Assistant Professor of Oral and Maxillofacial Surgery ...gtds.sbmu.ac.ir/uploads/local...
Transcript of Assistant Professor of Oral and Maxillofacial Surgery ...gtds.sbmu.ac.ir/uploads/local...
Arash Khojasteh, DMD, MSAssistant Professor of Oral and Maxillofacial Surgery
Shahid Beheshti University of Medical Sciences
Hyppocarates Stated:
• Divine is work to
subdue pain
26 October 2012
Local Anesthetics
Important points
• History• Some differences• How they work• Test dose• Onset
I. The Drugs
II. The Armamentarium
III. Techniques of Regional Anesthesia in Dentistry
IV. Complications, Questions and Future Trends
What are local anesthetics?
• Local anesthetic: produce loss of sensation to
pain in a specific area of the body without the
loss of consciousness
What are local anesthetics?
• A local anesthetic is an agent that interrupts
pain impulses in a specific region of the body
without a loss of patient consciousness.
Normally, the process is completely reversible-
-the agent does not produce any residual
effect on the nerve fiber.
History of Local Anesthetics
• Cocaine isolated 1856
• 1884 cocaine used in occular surgery
• 1880’s Regional anesthesia plexus
• 1898 cocaine used in spinal anesthesia
• 1905 1st synthetic LA (procaine) introduced
• 1943 lidocaine synthesized
• Mepivacaine (1957), Bupiv (’63), Ropiv (’96)
History
Indian Hemp (glycosides) Poppy (Opium)
History
• Coca leaves from the genus Erythroxylum• Erythroxylum contains high concentration of alkaloid up to
0.7-1.8%• Alkaloid has natural nitrogen bases found in the coca leaves,
also known as cocaine• In 1571, Pedro Pizarro, a conquistador of Inca, observed
nobles and high rank officials of the Inca empire consumed the coca plant
• Earliest cultivation and use of the coca leaf went back to about 700 BC in Bolivia and Andes regions
• New discoveries showed humans used coca more than 5,000 years ago in Ecuador
• In 1860, German chemist Albert Niemann successfully isolate the active principle of coca leaf; he named it cocaine
Cocaine Addiction
• More physicians began to do research of cocaine in the clinic
trials.
• The physician Sigmund Freud used the stimulant effect of
cocaine to treat the morphine addiction in patients
• An ophthalmologist Carl Koller realized the importance of the
alkaloid’s anesthetic effect on mucous membranes
• In 1884, he used the first local anesthetic on a patient with
glaucoma
• Freud, Halsted, and Koller became addicted to the drug
through self-experimentation
Neurophysiology
The Neuron
Biological Membrane
Hydrophil
Hydrophobe
Gate and Receptor
Neurophysiology
Nerve bundle anatomy
Core
bundles
Mantle
bundlesEpineural sheath
Epineurium
Perineurium
Covers fasciculi
Nerve fiber= single nerve cell
Endoneurium= cover each neuron
Fasciculi= bundles of 500 to 1000 nerve fibers
Nerve morphology
Classification and characteristic of peripheral nerve fibers
characteristic A A A A ----alphaalphaalphaalpha AAAA----betabetabetabeta AAAA----gammagammagammagamma AAAA----deltadeltadeltadelta BBBB CCCC
MyelinMyelinMyelinMyelin ++++++++++++ ++++++++ ++++++++ ++++++++ ++++ ----
DiameterDiameterDiameterDiameter (um)(um)(um)(um) 12 12 12 12 to to to to 20202020 5 5 5 5 totototo12121212 5 5 5 5 totototo12121212 1 1 1 1 to to to to 4444 1 1 1 1 to to to to 3333 0.5 0.5 0.5 0.5 to to to to 1111
Conduction Conduction Conduction Conduction velocity velocity velocity velocity (m/sec)(m/sec)(m/sec)(m/sec)
70 70 70 70 to to to to 120120120120 30 30 30 30 to to to to 70707070 30 30 30 30 to to to to 70707070 12 12 12 12 to to to to 30303030 14.814.814.814.8 1.21.21.21.2
Onset timeOnset timeOnset timeOnset time 6666 5555 4444 3333 1111 2222
functionfunctionfunctionfunctionMotor ,muscle,
proprioception
Touch,
pressure
proprioceptionTouch, motor
proprioception
Pain , temperature
Pressure
proprioception
Preganglionic
autonomic
(sympathetic)
activity
Pain , Itch, temperature,
Pressure
Postganglionic
Sympathetic activity
Electrophysiology of Nerve conduction (Action potential)
In resting state the nerve
membrane is :
- Slightly permeable to Na+
- Freely permeable to K+
- Freely permeable to Cl -
15 mv
Intra/extracellular Ionic concentration
IonIonIonIon IntracellularIntracellularIntracellularIntracellular
((((mEqmEqmEqmEq/L)/L)/L)/L)
ExtracellularExtracellularExtracellularExtracellular
((((mEqmEqmEqmEq/L)/L)/L)/L)
Ratio Ratio Ratio Ratio
(approximate(approximate(approximate(approximate
))))
PotassiumPotassiumPotassiumPotassium
(K+)(K+)(K+)(K+)
110 110 110 110 to to to to 170170170170 3 3 3 3 to to to to 5555 27 27 27 27 ::::1111
Sodium Sodium Sodium Sodium
(Na+)(Na+)(Na+)(Na+)
5 5 5 5 to to to to 10101010 140140140140 1111::::14141414
ChlorideChlorideChlorideChloride
(Cl(Cl(Cl(Cl----))))
5 5 5 5 to to to to 10101010 110110110110 1111::::14141414
Sodium channel transition stages
Membrane channels (depolarization)Rest Depolarization
Impulse SpreadNonmyelinated
Myelinated
Prevention Generation and
Conduction of nerve impulse
Possible Mode and Site of Action of LA
1. Altering the basic resting potential
2. Altering the threshold potential( Firing level)
3. Decreasing the rate of depolarization
4. Prolonging the rate of repolarization
Primary effect of local
Anesthesia occur during
the depolarization phase
of the action potential
Mechanism of action of L.A (Theories)
• Acetylcholine theory
• Calcium displacement theory
• Surface charge theory
• Membrane expansion theory
• Specific receptor theory
Membrane Expansion Theory
Specific receptor
Classification of Local Anesthetic substance According to Site and Mode of Acton
classification Site of Action Chemical substance
Class AReceptor site on External surface of nerve membrane
Biotoxins (e.g. ,tetritoxin and saxitoxin)
Class BReceptor site on internal surface of nerve membrane
Quaternary ammonium analogues of Lidocaine
Scorpion Venom
Class CReceptor - independent physiochemical mechanism
Benzocaine
Class DCombination of Receptor and Receptor - independent physiochemical mechanism
Most clinically useful local anesthetic agent (e.g. articaine
,Lidocaine , Mepivacaine,Prilocaine)
Tetrododoxin
• Toxin from puffer fish
• Blocks the Na channel
– Used in research
– Blocks from the outer side of cell
Membrane channels
125
61
104
Procaine replaced Novocaine
cocaine Problems
• In 1898, Professor Heinrich Braun
introduced procaine as the first
derivative of cocaine, also known
as the first synthetic local
anesthetic drug
• Trade name is Novocaine®
• Took too long to set (i.e. to produce the
desired anesthetic result)
• Wore off too quickly, not nearly as
potent as cocaine
• Classified as an ester; esters have high
potential to cause allergic reactions
• Caused high conc. of adrenaline resulted
in increasing heart rate, make people
feel nervous
Most dentists preferred not to used any
local anesthetic at all that time; they
used nitrous oxide gas.
Today, procaine is not even available for
dental procedures.
Types of Local Anesthetics
Local anesthetic Molecules
Ester type
Amide type
Henderson Hasselbalch equation
RNH RN + H+ +
RNH > RN + H+ +
RNH < RN + H+ +
PH- pKa = LogBase
Acid
Effect of pH, and pKa
• The pKa of amides ranges from 7.6 to 8.1. At physiologic pH (7.4), most of the local anaesthetic is in the ionized state (a charged base). For example, lidocaine has a pKa of 7.9. The above formulat determines that at physiologic pH, lidocaineexists in a ratio of 3:1 ionized to non-ionized:
• 7.9 - 7.4=log [ionized/non-ionized]
• 0.5 =log [ionized/non-ionized]
• 10^ 0.5=ionized/non-ionized
• 3ionized~
1non-ionized
Anesthetic pKa 7.9 ; pH 7.4
pH 7.4
Extracellular
pH 7.4
Nerve sheath
Intracellular
RNH+
750
RN
250
RN
70
RNH+
180
RN RNH
250
Drug : Neurophysiology (Effect of PH )
RNH+
7.5
pH 6
Extracellular
RNH+
990
RN
10
pH 7.4 Intracellular
RN
2.5
RN RNH+
10
Pharmacology of Local anesthesia
• Uptake
• Distribution
• Metabolism (biotransformation)
– Amides : LIVER , ... ... ...
– Esters : hydrolyzed in PLASMA by psudocholinesterase
• Excretion : kidney
Anesthetic pKa Onset Duration (with Epinephrine) in minutes
Max Dose (with Epinephrine)
Procaine 9.1 Slow 45 - 90 8mg/kg –10mg/kg
Lidocaine 7.9 Rapid 120 - 240 4.5mg/kg –7mg/kg
Bupivacaine 8.1 Slow 4 hours – 8 hours
2.5mg/kg –3mg/kg
Prilocaine 7.9 Medium 90 - 360 5mg/kg –7.5mg/kg
Articaine 7.8 Rapid 140 - 270 4.0mg/kg –7mg/kg
Benzocaine : Pka =3.5
Pharmacology of Local anesthesia
• Uptake
– All local anesthetics have vasodilation activity
– Procaine probably most potent vasodilator
– Cocaine the only local anesthetic producing vasoconstriction
– “Vasodilation” increase absorption into blood and decrease
the duration and quality of local anesthetic
Lipid solubility Drug Lipid solubility
Articaine 40
Mepivacaine 42
Prilocaine 55
Lidocaine 110
Bupivacaine 560
Lipid solubility is an
important
characteristic.
Potency is related to
lipid solubility,
because 90% of the
nerve cell membrane
is composed of lipid.
This improve transit
into the cell
membrane
Vasodilating activity
Drug Vasodilating activkity
Articane 1
Bupivacaine 2.5
Etidocaine 2.5
Lidocaine 1
Mepivacaine 0.8
Perilocaine 0.5
Protein binding
• Protein binding is related to the duration of action. The site of action (the Na channel) is primarily protein in a lipid environment. Binding affinity will thus affect duration of action.
• Protein binding also plays a part in the availability of the drug as LA binds to lipoproteins in the blood stream.
• And transfer to fetuses
Vasoconstrictors
• The addition of vasoconstrictors, such asepinephrine or phenylephrine can prolongduration of action of local anesthetics,decrease their absorption (and the peakplasma level) and enhance the blockade.
Factors affecting Local Anesthesia
action
FactorAction
affectedDescription
pKa OnsetLower pKa =
more rapid onset of action
Lipid solubility Anesthetic potencyIncreased lipid solubility =
Increased potency
Protein binding DurationIncreased protein binding=
Increasing Duration
Nonnervous Tissue
diffusibilityOnset
Increased diffusibility =
Decreased time of onset
Vasodilator activityAnesthetic potency
and onset
Greater vasodilatory activity=
Decreased potency /duration
Properties of Local AnestheticAgents
PROPERTIES AMINOESTERS AMINOAMIDES
Metabolism rapid by plasma cholinesterase slow, hepatic
Systemic toxicity less likely more likely
Allergic reaction possible - PABA derivatives form very rare
Stability in solution
breaks down in ampules (heat,sun)
very stable chemically
Onset of action slow as a general rule moderate to fast
pKa's higher than PH = 7.4 (8.5-8.9)close to PH = 7.4 (7.6-
8.1)
Oral Route
• Tocainide is a modification of lidocaine which
is used as an antidisrhytmic agent
Topical Anesthesia
• Benzocaine
• Solarcaine= Lidoocaine+ Benzocaine
• EMLA= Lidocaine + Prilocaine
Systemic Action of local Anesthesia
55
Pharmacology of Local anesthesia
• Systemic action of local anesthesia
– CNS (excitation – depression ... )
– Cardiovascular system (depression ,antiarrythmic effects ...)
– Respiratory system (direct relaxation , depression and arrest)
– Miscellaneous actions
• Neuromuscular blockade
• Drug interaction
• Malignant hyperthermia
56
Systemic action of Local Anesthesia (CNS)
Preconvulsive Sign and symptoms of CNS Toxicity
• Slurred speech
• Shivering
• Muscular twitching
• Tremor of face muscles and
extremities
• Generalized light headness
• Dizziness
• Visual disturbances
• Auditory disturbances
• Drowsiness
• Disorientation
• Numbness of the tongue and
circumoral region
• Warm ,flushed feeling of skin
• Pleasant dreamlike state
SIGNS SYPMTOMS
Pharmacology of Local anesthesia
• Systemic action of local anesthesia
– CNS (excitation – depression ... )
– Cardiovascular system (depression ,antiarrythmic effects ...)
– Respiratory system (direct relaxation , depression and arrest)
– Miscellaneous actions
• Neuromuscular blockade
• Drug interaction
• Malignant hyperthermia
59
The Drugs
• Pharmacology of Vasoconstrictors
– Increasing potency and duration of local anesthetic
– Decreasing systemic unfavorable effects of local
anesthetic
– Decreasing hemorrhage in the operation site
60
Sterile abscess
61
Effect of vasoconstrictor (epinephrine 1/200000 )
on peak local anesthetic level in blood
Local Local Local Local
anestheticanestheticanestheticanesthetic
DoseDoseDoseDose
(mg)(mg)(mg)(mg)
without without without without
vasoconstrictorvasoconstrictorvasoconstrictorvasoconstrictor
((((ugugugug/ml)/ml)/ml)/ml)
with with with with
vasoconstrictorvasoconstrictorvasoconstrictorvasoconstrictor
((((ugugugug/ml)/ml)/ml)/ml)
MepivacaineMepivacaineMepivacaineMepivacaine 500500500500 4.74.74.74.7 3333
LidocaineLidocaineLidocaineLidocaine 400400400400 4.34.34.34.3 3333
PrilocainePrilocainePrilocainePrilocaine 400400400400 2.82.82.82.8 2.62.62.62.6
EtidocaineEtidocaineEtidocaineEtidocaine 300300300300 1.41.41.41.4 1.31.31.31.3
Vasoconstrictors
• Catecholamine
– Epinephrine
– Norepinephrine
– Levonordefrine
– Isopretrenol
– Dopamine
• Non Catecholamine
– Amphetamine
– Methamphetamine
– Ephedrine
– Mephentramine
– Hydroxyphetamine
– Metaraminol
– Methoxamone
– phenylephrine
Vasoconstrictors
Direct acting Indirect acting Mixed - acting
Epinephrine Tyramine Metaraminol
Noreepinephrine Amphetamine Ephedrine
Levonordefrine Methamphetamine
Isopretrenol hydroxyamphetamine
Dopamine
Methoxamine
Phenylephrine
Adrenergic receptor Activity of Vasoconstrictors
DrugDrugDrugDrug αααα1111 αααα2222 ßßßß1111 ßßßß2222
EpinephrineEpinephrineEpinephrineEpinephrine ++++++++++++ ++++++++++++ ++++++++++++ ++++++++++++
NorepinephrineNorepinephrineNorepinephrineNorepinephrine ++++++++ ++++++++ ++++++++ ++++
LevonordefrineLevonordefrineLevonordefrineLevonordefrine ++++ ++++++++ ++++++++ ++++
Beta 1 Beta 2 Alpha1 Alpha2
Heart Bronchi Presynaptic
excitory
Post synaptic
inhibitory
Intestine Vascular Bed
Cardiac
stimulation
Uterous
lipolysis Vasodilation
bronchdilation
66
67
68
Prilocaine
• Greater Vasodilatory than Mepivacaine but less than Lidocaine
• Flypressin as a Vasoconstrictor
• Lung, Kidney, Liver
• Orthotoluidine
• Relatively contraindicated in SCC,
Acetaminophen user, Anemia
69
Articaine
• Thiophene Group
• Plasma esterase
• More penetration
• Pulpal and lingjual
anesthesia through
infiltration
• Risk of paresthesia
• Risk of Meth in IV
administration
70
• Significant Vasodialtion
• Long acting drug
• Management of Post op
Pain
• Pka=8.1 onset of
action
• Not recommended in
children
71
Benzocaine
72
The
Armamentarium
The Armamentarium
• The Syringe
• The Needle
• The Cartridge
• Additional Armamentarium
• Preparation of the armamentarium
75
The Armamentarium
• The Syringe
76
Original design of pressure syringe
(PDL)
77
Pressure syringe!
78
Second generation syringe (PDL)
79
SyriJet needleless injector
80
UltraSafety Plus XL syringe
81
Computer –controlled local anesthetic delivery system
the Wand
82
Anaeject Computer –controlled local anesthetic
delivery system
83
Problems
• Leakage during injection
• Broken cartridge
• Bent Harpoon
• Disengagement of the Harpoon from the Plunger during Aspiration
• Surface deposits
84
The Armamentarium
• The Needle
– Types
– Parts
– Gauge
– Length
85
The Needle (deflection effect)
BRIT Technique
86
Conventional / Nondeflecting needles
87
The Needle
• Care and handling
• Problems
– Breakage
– Pain on injection
– Injury to the patient or administrator
• Recommendations
88
The Armamentarium• The Cartridge
– Components
• Cylindrical glass tube
• Stopper
• Aluminum cap
• Diaphragm
Cylindrical glass
tube
Rubber
Diaphragm
Aluminum
cap
Silicon
rubber
Plunger
(Stopper)
89
Cartridge (Carpule)
• Ingredient
1. Local anesthetic drug (lidocaine 2% , prilocaine 3%)
2. Vasoconstrictor drug (epinephrine 1/80,000 )
3. Preservative for vasoconstrictor (Sodium bisulfate)
4. Sodium chloride
5. Distilled water
90
Cartridge Problems
1. Bubble in the cartridge
2. Extruded stopper
3. Burning upon injection1. Response to pH
2. Cartridge containing sterilization solution
3. Overheated cartridges
4. Use of a cartridges with vasoconstrictor
4. Sticky stopper
5. Corroded cap
6. “Rust” on the cap
7. Leakage during injection
8. Broken cartridge
91
Additional Armamentarium
1. Topical Antiseptic
2. Topical anesthetic
3. Applicator sticks
4. Cotton gauze
5. Hemostat
92
The Armamentarium
• Preparation of the armamentarium
93
Preparation of the armamentarium
94
Safety syringe
95
Safety syringe
96
Ultra Safety Plus XL (Septodont, Inc.)
97
Ultra Safety Plus XL (Septodont, Inc.)
98
Ultra Safety Plus XL (Septodont, Inc.)
99
Preparation of the armamentarium
• Recapping of Needle
100
The Armamentarium
• The Syringe
• The Needle
• The Cartridge
• Additional Armamentarium
• Preparation of the armamentarium
Techniques of Regional Anesthesia in Dentistry
Physical and psychological evaluation
102
Physical and psychological evaluation
• Medical History Questionnaire– Questions and Comments ... ... ... ...
• Dialogue History
• Physical Examination– Visual Inspection
– Vital signs
– Determination of medical risk
• Drug-Drug interactions
• Malignant hyperthermia
• Atypical Plasma Cholinesterase
• Methemoglobinemia
103
Physical and psychological evaluationA. Identification data
B. History
i. Chief complaint
ii. History of present illness
iii. Past medical history
iv. Family history
v. Past dental history
vi. Psychosocial history
vii. Review of systems
C. Physical examination
i. Extra / Intra oral exam
ii. Dental exam
iii. … … … …
D. Para clinical investigation
E. Clinical investigation
F. Diagnosis
G. Treatment plan
H. Follow up/ Rehabilitation
104
Physical and psychological evaluation
• Medical History Questionnaire– Questions and Comments ... ... ... (refer to reference !!)
• Dialogue History
• Physical Examination– Visual Inspection
– Vital signs 1. Blood Pressure
2. Heart rate /rhythm
3. Respiratory rate
4. Temperature
5. Height
6. weight
– Determination of medical risk
105
Physical and psychological evaluation
• Drug-Drug interactions
• Malignant hyperthermia– One of most intense life threatening(1/150,000 adult)
– Autosomal dominant ; male> female ;
– Tachycardia ,fever ,tackypnea, cardiac dysrythmias, muscle rigidity ,cyanosis and death
– Most probable with succynilcholine(77%),halothane (60%) ...
– Dantrolene,...
• Atypical Plasma Cholinesterase
• Methemoglobinemia
106
American Society of Anesthesiology
physical status classification
I. Normal healthy individual
II. Patient with mild to moderate systemic disease
III. Patient with severe systemic disease that limit
activity but not incapacitating
IV. Patient with severe systemic disease that limit
activity and is a constant threat to life
V. Moribund patient not expected to survive 24
hours with or without an operation
Drud-Drug Interaction
Interaction With local anesthetic
1. Local anesthetic• Ester
• Amide
2. Vasoconstrictors
Ester Local Anesthetics With
Sulfonamide Antibiotics
• Procaine with sulfamethoxazole
– Procaine is used infrequently; the procaine
metabolite p-amino benzoic acid may transiently
reduce sulfonamide antibiotic efficacy.
Lidocaine with bupivacaine
• Local anesthetic toxicity is additive
Amide Local Anesthetics With
Inhibitors of Metabolism
• Lidocaine with Cimetidine
• lidocaine with Propranolol
• Mepivacaine with Meperidine
• Lidocaine and Erythromycin
– Inhibition of local anesthetic metabolism will have
little effect on peak plasma levels of anesthetic
when given as a single injection.
Vasoconstrictor Interaction
113
Pharmacology of Vasoconstrictors
• Maximum recommended dose of Epinephrine
– Normal healthy patient 0.2 mg (200 ug)/ visit
• ( nine 1.8 cc cartridges with 1/80000 epinephrine)
– Patient with significant cardiovascular impairment (ASA
III ,IV)
0.04 mg (40 ug) /visit
• ( two 1.8 cc cartridges with 1/80000 epinephrine)
Antidepressants
Classification Generic name Trade name
MAOIIsocarboxazid Marplan
TCAsAmitriptyline,
Protriptyline
Imipramie
Amitril
Sinequan
Adapin
SSRIsFluoxetine Prozac
MAO +High Level TyramineFood & Beverages
( Cheese , Fish ,Beer,Red wine,Liver.. )Hypertensive Crisis,Intracranial bleeding
Excessive Fever , death
MAOIs
TCAs
TRICYCLIC ANTIDEPRESSANTS
(imipramine, amitriptyline, doxepin)
• Absolute Contraindication
– Levonordephrine
– Norepinephrine
• Relative contraindication
– Epinephrine (0.04mg)
Vasoconstrictor with nonselective
β-adrenoceptor antagonist
• Epinephrine with Propranolol
– BP
– PR
Vasoconstrictor with antipsychotic or
other α-adrenoceptor blocker
• Epinephrine with Chlorpromazine, Prazocin,
Risperidone
– BP
– Susceptible to orthostatic hypotension
Vasoconstrictor with adrenergic neuronal
blocker
• levonordefrin with guanithidine
– Sympathomimetic effects may be enhanced.
Vasoconstrictor should be used cautiously.
• Absolute contraindication
Vasoconstrictor with thyroid hormone
• Epinephrine with Thyroxine
– Summation of effects possible when thyroid
hormones are used in excess. Vasoconstrictor
should be used cautiously if signs of
hyperthyroidism are present
▪ Relative contraindication
Techniques of Regional Anesthesia in
Dentistry
Basic injection technique
122
Basic injection technique
1. Use sterilized sharp needle
2. Check the flow of anesthetic solution
3. Determine the temperature of syringe /cartridge
4. Position the patient
5. Dry tissue
123
Hand position during injection
Basic injection technique
6. Apply topical
antiseptic (optional)
7A. Apply topical
anesthetic (optional)
7B. Communicate with the
patient
124
125
Basic injection technique
8. Establish a firm hand rest
126
Basic injection technique
9. Make tissue taut
10. Keep the syringe out
of patient’s line of sight
127
Basic injection technique
11A. Insert the needle into the mucosa
11B . Watch and communicate
with the patient
128
Basic injection technique
12. Inject several drops of local anesthetic solution
(optional)
13. Slowly advance the needle toward the target
14. Inject several drops before touching the
periosteum
15. Aspirate
129
Basic injection technique
16 A. Slowly deposit the local anesthetic solution
16 B. Communicate with the patient
17. Slowly withdraw the syringe
18. Observe the patient
19. Record the injection on patient’s chart
Techniques of Regional Anesthesia in Dentistry
Physical and psychological evaluation
Basic injection technique
Anatomical consideration
131
Anatomical consideration Trigeminal Nerve
132
Cranial NervesNumber Name Type
I Olfactory Sensory
II Optic Sensory
III Occulomotor Motor
IV Trochlear Motor
V Trigeminal Mixed
VI Abducense Motor
VII Facial Motor
VIII Auditory Sensory
IX Glossopharyngeal Mixed
X Vagus Mixed
XI Accessory Motor
XII Hypoglossal Motor
133
Cranial Nerve
134
Cranial Nerve
135
Trigeminal Nerve
• Sensory
– Ophthalmic (V1)
– Maxillary (V2)
– Mandibular (V3)
136
Trigeminal Nerve
• Motor (Mandibular (V3) division only)
– Muscles of Mastication
• Masseter
• Temporalis
• Ptrygoideus medialis
• Ptrygoideus lateralis
– Mylohyoid
– Digastric (anterior belly)
– Tensor tympani
– Tensor Veli palatini
137
Ophthalmic (V1)
– Nasociliary
– Frontal
– Lacrimal
Maxillary (V2)
• Alveolar
– Posterior superior alveolar
(PSA)
– Middle superior alveolar (MSA)
– Anterior superior alveolar (ASA)
• Palate
– Nasopalatine
– Greater palatine
– Lesser palatine
138
139
Maxillary (V2)
140
Maxillary (V2)
141
Maxillary (V2)
142
Maxillary (V2)
143
Maxillary (V2)
144
Maxillary (V2)
145
Anterior Superior Alveolar nerve
146
Mandibular (V3)
• Inferior alveolar
– Mental branch
– Incisive branch
• Buccal
• Lingual
• Mylohyoid
• Auriculotemporal
147
Inferior alveolar nerve (IAN)
148
Inferior alveolar nerve (IAN)
149
Inferior alveolar nerve (IAN)
Jafarian Local Anesthesia 150
Techniques of Regional Anesthesia in Dentistry
Physical and psychological evaluation
Basic injection technique
Anatomical consideration
Techniques of maxillary anesthesia
152
Typical information in each technique
� ... Injection
� Other common Names
� Nerves Anesthetized
� Areas Anesthetized
� Indications
� Contraindications
� Advantages
� Disadvantages
� Positive Aspiration
� Alternatives
� Techniques
� Signs and Symptoms
� Safety Features
� Precautions
� Failures of Anesthesia
� Complication
Techniques of Regional Anesthesia in Dentistry
• Techniques of maxillary
anesthesia
– Local infiltration
– Field Block
– Nerve Block
153
154
Maxillary injection techniques
1. Supraperisteal (infiltration)
2. Periodontal Ligament (PDL)
3. Intraseptal
4. Intracrestal
5. Intraosseous
6. Posterior superior alveolar (PSA) nerve block
7. Middle superior alveolar (MSA) nerve block
8. Anterior Superior alveolar nerve block (ASA)
155
Supraperiosteal injection
156
Posterior Superior Alveolar Nerve
Block
157
Posterior Superior Alveolar Nerve
Block
• Depth of penetration (half of a long 40mm
needle)
Long dental needleShort dental needleLess risk of Hematoma
158
Posterior Superior Alveolar Nerve
Block
• The story of Mesiobuccal root of first Molar !!
• Significant difference in skull size
• Depth of penetration (half of a long 40mm
needle)
• Risk of Hematoma ; positive aspiration ~ 3.1%
159
Posterior Superior Alveolar Nerve
Block
• The story of Mesiobuccal root of first Molar !!
• Significant difference in skull size
• Depth of penetration (half of a long 40mm
needle)
• Risk of Hematoma ; positive aspiration ~ 3.1%
160
Middle Superior Alveolar Nerve Block
161
Middle Superior Alveolar Nerve Block
• Present in only 28% of population
• Positive aspiration negligible <3%
162
Anterior Superior Alveolar Nerve Block
163
Anterior Superior Alveolar Nerve Block
164
Anterior Superior Alveolar Nerve Block
• Although not accurate, the other name :
infraorbital Nerve Block
• Disadvantages is more Psychological both for
Administrator and patient ; injury to EYE !!
165
Palatal Anesthesia
• Necessary for any Dental Procedure involving soft/hard tissue of palate
• Steps !!1. Adequate topical anesthesia
2. Pressure anesthesia at the site both before and during needle insertion and the deposition of solution.
3. Maintain control over the needle
4. Deposit the anesthetic solution slowly
5. Trust yourself ... ... You can complete the procedure atraumtically !!
166
Palatal Anesthesia
167
Greater palatine Nerve Block
168
Greater palatine Nerve Block
169
Greater palatine Nerve Block
170
Greater palatine Nerve Block
171
Greater palatine Nerve Block
172
Greater palatine Nerve Block
173
Greater palatine Nerve Block
174
Prepuncture technique
an excellent technique !!
175
Nasopalatine Nerve block
176
Nasopalatine Nerve block
177
Multiple Needle Penetration
178
Local infiltration of the Palate
179
Anterior Middle Superior Alveolar Nerve Block
180
Palatal approach Anterior superior Alveolar Nerve
181
Maxillary Nerve Block
( High – tuberosity approach)
182
Maxillary Nerve Block
(Greater Palatine canal approach)
Techniques of Regional Anesthesia in Dentistry
Physical and psychological evaluation
Basic injection technique
Anatomical consideration
Techniques of maxillary anesthesia
Techniques of mandibular anesthesia
184
Anatomical consideration
185
Inferior Alveolar Nerve block
186
Inferior Alveolar Nerve block (variation)
Too far anteriorly
187
Inferior Alveolar Nerve block (variation)
Too far posteriorly
188
Inferior Alveolar Nerve block
Mylohyoid nerve block
189
Buccal Nerve block
190
Mandibular Nerve Block Gow - Gate
191
Mandibular Nerve Block Gow - Gate
192
Mandibular Nerve Block
Extraoral through sigmoid notch
193
Mandibular Nerve Block
Vazirani –Akinosy closed mouth
194
Mental Nerve Block
195
Mental Nerve Block
Lingual side
196
Incisive Nerve Block
197
Intraosseous Anesthesia
• Periodontal Ligament Injection
• Intraseptal injection
• Intraosseous injection
Intraosseous Anesthesia
• Periodontal Ligament
Injection (PDL)
198
199
Intraosseous Anesthesia
• Periodontal Ligament Injection
• Intraseptal injection
200
Intraosseous Anesthesia
• Periodontal Ligament Injection
• Intraseptal injection
• Intraosseous injection
201
Intrapulpal Anesthesia
202
Complications, Questions and Future Trends
• Local complication
• Systemic complication
• Question
• Future trends in pain control
Complication
Local complication
204
Local complication
1. Needle breakage
2. Persistent paresthesia or
anesthesia
3. Facial nerve paralysis
4. Trismus
5. Soft tissue injury
6. Hematoma
7. Pain on injection
8. Burning on injection
9. Infection
10. Edema
11. Sloughing of tissues
12. Postanesthetic intraoral
lesions
205
Local complication
1. Needle breakage
– Causes
– Problem
– Prevention
– Management
206
Local complication
2. Persistent Anesthesia or Paresthesia
– Causes (Mechanical /chemical trauma ...)
– Problem
– Prevention
– Management
207
Local complication
3. Facial nerve paralysis
– Cause
– Problem
– Prevention
– Management
208
Local complication
4. Trismus
– Cause
– Problem
– Prevention
– Management
209
Local complication
5. Soft tissue injury
– Cause
– Problem
– Prevention
– Management
210
Local complication
6. Hematoma
– Cause
– Problem
– Prevention
– Management
211
Local complication
7. Pain on injection
– Cause
– Problem
– Prevention
– Management
212
Local complication
8. Burning on injection
– Cause
– Problem
– Prevention
– Management
213
Local complication
9. Infection
– Cause
– Problem
– Prevention
– Management
214
Local complication
10. Edema
– Cause
– Problem
– Prevention
– Management
215
Local complication
11. Sloughing of tissues
– Cause
– Problem
– Prevention
– Management
216
Local complication
12. Postanesthetic Intraoral Lesions
– Cause
– Problem
– Prevention
– Management
217
Local complication
1. Needle breakage
2. Persistent paresthesia or
anesthesia
3. Facial nerve paralysis
4. Trismus
5. Soft tissue injury
6. Hematoma
7. Pain on injection
8. Burning on injection
9. Infection
10. Edema
11. Sloughing of tissues
12. Postanesthetic intraoral
lesions
Complications, Questions and Future Trends
Local Complication
Systemic Complication
219
Systemic Complication
• Principle 1 : No drug ever exerts a single action
• Principle 2 : No clinically useful drug is entirely
devoid of toxicity
• Principle 3 : the potential of a drug rests in
the hands hand of operator
220
Causes of Adverse Drug Reactions
• Toxicity caused by Direct Extension of the usual pharmacological effects of the drug
1. Side effects
2. Overdose Reactions
3. Local toxic effects
• Toxicity caused by Alteration in the Recipient of the drug
1. A disease process ( hepatic dysfunction , CHF , Renal dysfunction )
2. Emotional disturbances
3. Genetic aberrations ( Atypical plasma cholinesterase , malignant hyperthermia )
4. Idiosyncrasy
• Toxicity caused by Allergic responses to the drug
221
Comparison of Allergy and Overdose
Allergy Overdose
Dose Non-dose related Dose related
S & S Similar ,regardless of allergen Relate to pharmacology of the drug
Management Similar (epinephrine ,histamine blockers) Different :specific for the drug
Systemic Complication
Local anesthetic overdose
223
Local anesthetic overdose (Predisposing factors)
• Patient Factors
– Age
– Weight
– Other drugs
– Sex
– Presence of disease
– Genetics
– Mental attitude and
environment
• Drug Factors
– Vasoactivity
– Concentration
– Dose
– Rout of administration
– Rate of injection
– Vascularity of the injection
site
– Presence of vasoconstrictors
224
Overdose • Causes
1. Biotransformation of the drug is unusually slow.
2. The unbiotransformed drug is too slowly eliminated from
the body through the kidneys.
3. Too large a total dose is administered.
4. Absorption from the injection site is unusually rapid.
5. Inadvertent intravascular administered occurs.
225
Overdose
• Reverse Carotid blood flow
226
Overdose
• False Negative Aspiration
227
Overdose
• Local Anesthetic blood levels and action
228
Overdose • Causes
• Prevention
• Sign and Symptoms (Box !8 -4 p.313)
• Management
– P; ABCD emergency
– Definite treatment
Systemic Complication
Local anesthetic overdose
Vasoconstrictor Overdose
Vasoconstrictor Overdose
• Precipitating factors and
prevention
• Clinical manifestations
(Box 18-6 p.318)
• Management
230
Signs Symptoms
Sharp elevation of
BP
Fear , Anxiety
Elevated HR Tenseness
Possible
dysrhythmia
Restlessness
Throbbing headache
Tremor
Perspiration
Weakness
Dizziness
Pallor
Respiratory difficulty
Systemic Complication
Local anesthetic overdose
Vasoconstrictor Overdose
Allergy
232
Allergy
• Predisposing Factors
• Prevention
• Dental management
• Clinical manifestations
• Management
233
Palatal Anesthesia
234
Palatal Anesthesia
235
Palatal Anesthesia
236
Palatal Anesthesia
237
Palatal Anesthesia
238
Palatal Anesthesia
239
Palatal Anesthesia
240
Maxillary