LOCAL ANAESTHESIA

Presented by
Dr. Mehreen riaz
Demonstrator, omfs
iidh

DEFINITION
Loss of sensation in a circumscribed area of the body

caused by a depression of excitation in nerve endings or

an inhibition of the conduction process in peripheral
nerves.

OTHER METHODS:1) Mechanical trauma

2) Low Temperature
3) Anoxia
4) Chemical Irritant
5) Neurolytic agents
6)Chemical agents

CLASSIFICATION
ACCORDING TO SITE:1) Topical
2) Infiltration
3) Regional Block

ACCORDING TO CHEMICAL COMPOSITION:1) Amides

2)Esters
3)Alcohols
4)Others e.g oxathazin, chlorbutol, Clove Oil,

Eugenol

CLASSIFICATION
ESTERS:-

Esters of Benzoic acid: Butacaine

Cocaine
Ethyl aminobenzoate (benzocaine)
Hexyclaine
Piperocaine
Tetracaine

Esters of PABA:Chloroprocaine
Procaine
Propoxycaine

AMIDES: Articaine
Bupivacaine
Dibucaine
Etidocaine
Lidocaine
Mepivacaine
Prilocaine
Ropivacaine

MECHANISM OF ACTION
Displacement of Ca ion from Na channel
receptor
which permits

Binding of the L.A mol. To this

receptor site
which thus produces

Blockade of the Na channel

and a

Dec in Na conductances
Depression of the rate of electrical depolarization
and a.

Failure to achieve the threshold potential

with a

Lack of development of propogated action potential

which is called.

Conduction Blockade

PHARMACOLOGY
PHARMACOKINETICS:-

Uptake:L.A produce a degree of vasoactivity . Most producing vasodilatation except

Cocaine. Procaine is the most potent vasodilator.

Topical route:Tracheal Mucosa:- Absorption is as rapid as IV

Pharyngeal Mucosa :- Absorption is slower
Eosaphagus and Bladder mucosa :- Uptake is even slower

IV:Its the most rapid route of administration. Used in PVCs

PHARMACOKINETICS
DISTRIBUTION:

Distributed throughout the body

Highly perfused organs
Not highly perfused organs e.g. skeletal muscles
Cross BBB
Cross Placental Barrier
Procaine and Chloroprocaine shortest half life ( 0.1 hrs)
Etidocaine Longest Half Life ( 2.6 hrs )

PHARMACOKINETICS
METABOLISM (BIOTRANSFORMATION):ESTERS: Hydrolyzed in plasma by the enzyme pseudocholinesterase
Chloroprocaine most rapidly hydrolyzed
Tetracaine 16 times more slowly and is toxic
Allergic reaction due to PABA
Atypical Pseudocholinesterase
Difficulty during previous GA should be taken

AMIDE LOCAL ANESTHETICS: Primary site is liver

Prilocaine gets metabolized in liver Primarily but also in

lungs
Liver disease . Rate of biotransformation anesthetic
blood levels in blood toxicity

PHARMACOKINETICS
EXCRETION: Kidneys Primary organ for L.A and its metabolites
Renal Impairment eg glomerulonephritis , pyelonephritis, renal dialysis.

SYSTEMIC ACTIONS
CNS: Depression
Anticonvulsant properties ( procaine, lidocaine, mepivacaine)
CVS:Myocardium: Myocardial depression
Dec. electrical excitability
Dec . Conduction rate
Dec. force of contraction
Therapeutic advantage in cardiac arythmias , PVCs, Vtech. (lidocaine)

Blood Vessels:Cocaine Vasoconstriction

All other vasodilation
Hypotension ( procaine more effective) due to

myocardial depression and vasodilation .

LOCAL TISSUE TOXICITY:Skeletal muscles
Longer acting LA such as Etidocaine
Muscle regenerates after 2 wks after LA inj.

Respiratory Sys:

Non Over dose levels direct relaxant effect

Overdose Respiratory arrest may occur

VASOCONSTRICTOR
Catecholamines
Epinephrine
Nor Epinephrine
Levonordefrin
Isoproterenol
Dopamine

*Fellypressin .

Noncatecholamime
Amphetamine
Methamphetamine
Ephedrine
Mephentermine
Hydroxuamphetamine
Methoxamine
Phenylephrine

EPINEPHRINE
Source:

Available as synthetic
Adrenal Medulla of animals

Mode of action :

and adrenergic receptors. effects predominate

Systemic Actions:Cardiovascular dynamics: Inc in systolic and diastolic pressures

Inc in Cardiac output
Inc in stroke Vol.
Inc in strength of contraction
Inc in Myocardial O2 consumption

Hemostasis:Used as a hemostatic agent

Initial action on receptors and vasoconstriction and as tissue conc
dec. its affect will be on receptors and vasodilation occurs.

Respiration:Epi is a potent bronchodilator

Asthma drug of choice

CNS:Not a CNS stimulant in normal doses

In inc doses effects are prominent

 Metabolism:Inc O2 consumption in all tissues

Stimulates Glycogenolysis in the liver and skeletal muscles

Elimination:Re uptake by adrenergic nerves

Enzyme MAO & COMT ( catechol-O-methyltranferase)

Clinical Application:Allergic reactions

Bronchospasm
Cardiac Arrest
Vasoconstrictor
Mydriasis.

CONTENTS
Local anesthetic cartridge
Presevative..Methylparaben
AntioxidantNa bi sulphite, NA metabisulphite
Alkalizing agent Na hydroxide
NaCl isotonic
Fungicide Thymol

Maximum Safe Dose of Epi.

Maximum Safe dose for a healthy adult is 0.2 mg or

200g per app.

Maximum safe dose for a pt. with clinically significant
CVS disease is 0.04mg or 40 g per appointment.
Maximum Safe Dose of L.A
Max Safe dose =4.4mg/kg body weight
1 kg=4.4mg
60kg=4.4 x 60=264mg
1 dental cartridge =36mg per 1.8ml
264mg /36=7 cartridges.

TOPICAL ANAESTHETICS
SPRAYS:
1 0% lignocaine

1min onset

DOA 10 mins
OINTMENTS: 5% Lignocaine
3-4 mins to produce anesthesia
Enzyme hyaluronidase
Amethocaine & Benzocaine
Deep gingival scaling
EMULSIONS: 2% Lignocaine HCL
Full mouth Impressions
Relief Post op tenderness

ETHYL CHLORIDE: Refrigeration

Fluctuant abscess
Snow appears

JET SPRAY:Punct wound

Surface anesthesia produced

ARMAMENTARIUM

Different techniques of achieving

LA
Local infiltration
Field block
Nerve block
Intraligamentry
Intraseptal
Intrapulpal
Intraosseous injection
Jet injector
Computer controlled local anesthetic delivery system
Electronic dental anesthesia
Topical anesthesia

Local infiltration
In local infiltration, small terminal nerve endings in the

area of the surgery are flooded with local anesthetic

solution, rendering them insensitive to pain or preventing
them becoming stimulated & creating an impulse.

Incision is made into the same area

in which the LA has been deposited.

Field block
Method of securing regional anesthesia consisting of

depositing a suitable LA solution in proximity to the

large terminal nerve branches so that the area to be
anesthetized is circumscribed to prevent the central
passage of afferent impulses

Incision is made into an area

away from the site of injection

Nerve block
Method of securing regional anesthesia by depositing LA

solution within close proximity to a main nerve trunk

Usually at a distance from the site of

operative intervention

Periodontal ligament injection

Indications
1. Pulpal anesthesia of one
or two teeth in a quadrant
2.Treatment of isolated teeth in
mandibular quadrant
3. Patient for whom residual
soft tissue anesthesia is
undesirable
4. Situations in which regional
block is contraindicated

Contraindications
1. Infection or inflammation
at the site of injection

2. Primary teeth when the

permanent
tooth
bud
is
present

3. Patient
who requires a
numb
sensation
for
psychological discomfort

Intraseptal injection
Indications
When both haemostasis & pain control are desired
for soft tissue & osseous periodontal treatment

Contraindications
Infection or severe
inflammation at the
site of injection

Intrapulpal injection
Deposition of LA directly
into the pulp chamber of
a pulpally involved tooth
provides effective
anesthesia for pulpal
extirpation &
instrumentation where
other techniques have
failed.

Intraosseous injection
Indications
Pain control for
dental treatment
on
single
or
multiple teeth in a
quadrant

Contraindications
Infection or severe
inflammation at the
site of injection

Jet injector

Principle- based on principle that liquid forced through

very small openings, called jets, at very high pressure can
penetrate intact skin or mucous membrane
The primary use of jet injector is to obtain topical
anesthesia before the insertion of a needle
In addition it may be used to obtain mucosal anesthesia of
palate.

Disadvantages

Advantages
1. Does not require use
of needle
2. Delivers very small
amount of LA
3. Used in lieu of topical
anesthesia

1.

Is inadequate for pulpal

anesthesia
or
regional
anesthesia

2.

May damage
tissue

periodontal

3. Many patients dislike the

feeling accompanying use of
the jet injector
4. Post-injection soreness of soft
tissue may develop

Computer-controlled local
anesthetic delivery system
The system enables a dentist or hygienist to

accurately manipulate needle placement with

fingertip accuracy and deliver the LA with a
foot-activated control

Advantages

1.

Precise control of flow rate & pressure, hence a more comfortable injection

2.

Increased tactile feel

3.

Non-threatening

4.

Automatic aspiration

Rotational insertion technique minimizes needle deflection

Disadvantages

1.

2.

Need for additional armamentarium

Increased cost

Electronic Dental Anesthesia

The method of achieving local anesthesia involves the use

of the principle of transcutaneous electrical nerve

stimulation {TENS} which has been used for the relief of
pain
Indications
1. In patients with needle phobia
2. Ineffective LA

3. Instances where LA cannot be administered

Contraindications
1.

Cardiac pacemakers

2.

Neurological disorders

3.

Pregnancy

4.

Very young pediatric patients

5.

Older patients with senile dementia

Refrences
Stanley F. Malamed Handbook of local

anesthesia, fifth edition, published by Elsevier,

page no. 255-268 & 352-358