LECTURE 1 - 3RD LEVEL

Local anesthesia in
endodontics
Mokhtar Al-anesi
Associate Prof. Of Endodontics, Conservative Dept. Thamar Uni.
Outline
Uses of local anesthesia in endodontics
Types of local anesthetics
Possible adverse effects
Failure of anesthesia
maxillary & Mandibular injection techniques
Supplemental anesthesia
Uses :
– Decrease intraoperative and postoperative pain
– Decrease amount of general anesthetics used in the OR
– Increase patients cooperation
– Diagnostic testing/examination
Types of local anesthetics

Local anesthetics are divided into two functional groups based on their
chemical properties:
Esters and amides.

The ester group includes the earlier anesthetics procaine, cocaine, and novocaine.
Although generally the topical anesthetics are still part of the ester family.
The amide group includes lidocaine, mepivacaine, prilocaine , bupivacaine, and

etidocaine.

The amides are preferable to the esters because the means by which the body

breaks down the substance of the drug is less likely to cause an allergic

reaction. (Esters are reduced by esterases in the tissue and amides are reduced in

the liver and excreted in the kidneys.) The lipid solubility, potency, duration of

action, and ionization constant are all preferable in the amide group.
Anesthetic Action

(The Specific Receptor Theory)

The most popularly theory postulates that the local anesthetic interferes with the
sodium channel and blocks the sodium transfer necessary for nerve conduction.
This inhibits sodium flow through the membrane.
Pharmacology of Vasoconstrictors

The vasodilation activity of local anesthetics produces an increased rate of

absorption. This results in decreased effectiveness, short duration of anesthesia, and
a higher risk of toxicity. Bleeding in the area of injection is increased.

Vasoconstrictors are clinically useful in counteracting these effects. Vasoconstrictors

are added to local anesthetics to decrease the absorption of the drug and prolong
the anesthetic effect that produces anesthesia that is more profound. The
vasoconstrictor also serves to reduce the risk of toxicity because it is more slowly
absorbed by the circulatory system.
Epinephrine and levonordefrin are the most commonly used vasoconstrictors in
dentistry
Epinephrine is sensitive to heat and can be inactivated if left too warm for too
long.
 Possible adverse effects

Cardiovascular Reactions
Studies: small amounts of epinephrine can induce tachycardia after nerve block or
intraosseous injection.
This is primarily a pharmacologic effect. The cardiovascular effects are the result of alpha-
adrenoceptor stimulation by systemic distribution of the vasoconstrictor throughout the
vascular compartment.
Large doses or inadvertent IV injection may lead to lidocaine toxicity and CNS depression.
To reduce this risk, the clinician should always aspirate before making the injection.
When to use plain LA?
Patients with:
- History of myocardial infarction or stroke within past 6 months
- Unstable angina pectoris
- Severe hypertension
- Uncontrolled congestive heart failure
- Heart transplant
Systemic Effects

Acute toxicity from an overdose of a local anesthetic often is the result of inadvertent IV
administration or of a cumulative large dose (e.g., repeated injections).
Although systemic effects from a local anesthetic are rare, they can include an initial
excitatory phase (e.g., muscle twitching, tremors, grand mal convulsions) and a
subsequent depressive phase (e.g., sedation, hypotension, and respiratory arrest)
It should be noted that symptomatic management (possibly including cardiopulmonary
resuscitation [CPR], airway support, and supplemental oxygen) is the primary response
to this adverse event.
 An acute hypotensive crisis with respiratory failure also has been interpreted as
the result of hypersensitivity to local anesthetics

Finder and Moore proposed a “rule of 25” as a simple means of remembering maximal
local anesthetic dosages: with currently formulated local anesthetic cartridges, it
generally is safe to use one cartridge of local anesthetic for every 25 pounds (11.3 kg)
of patient weight (e.g., six cartridges for a patient weighing 150 pounds [67.5 kg])
 Methemoglobinemia
Metabolism of certain local anesthetics (e.g., prilocaine, benzocaine, articaine, and to a
lesser extent lidocaine) can produce a metabolite that causes methemoglobinemia; this
effect often occurs several hours after injection of the local anesthetic.
Typical signs and symptoms include cyanosis, dyspnea, emesis, and headache. In a study on
benzocaine-induced methemoglobinemia, 67% of reported adverse effects of benzocaine
were associated with methemoglobinemia; of these events, 93% occurred with spray
formulations of benzocaine, and only one case involved the gel formulation.

To reduce the risk of methemoglobinemia, clinicians should take care to refrain from giving
excessive dosages of local anesthetics.
Peripheral Nerve Paresthesia

Post injection paresthesia is a rare adverse effect of local anesthetics.

regular follow-up is important.
Allergic Reactions to Local Anesthetics and Latex

The amide local anesthetics appear to have little immunogenicity and therefore have an
extremely low rate of allergic reactions.
Some concern has been raised that the rubber latex stopper in dental anesthetic cartridges
might be a source of allergen to patients allergic to latex.
Local anesthetic formulations that contain vasoconstrictors also contain sulfite to prevent
oxidation of this agent.
Risk factors include an active history of asthma (perhaps 5% of asthmatics are at risk) and
atopic allergy.
No sulfite reaction in dental practice has ever been documented, possibly because the
amount of sulfite in local anesthetic cartridges is relatively small.
 Failure of anesthesia

1. Operator Inexperience
Always use a long 25 gauge needle (the red one)
2. Armamentarium: Deflection of the needle tip 2 reasons:
1. Less deflection
3. Patient factors: 2. Less false negative aspiration
1. Variations in anatomy
2. Accessory innervation
3. Unpredictable spread of LA
4. Local infection
5. Pulpal inflammation
6. Psychological issues Adjunctive Pharmacologic Therapy