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OUTLINE

INTRODUCTION DEFINITIONS HISTORY OF LOCAL ANAESTHESIA ASPECTS OF PAIN PAIN PATHWAY IDEAL PROPERTIES OF LA CONSTITUENTS OF LA AGENTS ARMAMENTARIUM MODE OF ACTION OF LA TYPES OF LA METHODS OF LA ADMINISTRATION COMPLICATIONS OF LA

INTRODUCTION

Although virtually everyone has experienced pain at some time and therefore from personal experience knows of its existence, no satisfactory definition of pain exists. It is often described as either a distressing sensation as of soreness or as a disturbed sensation causing suffering or soreness.

The biggest problem in dental practice is that of pain management because people generally associate dental treatment with pain. Therefore it is necessary to remove this misconception to reinforce their motivation for dental care.

DEFINITIONS

ANAESTHESIA This is loss of all forms of sensation including pain, touch, temperature and pressure sensation which may be accompanied by impairment of motor function. ANALGESIA Loss of pain sensation unaccompanied by loss of other forms of sensibility.

HISTORY OF LA
1855 Cocaine was discovered from the leaves of Erythroxylon coca which was a major milestone in the development of LA. An alkaloid extracted from the plant was used to produce surface anaesthesia of the cornea by Carl Koller. In 1884, the opthalmologist Koller was the first, who used cocaine for topical anesthesia in ophthalmological surgery.

1897 Freienstein invented the dental interchangeable needle. 1901 E. Mayer suggested the addition of adrenaline to the solution to promote vasocontriction. 1905 Alfred Einhorn and E. Uhlfelder produced procaine hydrochloride synthetically which was tested clinically by Henry Braun and marketed as Novocaine.

1930 Ringers solution was introduced to produce an isotonic solution. 1943 N. Lofgren synthesized Lignocaine. 1956 Mepivacaine was introduced to dental practice. 1959 Prilocaine was introduced.

ASPECTS OF PAIN

PAIN- As defined by C.R. Benette, is an unpleasant emotional experience usually initiated by noxious stimulus and transmitted over a specialized neural network to the central nervous system where it is interpreted as pain.

PAIN PERCEPTION Occurs when a noxious stimulus reaches sufficient intensity to invoke an action potential in the sensory nerve. The severity of the pain perceived by the patient depends on the number of fibres that are activated and not on alterations in the size of the impulses conveyed by individual nerve fibres.

PAIN REACTION This is the way and


manner in which an individual responds to pain and this varies widely among individuals. The variable response to identical pain stimuli is not due to a difference in pain perception but to a variation in pain reaction

PAIN THRESHOLD A measure of the


intensity of stimulus required to invoke the perception of pain and bring about a reaction and is inversely proportional to pain reaction. It is affected by emotional and psychological factors.

PAIN PATHWAY
PUL P V2 & V3 CELL BODY IN G GANGLIO N

POSTERIOR CENTRAL CONVOLUTIO N OF CONTRALATE RAL CORTE X

SENSO RY NEURO N OF TG NERVE

POSTERIO R VENTRAL NUCLEUS

IDEAL PROPERTIES OF LA AGENT


POTENCY AND RELIABILITY- Should effectively produce analgesia when administered in adequate dosage. REVERSIBILITY OF ACTION- Must be completely reversible within predictable time. SAFETY- Should not be toxic. Therapeutic Lethal dose(LD50) ratio = Effective dose(ED50) The higher the ratio the greater the safety margin. LACK OF IRRITATION- It should be isotonic with a pH compatible to that of the tissues.

IDEAL PROPERTIES- Contd

RAPIDITY OF ONSET- Ideally, injection should be followed by immediate onset of LA. DURATION OF EFFECT The effect till last till the completion of treatment. STERILITY ADEQUATE SHELF LIFE- Average is 2-2.5 years. PENETRATION OF MUCOUS MEMBRANE- It should have penetrating ability.

CONSTITUENTS OF LOCAL ANAESTHETIC SOLUTIONS


Local anaesthetic agent Vasoconstrictor Reducing agent Preservative Fungicide vehicle

LA AGENT
 ESTER LINKAGE- e.g. Procaine, Cocaine,

Tetracaine.  AMIDE LINKAGE e.g. Lignocaine, Prilocaine, Mepivacaine, Articaine, Etidocaine, Bupivacaine.

Short acting
3% Mepivacaine (20-40mins) 4% Prilocaine (5-10mins)

y Long acting
a) 2% Lidocaine with VC (60mins) b) 0.5% Bupivacaine with VC

(>90mins) c) 1.5% Ethidocaine with VC (>90mins) d) 4% Articaine (60mins) e) 4% Prilocaine with VC (60-90mins)

CONSTITUENTS OF LA AGENT Contd.

VASOCONSTRICTORS a. Adrenaline-A synthetic substance similar to that secreted in human body b. Felypressin- A synthetically produced polypeptide similar to that secreted from human posterior pituitary gland. It is contraindicated in pregnant women because it is believed to have an oxytocin-like effect. c. NoradrenalineThe common concentrations of adrenaline or noradrenaline are;1:50,000 1:80,000 1:100,000. Felypressin is only available in citanest in a concentration of 0.031U/ml.

Advantages;

Reduces toxic effect by retarding the absorption of the constituents. By confining the local anaesthetic agent to a localised area,it increases the depth and duration of anaesthesia. Produces a bloodless field of operation for surgical procedures.

REDUCING AGENT
y

Sodium bimetasulphite in small quantity is included in the solution to prevents oxidation of the vasoconstrictors as they are unstable in solutio,especialy on exposure to sunlight.

CONSTITUENTS Contd.

PRESERVATIVE
y

Caprylhydrocupreinotoxin in xylotox helps to maintain sterility of the solution and also increases its shelf life. Thymol prevents proliferation of minute fungae which cause cloudiness of the solution.

FUNGICIDE
y

VEHICLE
y

Ringers solution(modified) is an isotonic solution in which all the other constituents are dissolved to minimize discomfort during injection of the LA.

ARMAMENTARIUM

METAL SYRINGES- Consist of a metal barrel and plunger united by a spring loaded hinge mechanism.
a. b.

Standard non-aspirating syringe. Aspirating syringe.

LA CARTRIDGE It contains the LA agent and is made of presterilized pyrogen-free glass to avoid breakdown or contamination of the solution. It has a metal cap with soft metal centre at one end and an all-rubber sealing cap at the other end. They come in 2.2ml or 1.8ml capacity.

ARMAMENTARIUM Contd.

DENTAL NEEDLE They come in


different lengths and gauges. y Length a) Short: 2cm or 2.5cm used for infiltration b) Long : 3.5cm used for block y Gauge a) Fine :Gauge 27 b) Finer :Gauge 30

ARMAMENTARIUM Contd.
TOPICAL ANAESTHETIC ARTERY FORCEPS ANTISEPTICS (0.5% chlorhexidine) AND COTTON WOOL

MODE OF ACTION

LA agent is made up of a weak base and strong acid which is hydrolyzed in the alkaline medium of human tissues to liberate the alkaloid base. This stabilizes the axonal limiting membrane of the nerve fibres thereby preventing the inflow of sodium ions into the cell and the resultant depolarization of the cell membrane. Impulse conduction is thus prevented so that pain stimulus is not transmitted.

METABOLISM AND EXCRETION


ESTER TYPE- Dissociated in the liver and blood by esterases and hydrolyzed to benzoic acid and alcohol which is excreted in via urine. AMIDE TYPE More complex and slower. Hydrolysis takes place in the liver mainly in the presence of catalyst .

Tips for painless injection


Control Communication Confidence slow injection[slower still in tense tissue] Pre-anesthesia Needle insertion[sharp &slow] Distraction Small guage needles Solution warming

METHOD OF LA ADMIN

TOPICAL
Suitable LA is applied either to an area of skin or mucous membrane which it penetrates to act at the superficial nerve endings.
y Sprays : 10% Lignocaine HCl y Ointment : 5% Lignocaine HCl y Emulsion : 2% Lignocaine HCl

INFILTRATION
y Submucous injection : the solution is

deposited just beneath the mucous membrane. This method is used for anaesthetizing the long buccal nerve. y Sub-periosteal injection: The solution is deposited between periosteum and cortical plate of bone. E.g in palate.

Supra-periosteal injection: The solution is deposited outside the periosteum. Most frequently used in the maxilla where the cortical plate of the alveolar bone is thin and perforated by tiny vascular canals.

METHOD CONTD
y Intraosseous-The solution is deposited

within the medullary bone. y Intraseptal- The solution is deposited into the soft bone of the alveolar crest.

REGIONAL BLOCK
y This is deposited near the nerve trunk

and blocks the areas supplied by the nerve trunk. It is reliable in the mandible due to the thickness of the bone.

LA IN MAXILLA
MAXILLARY

Posterior superior alveolar nerve block: The upper 3rd,2nd and the distobuccal and palatal roots of the 1st molar are innervated by posterior superior alveolar nerve.
 LA is deposited between the 2nd and 3rd

molars. Serves the three maxillary molars and related buccal soft tissue (except the MB root of 1st molar).

METHODS Contd.
 Anterior and middle superior alveolar

nerve The mesiobuccal root of the 1st molar, both pre molars are supplied by this nerve.

 LA is deposited just above the upper limit

of the attached gingivae with the needle in-line with the long axis of the tooth. Serves premolars, all anterior teeth and overlying buccal mucosa and bone.

LA IN MAX CONTD
GREATER PALATINE NERVE This is given

over the estimated area of the apex of the root and should never be deposited distal to the 2nd molar because it will produce anaesthesia of the soft palate and uvular area making swallowing difficult for the patient. NASOPALATINE NERVE This is deposited beneath the incisive papilla at a site lateral to central rugae and deposited slowly to reduce discomfort. Provides anaesthesia of hard and soft tissue of the pre maxilla as far as the distal aspect of the 1st premolar.

LA IN MANDIBLE
Due to the density of the buccal plate of bone infilteration technics are of limited value in the mandible and regional or block anaesthesia is most frequently used. E g inferior alveolar nerve block is done in the pterygomandibular space. PTERYGOMANDIBULAR SPACE Anaesthesia in the mandible is achieved by deposition of the solution around the inferior alveolar and lingual nerve in the pterygo-mandibular space.

BOUNDARIES ANTERIOR-;pterygo-mandibular
raphe(formed by the posterior fibres of the buccinator and the anterior fibres of the superior constrictor). POSTERIOR-;parotid gland LATERAL-;Inner surface of the ascending ramus of the mandible. FLOOR-;Medial pterygiod muscle. ROOF-;Lateral pterygoid muscle.

MANDIBULAR

The LA is deposited into the pterygomandibular space. This anaesthetizes the inferior alveolar nerve, Gives pulpal anaesthesia from 3rd molar to canine.  MENTAL NERVE LA is deposited just above the mental foramen which is between the premolars but not into the foramen. It anaesthesizes the incisors, canine and premolars. for both lingual infiltration is still required for lingual mucosa
 INFERIOR DENTAL NERVE

COMPLICATIONS

LAs are frequently used in dentistry and thus can be expected to be a major source of drug-related complications especially in the treatment of risk patients (i.e. patients with CVS disease or allergies). These complications can either be localized or systemic. Complications are usually due to overdosage but the following are predisposing factors; Patients age Patients weight

COMPLICATIONS Contd.

State of health Other medications Note that vasoconsrictors are often present in many of these agents because LAs have vasodilating effect.

COMPLICATIONS Contd.
LOCAL

 Failure to obtain anaesthesia

y Patient factors :

- Infection at site of injection - Anatomical variation - Aberrant innervation - Anxiety - Obese patients

 Pain during and after injection  Haematoma at site of injection  Blanching

y Operators factors

- Faulty technique - Intravascular injection - Expired product

 Trismus  Facial paralysis  Prolonged impairment of sensation  Breakage of needle  Infection  Lip trauma  Optic nerve block causing visual

disturbances

GENERAL
 Syncope  Drug interaction  Sensitivity  Seizure  Bronchospasm  CNS depression  Respiratory collapse  Occupational dermatitis  Cardiorespiratory emergencies

THANK YOU.

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