(lanchin$ o# !urroun*in$ ti!!ue! an* re!i!tance to the *e"o!ition o# ane!thetic !olution i! nor al3 / Ane!the!ia 1ill %e "ro2i*e* to the !o#t an* har* ti!!ue o# the lin$ual a!"ect o# the anterior teeth #ro the *i!tal o# the canine on one !i*e to the *i!tal o# the canine on the o""o!ite !i*e Anterior Middle "uperior alveolar nerve bloc4 / Re"orte* %y Frie* an an* Hoch an in G@@: 1ith CCLAD !y!te / Pro2i*e! ane!the!ia o# ulti"le a&illary teeth inci!or!5 canine!5 "re olar! #ro !in$le in+ection !ite3 -HAT IS AMSA NERAE (LOC)

/ It i! a #iel* %loc4 o# the ter inal %ranche! !u%neural *ental "le&u! o# the ASA ner2e that inner2ate! the inci!or! to "re olar teeth3 / T1o anato ical !tructure! the na!al a"erture an* a&illary !inu! cau!e the con2er$ence o# the %ranche! o# ASA 5 MSA ner2e! an* a!!ociate* !u%neural *ental "le&u! in the re$ion o# a"ice! o# the "re olar!

INOECTION SITE

Har* "alate a%out hal# 1ay alon$ the i a$inary line connectin$ the i* "alatal !uture to the #ree $in$i2al ar$in3 / The location o# the line i! at the contact "oint %et1een #ir!t an* !econ* "re olar!3 ADAANTAGES / A! local ane!the!ia i! *e"o!ite* on the "alate !o #acial e&"re!!ion an* u""er li" are not ane!theti>e*3 / Mini u 2olu e o# local ane!the!ia i! nee*e*3 u!cle! o#

AREAS ANESTHETIQED / Pul"al ane!the!ia o# a&illary inci!or!5 canine! an* Pre olar!3 / (uccal attache* $in$i2a o# the !a e teeth / Attache* "alatal ti!!ue! #ro i*line to #ree $in$i2al ar$in o# the a!!ociate* teeth3 PALATAL APPROACH NERAE (LOC) ANTERIOR SUPERIOR ALAEOLAR

/ /

De#ine* %y Frie* an an* Hoch an 1ith CCLAD3

/ P ASA i! !i ilar to na!o"alatine ner2e %loc4 in any a!"ect! %ut it *i##er! #ro it in it! #inal tar$et3 / The "o!ition o# the nee*le i! 1ithin the inci!i2e canal / Aolu e o# ane!thetic a* ini!tere* i! G3M to G3< l / Ner2e! ane!theti!e* Na!o"alatine 5 Anterior %ranche! o# ASA / Area! ane!theti!e* / Pul"! o# a&illary central inci!or!5 lateral inci!or!5 an* the canine!B%ilaterallyC / Facial "erio*ontal ti!!ue a!!ociate* 1ith the !a e teeth / Palatal "erio*ontal ti!!ue a!!ociate* 1ith the !a e teeth / Area o# in!ertion Ou!t lateral to the inci!i2e "a"illa in the "a"illary $roo2e3 En!ure the nee*le i! in contact 1ith the inner %ony 1all o# the canal / A 1ell *e#ine* na!o6"alatine canal ay not %e "re!ent in !o e "atient!

TE!#N$A(E"

+ MAN8$9(LA ANE"T#E"$A

TE!#N$A(E" + MAN8$9(LA* *ED$ NAL ANE"T#E"$A / Techni,ue! u!e* in clinical "ractice #or the ane!the!ia o# the har* an* !o#t ti!!ue! o# the an*i%le inclu*e the !u"ra"erio!teal techni,ue5 PDL in+ection5 intra"ul"al ane!the!ia5 intra!e"tal in+ection5 in#erior al2eolar ner2e %loc45 lon$ %uccal ner2e %loc45 Go1 6Gate! techni,ue5 Aa>irani6A4ino!i clo!e* outh an*i%ular %loc45 ental ner2e %loc45 an* inci!i2e ner2e %loc43 / -hen ane!theti>in$ the an*i%le the "atient !houl* %e in the !e i!u"ine or recline* "o!ition3 The ri$ht han*e* o"erator !houl* !tan* at the nine oNcloc4 to ten oNcloc4 "o!ition 1herea! the le#t han*e* o"erator !houl* !tan* at the three oNcloc4 to #our oN cloc4 "o!ition

INFERIOR ALAEOLAR NERAE (LOC) 7 an*i%ular %loc48 / The in#erior al2eolar ner2e %loc4 i! one o# the o!t co only e "loye* techni,ue! in an*i%ular re$ional ane!the!ia3 / It i! u!e* 1hen ulti"le teeth in one ,ua*rant re,uire treat ent3 / -hile e##ecti2e5 thi! techni,ue carrie! a hi$h #ailure rate e2en 1hen !trict a*herence to "rotocol i! aintaine*3 / The tar$et #or thi! techni,ue i! the an*i%ular ner2e a! it tra2el! on the e*ial a!"ect o# the ra u!5 "rior to it! entry into the an*i%ular #ora en3 The lin$ual5 ental5 an* inci!i2e ner2e! are al!o ane!theti>e*3 A LI $au$e lon$ nee*le i! "re#erre* #or thi! techni,ue3 Technique / The "atient !houl* %e in the !e i!u"ine "o!ition3 / The ri$ht han*e* o"erator !houl* %e in the ei$ht oNcloc4 "o!ition 1herea! the le#t han*e* o"erator !houl* %e in the #our oNcloc4 "o!ition3 / -ith the outh o"en a&i ally5 i*enti#y the coronoi* notch an* the "tery$o an*i%ular ra"hae3 / Three ,uarter! o# the antero"o!terior *i!tance %et1een the!e t1o lan* ar4!5 an* a""ro&i ately !i& to ten illi eter! a%o2e the occlu!al "lane i! the in+ection !ite

(rin$ the nee*le to the in+ection !ite #ro the contralateral "re olar re$ion3 / A! the nee*le "a!!e! throu$h the !o#t ti!!ue5 *e"o!it one or t1o *ro"! o# ane!thetic !olution3 / A*2ance the nee*le until %one i! contacte*3 / Once %one i! contacte*5 1ith*ra1 the nee*le one illi eter an* re*irect the nee*le "o!teriorly %y %rin$in$ the %arrel o# the !yrin$e to1ar*! the occlu!al "lane / A*2ance the nee*le to three ,uarter! o# it! *e"th5 a!"irate5 an* in+ect three ,uarter! o# a cartri*$e o# ane!thetic !olution !lo1ly o2er the cour!e o# one inute3
/

Succe!!#ul e&ecution o# thi! techni,ue re!ult! in ane!the!ia o# the an*i%ular teeth on the i"!ilateral !i*e to the i*line5 a!!ociate* %uccal an* lin$ual !o#t ti!!ue5 lateral a!"ect o# the ton$ue on the i"!ilateral !i*e5 an* lo1er li" on the i"!ilateral !i*e

(uccal Ner2e (loc4

/ The %uccal ner2e %loc45 other1i!e 4no1n a! the lon$ %uccal or %uccinator %loc45 i! a u!e#ul a*+unct to the in#erior al2eolar ner2e %loc4 1hen ani"ulation o# the %uccal !o#t ti!!ue in the an*i%ular olar re$ion i! in*icate*3 / The tar$et #or thi! techni,ue i! the %uccal ner2e a! it "a!!e! o2er the anterior a!"ect o# the ra u!3 / Contrain*ication! to the "roce*ure inclu*e acute in#la ation an* in#ection o2er the !ite o# in+ection3 A LI $au$e lon$ nee*le i! "re#erre* #or thi! techni,ue3 Techni,ue / The "atient !houl* %e in the !e i!u"ine "o!ition3 The ri$ht han*e* o"erator !houl* %e in the ei$ht oNcloc4 "o!ition 1herea! the le#t han*e* o"erator !houl* %e in the #our oNcloc4 "o!ition3 / I*enti#y the o!t *i!tal olar tooth on the !i*e to %e treate*3 The ti!!ue +u!t *i!tal an* %uccal to the la!t olar tooth i! the tar$et area #or in+ection

The %e2el o# the nee*le !houl* %e to1ar* %one an* the !yrin$e !houl* %e hel* "arallel to the occlu!al "lane on the !i*e o# the in+ection3 / The nee*le i! in!erte* into the !o#t ti!!ue an* a #e1 *ro"! o# ane!thetic !olution are a* ini!tere*3 / The nee*le i! a*2ance* a""ro&i ately one or t1o illi eter! until %one i! contacte*3 / Once %one i! contacte* an* a!"iration i! ne$ati2e5 ;3Lcc o# local ane!thetic !olution i! *e"o!ite*3 / Succe!!#ul e&ecution o# thi! techni,ue re!ult! in ane!the!ia o# the %uccal !o#t ti!!ue o# the an*i%ular olar re$ion Go1 6Gate! Techni,ue
/

The Go1 6Gate! techni,ue or thir* *i2i!ion ner2e %loc4 i! u!e#ul alternati2e to the in#erior al2eolar ner2e %loc4 an* i! o#ten u!e* 1hen the latter #ail! to "ro2i*e a*e,uate ane!the!ia3 / A*2anta$e! o# thi! techni,ue 2er!u! the in#erior al2eolar techni,ue are it! lo1 #ailure rate an* lo1 inci*ence o# "o!iti2e a!"iration3 / The Go16Gate! techni,ue ane!theti>e! the auriculote "oral5 in#erior al2eolar5 %uccal5 ental5 inci!i2e5 ylohyoi* an* lin$ual ner2e!3 / Contrain*ication! to thi! "roce*ure inclu*e acute in#la ation an* in#ection o2er the !ite o# in+ection an* tri! atic "atient!3 / A LI $au$e lon$ nee*le i! "re#erre* #or thi! techni,ue Techni,ue / The "atient !houl* %e in the !e i!u"ine "o!ition3 / The ri$ht han*e* o"erator !houl* %e in the ei$ht oNcloc4 "o!ition 1herea! the le#t han*e* o"erator !houl* %e in the #our oNcloc4 "o!ition3 / The tar$et area #or thi! techni,ue i! the nec4 o# the con*yle %elo1 the area o# in!ertion o# the lateral "tery$oi* u!cle3 / A retraction in!tru ent i! u!e* to retract the chee43
/

The "atient i! a!4e* to o"en a&i ally an* the e!iolin$ual cu!" o# the a&illary Ln* olar on the !i*e o# *e!ire* ane!the!ia i! i*enti#ie*3 / The in!ertion !ite o# the nee*le 1ill %e +u!t *i!tal to the a&illary Ln* olar at the le2el o# the e!iolin$ual cu!"3
/

(rin$ the nee*le to the in!ertion !ite in a "lane that i! "arallel to an i a$inary line *ra1n #ro the intertra$ic notch to the corner o# the outh on the !a e !i*e a! the in+ection3 / A*2ance the nee*le throu$h !o#t ti!!ue a""ro&i ately LI until %one i! contacte* at the nec4 o# the con*yle3 / Once %one i! contacte*5 1ith*ra1 the nee*le one illi eter an* a!"irate3 / Re*irect the nee*le !u"eriorly an* rea!"irate3 / I# a!"iration in t1o "lane! i! ne$ati2e5 !lo1ly in+ect one cartri*$e o# local ane!thetic !olution o2er the cour!e o# one inute3
/

/ Succe!!#ul e&ecution o# thi! techni,ue "ro2i*e! ane!the!ia to the i"!ilateral an*i%ular teeth u" to the i*line5 an* a!!ociate* %uccal an* lin$ual har* an* !o#t ti!!ue3 / The anterior t1o thir*! o# the ton$ue5 #loor o# the outh5 !4in o2er the >y$o a5 "o!terior a!"ect o# the chee4 an* te "oral re$ion on the i"!ilateral !i*e o# in+ection are al!o ane!theti>e* Aa>irani 6A4ino!i Clo!e* Mouth Man*i%ular (loc4 / The Aa>irani 6A4ino!i clo!e* outh an*i%ular %loc4 i! a u!e#ul techni,ue #or "atient! 1ith li ite* o"enin$ *ue tri! u! or an4ylo!i! o# the te "oro an*i%ular +oint3 / Li ite* an*i%ular o"enin$ "reclu*e! the a* ini!tration o# the in#erior al2eolar ner2e %loc4 or u!e o# the Go16Gate! techni,ue %oth o# 1hich re,uire the "atient to %e o"en a&i ally3

Other a*2anta$e! to thi! techni,ue are the ini al ri!4 o# trau a to the in#erior al2eolar ner2e5 artery5 2ein5 an* "tery$oi* u!cle5 lo1 co "lication rate an* ini al *i!co #ort u"on in+ection3 / Contrain*ication! to thi! techni,ue are acute in#la ation an* in#ection in the "tery$o an*i%ular !"ace5 *e#or ity or tu or in the a&illary tu%ero!ity re$ion or an ina%ility to 2i!uali>e the e*ial a!"ect o# the ra u!3 A LI $au$e lon$ nee*le i! "re#erre* #or thi! techni,ue3
/

TECHNI'UE / The "atient !houl* %e in the !e i!u"ine "o!ition3 / The ri$ht han*e* o"erator !houl* %e in the ei$ht oNcloc4 "o!ition 1herea! the le#t han*e* o"erator !houl* %e in the #our oNcloc4 "o!ition3 / The $in$i2al ar$in a%o2e the a&illary Ln* an* Pr* olar! an* the "tery$o an*i%ular ra"hae are the lan* ar4! #or thi! techni,ue3 / A retraction in!tru ent i! u!e* to !tretch the chee4 laterally3 / The "atient !houl* occlu*e $ently on the "o!terior teeth3 / The nee*le i! hel* "arallel to the occlu!al "lane at the le2el o# the $in$i2al ar$in o# the a&illary Ln* an* Pr* olar!3
/

The %e2el i! *irecte* a1ay #ro i*line3

the %one #acin$ the

The nee*le i! a*2ance* throu$h the ucou! e %rane an* %uccinator u!cle to enter the "tery$o an*i%ular !"ace3 / The nee*le i! in!erte* to a""ro&i ately one hal# to three ,uarter! o# it! len$th / At thi! "oint the nee*le 1ill %e in the i*!ection o# the "tyery$o an*i%ular !"ace3
/

A!"irate an* i# ne$ati2e5 ane!thetic !olution i! *e"o!ite* o2er the cour!e o# one inute3 / Di##u!ion an* $ra2itation o# the local ane!thetic !olution 1ill ane!theti>e the lin$ual an* lon$ %uccal ner2e! in a**ition to the in#erior al2eolar ner2e3 / Succe!!#ul e&ecution o# thi! techni,ue "ro2i*e! ane!the!ia o# the i"!ilateral an*i%ular teeth u" to the i*line5 an* a!!ociate* %uccal an* lin$ual har* an* !o#t ti!!ue3 The anterior t1o thir*! o# the ton$ue an* #loor o# the outh are al!o ane!theti>e* MENTAL NERAE (LOC) / The ental ner2e %loc4 i! in*icate* #or "roce*ure! 1here ani"ulation o# %uccal !o#t ti!!ue anterior to the ental #ora en i! nece!!ary3 / Contrain*ication! to thi! techni,ue are acute in#la ation an* in#ection o2er the in+ection !ite3 A LI or L: $au$e !hort nee*le i! "re#erre* #or thi! techni,ue
/

Techni,ue / The "atient !houl* %e in the !e i!u"ine "o!ition3 / The ri$ht han*e* o"erator !houl* %e in the ei$ht oNcloc4 "o!ition 1herea! the le#t han*e* o"erator !houl* %e in the #our oNcloc4 "o!ition3 / The tar$et area i! the hei$ht o# the uco%uccal #ol* o2er the ental #ora en / The #ora en can %e anually "al"ate* %y a""lyin$ $entle #in$er "re!!ure to the %o*y o# the an*i%le in the area o# the "re olar a"icie!3

The "atient 1ill #eel !li$ht *i!co #ort u"on "al"ation o# the #ora en
/

U!e a retraction in!tru ent to retract the !o#t ti!!ue3 / The nee*le i! *irecte* to1ar* the ental #ora en 1ith the %e2el #acin$ the %one3 / Penetrate the !o#t ti!!ue to a *e"th o# #i2e illi eter!5 a!"irate an* in+ect a""ro&i ately ;3Jcc o# ane!thetic !olution3 / Succe!!#ul e&ecution o# thi! techni,ue re!ult! in ane!the!ia o# the %uccal !o#t ti!!ue anterior to the #ora en5 lo1er li" an* chin on the !i*e o# the in+ection3
/

Inci!i2e Ner2e (loc4 / The inci!i2e ner2e %loc4 i! not a! #re,uently e "loye* in clinical "ractice / Ho1e2er it "ro2e! 2ery u!e#ul 1hen treat ent i! li ite* to an*i%ular anterior teeth an* #ull ,ua*rant ane!the!ia i! not nece!!ary3 / The techni,ue i! al o!t i*entical to the ental ner2e %loc43 / (oth the ental an* inci!i2e ner2e! are ane!theti>e* u!in$ thi! techni,ue3 / Contrain*ication! to thi! techni,ue are acute in#la ation an* in#ection at the !ite o# in+ection3 / A LI or L: $au$e !hort nee*le i! "re#erre* #or thi! techni,ue3 Techni,ue / The "atient !houl* %e in the !e i!u"ine "o!ition3 / The ri$ht han*e* o"erator !houl* %e in the ei$ht oNcloc4 "o!ition 1herea! the le#t han*e* o"erator !houl* %e in the #our oNcloc4 "o!ition / The tar$et area i! the hei$ht o# the uco%uccal #ol* o2er the ental #ora en / I*enti#y the ental #ora en a! "re2iou!ly *e!cri%e*3 / Gi2e the "atient a ental ner2e %loc4 a! *e!cri%e* a%o2e an* a""ly *i$ital "re!!ure at the !ite o# in+ection *urin$ a* ini!tration o# ane!thetic !olution3 / Continue to a""ly *i$ital "re!!ure at the !ite o# in+ection t1o to three inute! a#ter the in+ection i! co "lete to ai* the ane!thetic in *i##u!in$ into the #ora en3 / Succe!!#ul i "le entation o# thi! techni,ue "ro2i*e! ane!the!ia to the "re olar!5 canine5 inci!or teeth5 lo1er li"5 !4in o# the chin5 an* %uccal !o#t ti!!ue anterior to the ental #ora en3

"(%%LEMENTAL $NCE!T$ N
PERIODONTAL LIGAMENT INOECTION / Al!o calle* intrali$a entary in+ection / Ter inal ner2e en*in$! at the !ite o# in+ection are anae!theti>e* / Techni,ue 0 / L: $au$e nee*le i! in!erte* at lon$ a&i! o# tooth to %e treate* at *e"th o# $in$i2al !ulcu! / De"o!it ;3L l in L; !ec! / Treat ent to !tart a#ter P; !ec! an* la!t! #or I6II in! PERIODONTAL LIGAMENT INOECTION 7"re!!ure !yrin$e!8

INTRASEPTAL INOECTION / Si ilar to "*l in+ection / Ane!theti>e! ter inal ner2e en*in$! / (one5 !o#t ti!!ue5 root !tructure are ane!theti>e* / Area o# in!ertion0centre o# inter*ental "a"illa a*+ to the tooth to %e treate* / Orient the nee*le at MI; to the lon$ a&i! o# the tooth / De"o!it ;3L to ;3M l o# local ane!thetic in L;!ec! Intra!e"tal in+ection

INTRAOSSEOUS INOECTION

Here a "er#oration i! a*e into the %one into 1hich the local ane!thetic i! in+ecte* / Sta%i*ent !y!te i! re"lace* %y Intra#lo1 IO !y!te / A *rill a4e! a "er#oration thro the %one in a "ec4in$ otion an* the $ui*e !lee2e i! le#t in "lace until the LA i! in+ecte* / L a"ical to the $in$i2al ar$in i! the in+ection !ite / Pul"al ane!the!ia o# %et1een GI an* P; in! can %e e&"ecte* / Fi!tula #or n i! the o!t co on co "lication
/

$ntra osseous anesthesia

INTRAPULPAL INOECTION

De"o!it! LA *irectly into the "ul" cha %er Aery e##ecti2e #or "ul" e&tir"ation an* in!tru entation "roce*ure! / A ! all o"enin$ in the "ul" cha %er i! !u##icient #or a& e##ecti2ene!! / There i! a %rie# "erio* o# !en!iti2ity #ollo1e* %y relie# Local ane!thetic *o!e calculation / Do!e! are e2en ore critical in the "ae*iatric "atient5 an* it i! i "ortant to note ho1 little one !houl* $i2e to a chil*33 / Hi$h6concentration !olution!5 na ely "rilocaine an* articaine5 reach to&ic le2el! 1ith #e1er cartri*$e!3 / !alculations of 8oses Percent !olution! re"re!ent $ra ! "er G;; L Bi3e3 li*ocaine LH V L; $= LC Mo!t cartri*$e! V G3< L3 There#ore5 one cartri*$e o# LH li*ocaine contain! G3< L & L; $= L V PJ $
/ /

! M%L$!AT$ N" of ANE"T#E"$A

INTRODUCTION / An ane!thetic co "lication ay %e *e#ine* a! any *e2iation #ro the nor ally e&"ecte* "attern *urin$ or a#ter the !ecurin$ o# re$ional anal$e!ia3 / Co "lication! ay %e cla!!i#ie* a! #ollo1!0 G3"ri ary or !econ*ary3 L3 il* or !e2ere P3tran!ient or "er anent

They can %e cla!!i#ie* accor*in$ to the !ite G3Locally in the re$ion o# the in+ection L3 or !y!te ically Local Co "lication! / / / / / / / / / / / / GCNee*le (rea4a$e LCPer!i!tent anae!the!ia PCFacial Ner2e "araly!i! MCTri! u! IC!o#t ti!!ue in+ury JChe ato a :C"ain on in+ection <C%urnin$ on in+ection @CIn#ection G;CE*e a GGCSlou$hin$ o# ti!!ue! GLC"o! anae!thetic intraoral le!ion!

Sy!te ic co "lication! / GCo2er*o!e / LCaller$y / PCI*io!yncra!y

!lassification of Adverse drug reactions / GCto&icity cau!e* %y *irect e&ten!ion o# the u!ual "har acolo$ical e##ect! o# the *ru$06 6Si*e E##ect! 6O2er*o!e

6Local To&ic e##ect!

/ LCTo&icity cau!e* %y the alteration in reci"ient o# the *ru$ 06

6*i!ea!e "roce!! ? he"atic *y!#unction5 heart #ailure 6E otional *i!tur%ance! 6Genetic a%%eration! ? aty"ical "la! a choline!!ter!e 5 ali$nan hy"erther ia 6 I*io!yncra!y / PC To&icity cau!e* %y aller$ic re!"on!e! to the *ru$ / Co "lication! ay %e #urther *i2i*e* into L $rou"!0 G3Tho!e attri%ute* to the !olution! u!e* L3 Tho!e attri%ute* to the in!ertion o# the nee*le Those attributed to the solutions used G3To&icity L3I*io!yncra!y P3Aller$y M3Ana"hylactoi* reaction! I3In#ection! cau!e* %y conta inate* !olution!3 J3Local irritation! or ti!!ue reaction! cau!e* %y !olution! Those attributed to the insertion of the needle G3Synco"e L3Mu!cle tri! u! P3Pain or hy"eral$e!ia M3E*e a I3In#ection! J3(ro4en nee*le! :3Prolon$e* ane!the!ia other than #ro the ane!thetic !olution3 <3He ato a @3Slou$hin$ G;3(i>arre neurolo$ical !y "to ! COMPLICATIONS CAUSED BY THE ANESTHETIC SOLUTION Toxicity The term toxicity, or toxic overdose, refers to the symptoms manifested as the result of over dosage or excessive administration of a drug Thi! co "lication *e"en*! on a !u##icient

concentration o# the *ru$ in the %loo* !trea to a*2er!ely a##ect the central ner2ou! !y!te 5 the re!"iratory !y!te 5 or the circulatory !y!te / To&icity

LA blood level high enough to cause the symptoms of toxic overdose may come about in one or more of the following four ways: 1. Too large a dose of local anesthetic drug 2. Unusually rapid absorption of the drug or intravascular injection 3. Unusually slow biotransformation

M3 Slo1 eli ination or re*i!tri%ution

The blood level necessary to create a toxic overdose is variable and depends on a variety of factors, some of which follow: 1. Patients general physical condition at the time of the injection 2. Rapidity of injection 3. Route of administration (for example, inadvertent intravascular injection) 4. Amount of the drug used

Usually early central nervous system stimulation followed by a proportionate degree of depression. (On occasion central nervous system depression may appear as the first sign of toxicity.) 1. Cerebral cortical stimulation a. Talkativeness b. Restlessness c. Apprehension d. Excitement 2. Cerebral cortical depression a. Lethargy b. Sleepiness c. Unconsciousness After mild cortical stimulation the may be little or no cortical depression. However, convulsions are usually followed by severe cortical depression and unconsciousness. 3. Medullary stimulation a. increased blood pressure

I3 A$e o# "atient SYMPTOMS.

b. Increased pulse rate c. Increased respirations d. Possible nausea and vomiting 4. Medullary depression will usually occur in proportion to the amount of medullary stimulation. a. Blood pressure may remain normal in mild cases or drop to zero in severe cases. b. Pulse may range from normal to weak, thready, or absent. c. Respiratory changes may be slight, or the patient may become apneic in severe cases Treatment should be directed toward alleviating symptoms;early recognition and early treatment are imperative. 1. Mildly stimulated patients should require no treatment other than the discontinuing of further administration of the anesthetic drug 2. Moderately stimulated patients should be given pentobarbital sodium or secobarbital intravenously very slowly until they are calmed, plus inhalations of oxygen 3. Convulsive patients should receive 20 to 40 mg of succinylcholine chloride intravenous or double the dose intramuscularly to control the convulsions. Adequate ventilation must be maintained. 4. Treatment of central nervous system depression should be directed toward supporting respiration with artificial ventilation and maintaining adequate cardiovascular system function through positional changes and vasopressors, if required PREVENTION To&icity 1. Aspiration must be performed before injecting. 2. The smallest possible volume of drug should be used. 3. The weakest efficient percentage strength of the drug should be used. 4. The anesthetic drug should be injected slowly

5 A vasoconstrictor should be employed with the local anesthetic if not contraindicated IDIOSYNCRASY

The term idiosyncrasy is often assigned to a bizarre type of reaction that cannot be classified as toxic or allergic ALLERGIC REACTIONS CAUSE. The primary cause of allergic reactions is a specific antigen antibody reaction in a patient who has previously been sensitized to a particular drug or chemical derivative thereof SYMPTOMS. Reaction affects a particular shock organ, most likely the skin, mucous membrane, or blood vessels. 1. Rashes 2. Urticaria 3.Angioneurotic edema 4.Mucous membrane congestion a. Rhinitis b. Asthmatic symptoms TREATMENT 1. Antihistaminic agents (Benadryl, 20 to 50 mg) 2. Isoproterenol or epinephrine inhalants 3. Epinephrine (0.5 ml of 1:1,000 intramuscularly) 4. Aminophylline (0.5 gm intravenously) 5. Oxygen

PREVENTION 1. Adequate preanesthetic evaluation must be done.

2. No drug or drugs should be used if the patient previous allergic reaction to them. 3. No patient should be tested to attempt to disprove his allergic history !omplications attributed to the needle insertion or technical complications / "BN! %E / Synco"e or #aintin$ i! "erha"! the o!t #re,uent co "lication a!!ociate* 1ith local ane!the!ia in the *ental o##ice3Thi! i! a #or o# neuro$enic !hoc4 an* i! cau!e* %y cere%ral i!che ia !econ*ary to a 2a!o*ilatation or an increa!e in the "eri"heral 2a!cular %e*5 1ith a corre!"on*in$ *ro" in %loo* "re!!ure In most instances it is possible to detect a change in the patients appearance, such as pallor. The patient may also complain of feeling different or strange. The operator should discontinue any procedures in progress and lower the chair back while the patients legs are slightly elevated, thus placing the patient in a semireclining position .This position aids venous return from the lower portions of the body while preventing venous congestion in the upper body, as with the conventional Trendelenburg (head down) position Muscle Trismus Muscle trismus is a fairly common complication of regional analgesia or anesthesia, particularly after blocks of the inferior alveolar nerve The most common cause of trismus is trauma to a muscle during the insertion of the needle. Irritating solutions, hemorrhage, or low-grade infection within the muscle may also cause varying degrees of trismus The treatment should depend on the cause of the trismus. If the condition arises as the result of trauma, slight exercises and drug therapy may be necessary to relieve pain, if sufficiently severe.

Centrally acting muscle relaxants such as diazepam (Valium) 2.5 to 5.0 mg four times per day or meprobamate, 1200 to 1600 mg per day in three or four doses coupled with the application of warm moist compresses for 15 to 20 minutes per hour will usually relieve the symptoms in several days

Mild analgesics may also be used for discomfort. Physiotherapy consisting of opening and closing the mouth as well as movement from side to side for 5 to 10 minutes every 3 or 4 hours will also assist recovery Trismus may be prevented by the use of sharp, sterile needles so that the trauma of insertion and any subsequent lowgrade infections are prevented. The area of insertion should be cleansed and painted with a suitable antiseptic solution. Care should be exercised also so that the needle is inserted atraumatically and no muscles are penetrated Pain or hyperesthesia Pain during or after the administration of a regional anesthetic is very common. It is much more common that it need be, and in many instances it is the result of carelessness or indifference. Every precaution should be taken to make those maneuvers associated with securing anesthesia as painless as possible Only sharp needles should be used, and the area of penetration should be anesthetized with a topical anesthetic. The insertion of the needle should be slow and as atraumatic as possible. Multiple insertions in the same area should be avoided. Solutions should be sterile and compatible with the tissue They should also be forced into the tissue very slowly and with as little pressure as possible. Excessive volumes in

constricted areas should be avoided. Rational concentrations of vasoconstrictors should be used. Infections, low grade or otherwise, are a common cause of pain after the use of regional anesthesia or analgesia. Extreme care should be exercised in maintaining aseptic conditions. There is no excuse for careless contamination or for failure to appreciate the importance of asepsis

Edema

Edema, or swelling of the tissues, is usually a symptom and rarely an entity in itself. Trauma, infection, allergy, hemorrhage, and other factors can produce edema. Each cause of edema should be considered under own classification in regard to prevention and treatment

Infection

Infection as a factor in producing pain needs little or no discussion, since it is so obvious. Dentists should constantly apply all means at their command to prevent infections. All areas, instruments, needles, and solutions should be as aseptic as possible, The operators hands should be scrupulous1y cleansed before working on each patient. All areas should be cleansed with a suitable antiseptic before needle insertion is performed. Care should be exercised to avoid passing the needle through infected areas (RO)EN NEEDLES Breakage of needles is one of the most annoying and depressing,complications of regional anesthesia. dentists should not violate fundamental principles when using them.

The #ollo1in$ "rinci"le! !houl* %e o%!er2e* to "re2ent the "o!!i%ility o# a %ro4en nee*le

1. Do not attempt to force a needle against resistance. 2. Do not attempt to change the direction of the needle while it is embedded in the tissue. 3. Do not use a needle of too fine a gauge.

4. Do not use resterilizable needles.

I3 Do not atte "t in+ection! i# you are uncertain a%out the anato y o# the area o# the techni,ue! e "loye* 6. Do not insert the needle so far as it is out of sight in
tissue. 7. Do not surprise the patient with a sudden unexpected needle insertion. The informed patient is always the best patient and is much more cooperative Prolonged anesthesia other than from the anesthetic solution Most cases of prolonged anesthesia are caused by solutions contaminated by alcohol or other sterilizing media. The most likely cause associated with the needle insertion is hemorrhage into the neural sheath caused by the mild trauma of a needle bumping into the nerve, which creates pressure and subsequent anesthesia.

Hematoma
Hematoma is a common complication of intraoral regional analgesia. is most commonly associated with the posterior superior alveolar and infraorbital nerve blocks. He ato a i! an e##u!ion o# %loo* into the !urroun*in$

ti!!ue a! the re!ult o# a torn %loo* 2e!!el3 A! a rule5 the atrau atic "uncture o# a 2ein 1ill not "ro*uce a he ato a
No attempt should be made to aspirate or to interfere with the normal absorption of the blood in the tissues. The patient should be told what happened and put at ease by an explanation of the conditions lack of severity Bizarre neurological symptoms On rare occasions unexplained neurological symptoms may occur following the insertion of a needle and the injection of a solution in a given area. Patients may exhibit facial paralysis, crossed eyes, muscular weakness, temporary blindness, and many other unexpected complications.

 They are rare and are usually caused by inadvertent anesthesia to nerves in the area

Facial ner2e "araly!i!

The best method of preventing these complications is to follow closely the accepted techniques and to adhere to all the basic concepts of accepted procedure

Re#erence! / Local ana!the!ia %y Stanley Mala e* / Monhei ! ? local ana!the!ia in *ental "ractice / Path1ay! o# the "ul" ? Ste"hen cohen / (oo4 o# En*o*ontic!6 In$le