Local Anesthesia

for
Dental Child Patient

Presented by:
Mohamed Magdy
Pain:
Pain is an unpleasant emotional experience usually
initiated by noxious stimulus and transmitted over a
specialized neural network to the CNS where it is
interpreted as such.

Local anesthesia:
Reversible loss of sensation in a circumscribed area
of the body caused by a depression of an excitation in
nerve ending or an inhibition of the conduction process
in peripheral nerves.
Various methods of inducing local anesthesia:
• Mechanical trauma
• Low temperature
• Anoxia
• Neurolytic agents like alcohol and phenol
• Chemical agents like local anesthesia
Classification of LA :
• Based on composition.
• Based on duration of action.
• Based on mode of administration.
ACC to Duration of Action
Ultra short acting (less than 30 mins) ---
• 2 % plain lignocaine
• 3% plain mepivacaine
• 4% prilocaine
Short acting (45-75 mins) ---
• procaine
• chloroprocaine
Medium acting (90-150 mins) ---
• lidocaine
• prilocaine
Long acting (180 mins or longer) ---
• bupivacaine
• ropivacaine
• tetracaine
Composition:
1) Local anesthetic agent:
• Lignocaine hydrochloride 2% is most
commonly used local anesthetic agent.
• 2% lignocaine mean …
○ 2g in 100 ml
Or
○ 20 mg in 1 ml
♦ Uses – Conduction Blockade
2) Vasoconstrictor:
Adrenaline in the concentration of
1:50,000 to 1:200,000 is commonly used.
◘ 1:200000 means …
○ 1 gm in -------- 200,000 ml
Or
○ 1 mg in -------- 200 ml (0.02 mg/ml)
♦ Uses of vasoconstrictor:
• ↓ the blood flow to the injection site
• Absorption of LA into CVS is lowed leading
to lower LA level in blood
• ↓ the risk of toxicity due to LA
• ↑ The duration of action of the LA
• ↓ bleeding and are useful when increased
bleeding is anticipated
3) Antioxident / reducing:
• Sodium metabisulphite is used to prevent
the oxidation of the vasoconstrictor. It
oxidized to form sodium metabisulfate
Sodium metabisulfite is acidic and increases
acidity of solution.
• Therefore old local anesthetic solutions
cause burning or discomfort during injection.
4) Preservative agent:
• Methyl paraben
( hypersensitive reaction due to methyl
paraben= caprylhydro cuprienotoxin)

5) Fungicide:
• Thymol is used as fungicide
6) lsotonic agent:
• Sodium chloride is used to make the
solution isotonic with the tissues.
• It makes the solution alkaline.

7) Vehicle:
• Distilled water is used as vehicle.
• It produces the volume of the solution and
act as diluent.
♦ Order of sensory function block:
1. pain
2. cold
3. warmth
4. touch
5. deep pressure
6. motor
♦ EXCRETION
• Kidneys are the primary excretory organs for
both the local anesthetic and its metabolites
• A percentage of given dose of local anesthetic
drug is excreted unchanged in the urine.
• Significant renal disease (ASA IV to V)
represents a relative contraindication to the
administration of LA.
• This includes patients undergoing
dialysis, and those with
chronic glomerulonephritis or pyelonephritis.
Table 1: American Society of Anesthesiologists
(ASA) Physical Status Classification System

Category Health Status

ASM Normal healthy patient

ASA II Patients with mild systemic disease

ASA III Patients with severe systemic disease

Patients with severe systemic disease that Is a constant
ASA IV threat to life

ASA V Moribund patients who are not expected to survive

without the operation

ASA VI A declared brain-dead patient whose organs are being

removed for donor purposes
♦ Selection Of Local Anesthesia:
• During the selection of LA the patients size and
age must be considered...doses must be reduced
in accordance with patients Age, Size.
• On reducing the dosage in accordance with
patients Age .YOUNGS RULE may be followed
1. child's dose - child age X adult dose
age+12
2 patients body weight, CLARKS RULE may be
followed child's dose = child weight X adult dose
150
♦ Rule of 10:
• A method of providing a guide as to whether
an infiltration or a block injection of local
analgesic is appropriate for a child requiring
treatment to a mandibular tooth.
• The primary tooth to be anaesthetized is
assigned a number from 1 to 5 according to its
location in the dental arch (central incisor = 1,
second molar =5).
• This number is added to the age of the child (in
years), and if the number is 10 or less then an
infiltration analgesic is most appropriate; if
greater than 10, then an inferior dental nerve
block is likely to be more effective.
♦ Rule of 25
• According to this a dentist can safely use 1
cartridge of anesthetic for every 25 pounds
of patient weight.
• That is 1 cart = 25 pound
2 cart = 50 pound
3 cart = 75 pound
◘ PROCAINE:
• Classification: ester
• Prepared by-Alferd Einhorn ,1904-1905
• Chemical formula:
2diethyleaminoethyl4aminobenzoate hydrochloride.
• Metabolism: hydrolyzed rapidly in plasma by plasma
pseudocholinesterase
• Excretion: more then 2% unchanged in urine(90% as PABA,
E% as diethyleaminoethanol).
• Vasodilating properties: prod uces the greatest vasodilation
of all currently used local anesthetics.
♦ Trade name – novucain:
◘ PROPXYCAINE:
• Classification : ester
• 2-diethylaminoethyl 4-amino-2-
propoxybenzoate Prepared by - Clinton and
Laskowski,1952
• Hydrolyzed in both plasma and liver
○ MAXIMUM DOSAGE
• 6.6mg/kg
○ MAXIMUM TOTAL ANAESTHETIC DOSAGE
• should not exceed 400mg
◘ LIDOCAINE:
• Classification: Amide
• Chemical formula:
2diethyleamino 2,6acetoxyldidehydrochloride
• Prepared by Nils Lofgren in 1943
• Metabolism: in the liver
• Excretion: via kidneys; less than 10% unchanged,
more than 80% various metabolites
• Vasodilating properties: considerably less than
those of procaine; however, more than those of
Prilocaine or mepivacaine
◘ MAXIMUM DOSAGE:
• 4.4mg/kg
• 7mg/kg (wt vasoconstrictor)
◘ TOTAL MAXIMUM DOSAGE
• 300mg
• 500mg(wt vasoconstrictor)
◘ MEPIVACAINE:
• Classification: Amide
• Chemical formula:
1-N-methyl pipecolic-acid 2,6,dimethyl-anilide
• Prepared by- A.EEkenstam ,1957, introduced in
dentistry in 1960
• Metabolism: in the liver
• MAXIMUM DOSAGE 6.6mg/kg
• TOTAL MAXIMUM DOSAGE 400mg
BUPIVACAINE
• Classification: Amide
• Prepared by: A.F.Ekanstam,1957
• Chemical formula:
lbutyl 2',6'pipecoloxylidine hydrochloride
• Metabolism: in the liver by amidases
• Excretion: via kidneys 16% of anesthetic
dose is excreted unchanged
♦ MAXIMUM DOSAGE
• 2mg/kg
• 2mg/kg(with vasoconstrictor)
♦ TOTAL MAXIMUM DOSAGE
• 175mg
• 225mg (with vasoconstrictor)
◘ PRILOCAINE
• Classification: Amide
• Chemical formula:
2-Propylamino-o-proplionotoluidide hydrochloride
• Prepared by - Lofgren and Tegner, 1953
• MAXIMUM RECOMMENDED DOSAGE 7.9mg/kg
• TOTAL MAXIMUM DOSAGE 600mg
◘ ARTICAINE
• Classification: Amide
• Chemical formula:
3-N-Propamino-proprionylamino-2 carbomethoxy-
4-methylthiopene hydrochloride
• Prepared by - H.Rusching et al , 1969
• MAXIMUM RECOMMENDED DOSE 7mg/kg
• TOTAL MAXIMUM DOSE 500MG
Topical Anesthesia
Topical anesthesia or surface anesthesia:
Forms of topical anesthesia:
• Paste (ointment, cream, gel).
• Solution (spray in pressurized container).
• Cotton pellets.
• Adhesive discs.
• The application of a topical anesthetic may help
minimize discomfort caused during administration of
local anesthesia.
• Effective up to 2-3mm in depth to reduce painful needle
penetration of the oral mucosa
• Topical anesthetic agents are available in gel, liquid,
ointment, patch, and aerosol forms
• FDA has issued a warning about the use of
compounded topical anesthetics and the risk of
methemoglobinemia.
• Risk of acquired methemoglobinemia has been
associated primarily with two local anesthetics:
prilocaine and benzocaine
• Prilocaine is available topically combined
with lidocaine and in an injectable form
• Benzocaine, the most commonly used
topical anesthetic, is available in
concentrations up to 20% and comes in
liquid, spray, and gel forms.
• Lidocaine is available as a topical solution
or ointment up to 5% and as a spray up to
10% concentration.
Advances in Dental
Local Anesthesia
♦ Electronic Dental Anesthesia
• Principle of Transcutaneous Electrical Nerve Stimulation
(TENS) which has been used for the relief of pain.
• Some limitations are increased salivary flow and inability to
use metal instruments freely.
• It is powered by a battery ,two small sponges are placed in
the patients mouth or on the face, which are attached to the
control box that the patient uses to select the depth of
anesthesia
♦ Indication:
■ Patient having needle phobia
■ Ineffective LA
■ Instances where LA cannot be administered
■ TMJ(chronic pain)
♦ Nonsurgical periodontal pain
■ Restorative dentistry
■ Fixed prosthodontic procedure
♦ Advantages:
• No need of needle
• No need for injections of drugs
• Patient is in control of the anesthesia
• No residual anesthetic effect at the end of
procedure
• Residual analgesic effect remains for several
hours
♦ Disadvantages:
• Cost of the unit
• Training
• 'Learning curve' initial success may be low but
increases with experience
• Intraoral electrode: Weak link in the entire
system
• It is contraindicated in severalconditions such as
heart disease, seizures, neurological disorders,
brain tumors, patients wearing pacemakers and
cochlear implants
CCLAD Systems (Computer Controlled Local Anesthesia
Delivery System)
• Wand" has 3 components: Base unit, Foot
pedal and Disposable Handpiece assembly
• Base unit consists of a microprocessor and
connects to the foot pedal and Handpiece
assembly that accepts the LA cartridge.
• LA solution from the cartridge passes
through the microbore tubing in the
Handpiece assembly and needle into the
target tissue
♦ Rate of Injection:
Foot pedal controls the rate of injection
and if aspiration feature is enabled, it
prevents inadvertent intravascular injections.
1. Slow: 0.005ml/s - needle insertion, PDL
injection, Palatal administration
2. Fast: 0.03ml/s- buccal infiltrations, nerve
block
3. Turbo: 0.06ml/s
Advantages of CCLADs:
1) Ability to administer small quantities of LA
solution continuously during needle insertion,
which anesthetizes the tissue immediately ahead
of the advancing needle.
2) Steady infusion of the anesthetic solution at the
target site reduces the discomfort associated with
less controlled injections.
3) More accurate needle insertion
4) Less pain on injection
5) Less fear of injection
6) More controlled insertion of the needle
♦ Comfort Control Syringes:
• Consists of two components; base unit and syringe.
• The most important functions of the unit (injection
and aspiration) can be controlled directly from the
syringe.
• Rate of injection: Five different basic injection rate
settings for specific applications: block, infiltration, PDL,
10 and Palatal regions.
• The unit uses two stage delivery rates for every
injection.
• It initially expresses the LA solution at an extremely
low rate and after 10 seconds the rate slowly increases
to the pre-programed value for the selected injection
technique.
♦ Intra-Osseous Anesthesia:
• The use of motor driven perforator to
penetrate the buccal gingiva and bone
can be considered as the first modern
technique of 10 anesthesia.
• The devices used for this technique,
inject the solution into the cancellous
bone adjacent to the root apex.
Intraflow:
• The Intraflow Anesthesia Delivery System is an "all in
one" system that allows the operator to perforate the
bone and deposit the anesthetic solution in a single
step.
• The device is a dental handpiece equipped with an
injection system built into its body. A 24 gauge hollow
perforator is used to penetrate the bone and infuse the
LA solution.
Vibrotactile devices aimed at easing
the fear of the needle take advantage of
the gate control theory of pain
management, which suggests that pain
can be reduced by simultaneous
activation of nerve fibers through the
use of vibration
Devices are : vibrajet, dentvibe and
accupal.
Vibrajet:
It is a small battery-operated attachment
that snaps on to the standard dental syringe.
It delivers a high-frequency vibration to the
needle that is strong enough for the patient
to feel.
DentalVibe:
It is a small battery-operated attachment
that snaps on to the standard dental syringe.
It delivers a high-frequency vibration to the
needle that is strong enough for the patient
to feel.
Accupal:
A cordless device that uses both vibration and
pressure to precondition the oral mucosa.
Accupal provides pressure and vibrates the
injection site 360 proximal to the needle
penetration, which shuts the pain gate, according
to the manufacturer.
Applying moderate pressure, the unit light up the
area and begins to vibrate. The needle is placed
through a hole in the head of the disposable tip,
which is attached to the motor.
Jet injection:
• Jet-injection technology is based on the principle of
using a mechanical energy source to create a release
of pressure sufficient to push a dose of liquid
medication through a very small orifice.
• Creating a thin column of fluid with enough force
that it can penetrate soft tissue into the
subcutaneous tissue without a needle

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