ARMENTARIUM

SYRINGE
ADA Criteria for acceptance of L.A. syringes
1. durable and withstand repeated sterilization without damage. (If the unit is disposable, it
should be packaged in a sterile container.) DURABLE
2. accepting a wide variety of cartridges and needles of different manufacture, and should
permit repeated use. ACCEPTS ANY CARTRIDGE AND NEEDLE
3. INEXPENSIVE, SELF-CONTAINED, LIGHTWEIGHT, AND SIMPLE TO USE WITH ONE
HAND
4 PROVIDE FOR EFFECTIVE ASPIRATION and be constructed so that blood may be easily
observed in the cartridge

ASPIRATION TEST
• An aspiration test must be carried out purposefully by the administrator before or during drug
deposition.
• A positive aspiration happens, provided the needle is of adequate gauge, when negative
pressure is exerted on the thumb ring by the administrator and blood enters into the
needle and is visible in the cartridge if the needle tip rests within the lumen of a blood vessel.
• No blood visible in the cartridge in a negative aspiration.
• AN ASPIRATION TEST IS NOT OPTIONAL. IT IS REQUIRED

➢ Purpose:
• Local anesthetics are extremely safe drugs when used as recommended. However,
whenever any drug, including local anesthetics, is used, the potential for unwanted and
undesirable responses exists.
• For an overdose reaction to develop, a large enough amount of the drug must be
administered to result in excessive blood levels in the drugs target organ.

• Aspiration prior to depositing of local anesthesia at the target site ensures that the
local anesthetic is deposited in tissue adjacent to the nerve and NOT directly into the
blood stream.

SBA notes:
“Aspiration must always be carried out prior to depositing a large volume of local
anesthetic at any site”. Briefly explain this sentence and the principle behind
aspiration.
 To prevent accidental intravascular injection, aspiration must always be carried out
prior to depositing a large volume of local anesthetic at any site. When injecting into
a blood vessel, during intravenous sedation for instance, it is essential to aspirate
blood into the syringe prior to drug administration to ensure that the tip of the needle
is lying within a vein. The high incidence of intravascular injection during inferior
alveolar nerve block proves that aspiration is necessary because the failure of
anesthesia is accompanied by an increased likelihood of serious systemic
complications, which may even endanger the life of the patient.

What is meant by a negative aspiration?

A negative aspiration means there is no blood seen on withdrawal of the plunger.

This may occur because the needle tip is not in a vessel (true negative) but can also
occur if the needle tip is in a vessel, but due to the physics of flow or vessel collapse,
and blood will not pass back up into the syringe (false negative). It is okay to continue
with injection if negative aspiration occurs, however movement is not allowed after
that.

What is meant by a positive aspiration?

Getting a positive aspirate means an anesthesiologist will see blood in the needle
hub. This is why looking at the hub of the needle during aspiration is crucial. It occurs
when there is a blood flow in the syringe, indicating that a blood artery has been
pierced by the needle or cannula. The injection attempt should be discontinued and
the needle or cannula should be adjusted if there is positive aspiration.

PARTS

TYPES:
1. non-disposable syringes:
*BREECH-LOADING, PLASTIC, CARTRIDGE-TYPE, ASPIRATING
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 * BREECH-LOADING, METALLIC, CARTRIDGE-TYPE, ASPIRATING
Advantages:
• Visible cartridge
• Aspiration with one hand
• Autoclavable
• Rust resistant
• Long lasting with proper maintenance

Disadvantages:
• Weight (heavier than plastic syringe)
• Syringe may be too big for small operators
• Possibility of infection with improper care

* BREECH-LOADING, METALLIC, CARTRIDGE-TYPE, SELF-ASPIRATING

• These syringes use the elasticity of the rubber diaphragm in the anesthetic cartridge to
obtain the necessary negative pressure for aspiration.
• The diaphragm rests on a metal projection inside the syringe that directs the needle into
the cartridge

* PRESSURE SYRINGE FOR PERIODONTAL LIGAMENT INJECTION

Syringe: JET INJECTOR (NEEDLE-LESS SYRINGE)
Syrjet
• liquids forced through very small openings, called jets, at very high pressure can penetrate
intact skin or mucous membrane
• primary purpose of the jet injector is to obtain topical anesthesia before insertion of a needle
• Regional nerve blocks or supraperiosteal injections are still necessary for complete
anesthesia.

2) Disposable Syringes

LUER-LOK
1. used in medicine
2. used for IV sedation

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 • Advantages
1. Disposable, single use
2. Sterile until open
3. Lightweight

• Disadvantages
1. Does not accept pre-filled dental
cartridges
2. Aspiration difficulty

SAFETY SYRINGE

SYRINGE: COMPUTER-CONTROLLED LOCAL ANESTHETIC DELIVERY (C-CLAD)

SYSTEMS
• The dental syringe is a drug delivery device requiring that the operator simultaneously attempt
to control the variables of drug infusion and the movement of a penetrating needle. The
operator's inability to precisely control both of these activities during an injection can
compromise an injection technique.
• The operator is now able to focus attention on needle insertion and positioning, allowing
the motor in the device to administer the drug at a preprogrammed rate of flow. It is likely that
greater ergonomic control coupled with fixed flow rates is responsible for the improved
injection experience demonstrated in many clinical studies conducted with these devices in
dentistry.

POSSIBLE PROBLEMS AND TROUBLE SHOOTING

1. Leakage During Injection
2. Broken Cartridge
3. Bent Harpoon
4. Disengagement of the Harpoon from the Plunger During
Aspiration
5. Surface Deposits

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 NEEDLE
• is the vehicle that permits local anesthetic solution to travel from the dental cartridge into the
tissues surrounding the needle tip.
• Most commonly made of stainless steel

PARTS

1. BEVEL
 • defines the point or tip of the needle.
• described by manufacturers as long, medium, and short.
• Several authors have confirmed that the greater the angle of the bevel with the
long axis of the needle, the greater will be the degree of deflection as the needle
passes through hydrocolloid (or the soft tissues of the mouth)

NONDEFLECTING NEEDLE : tip in the center of the shaft, thereby minimizing deflection as
the needle penetrates soft tissues.

Conventional dental needle.: tip lies at the lower edge of the needle shaft, thereby producing
deflection as the needle passes through soft tissue.

Deflection
• Larger-gauge needles (e.g., 25-gauge, 27-gauge) have distinct advantages over smaller ones
(30-gauge) less deflection occurs as the needle passes through tissues.
• Radiograph demonstrating varying degrees of needle deflection with different gauges

Deflection of Needles inserted in hydrocolloid tubes to their hubs

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 2. SHAFT
• one long piece of tubular metal running from the tip of the needle through the hub,
and continuing to the piece that penetrates the cartridge.

Note: Two factors to be considered about this component of the needle are
- the diameter of its lumen (e.g., the needle gauge)
-the length of the shaft from point to hub. (long/ short)

3. HUB
• a plastic or metal piece through which the needle attaches to the
syringe.
The interior surface of metal-hubbed needles is prethreaded, as are most but not all plastic-
hubbed needles.
• THE WEAKEST POINT in the needle

4. CARTRIDHE – PENETRATING END

• the dental needle extends through the needle adaptor and perforates the diaphragm of the
local anesthetic cartridge. Its blunt end rests within the cartridge

25 - larger diameter
GAUGE 27 and 30 - smaller diameter (advantage)
• Diameter of the lumen
• Smaller the number the greater the diameter of the lumen SMALL GAUGE# = GREATER
DIAMETER
• Gauge 25 needle is recommended
• Most common used are gauge 27(long) and 30( short)
• 25 gauge is the needle of choice for injections that have a high potential for a positive
aspiration

27 and 30 (larger gauge)

Larger gauge needles advantages over smaller gauge needles: small diameter
1. less deflection of the needle tip results in greater accuracy
2. less chance of needle breakage (separation)
3. easier aspiration of blood through the larger lumens
4. undetectable pain differences between 25 and 30-gauge needles
5. it is safer, as breakage is less likely to occur.

In the United States, needles are color-coded by gauge:

LENGTH:
• From hub to tip
• average length of short needles: 20 mm
• average length of long needles: 32 mm
• needles should not be inserted to the hub unless absolutely necessary for the success of the
injection

REMEMBER:
1. Needles must never be used on more than one patient.
2. Needles should be changed after several (three or four is recommended) tissue penetrations
in the same patient.
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 a) After 3-4 insertions, stainless steel disposable needles become dulled. Tissue penetration
becomes increasingly traumatic with each insertion, producing pain on insertion and soreness
when sensation returns after the procedure.
3. Needles should be covered with a protective sheath when not being used to prevent
accidental needle-stick with a contaminated needle.
4. Attention should always be paid to the position of the uncovered needle tip, whether inside
or outside the patient's mouth.

SINGLE HANDED SCOOP TECHNIQUE

A. “Scoop” technique for recapping contaminated local anesthetic needle

B. Plastic needle cap holder.

5. Needles must be properly disposed of after use to prevent possible injury or reuse by
unauthorized individuals.
Ø Contaminated needles (as well as all other items contaminated with blood or saliva, such
as cartridges) should be disposed of in special “contaminated” or “sharps” containers, never
in open trash containers
 NOTE: WITHDRAW BEFORE REDIRECT

• No attempt should be made to change the direction of a needle when it is embedded in tissue.
• If the direction of a needle must be changed, the needle should first be withdrawn almost
completely from the tissue and then its direction altered.
• No attempts should be made to force a needle against resistance (needles are not designed
to penetrate bone).
• Smaller (30- and 27-gauge) needles are more likely to break than larger (25-gauge) needles.
• Needles should remain capped until used and should be made safe immediately when
withdrawn.
• Needles should be discarded and destroyed after use to prevent injury or reuse by
unauthorized persons

POSSIBLE PROBLEMS AND TROUBLE SHOOTING

• Pain on Insertion
• Breakage
• Pain on Withdrawal
• Injury to the Patient or Administrator

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 CARTRIDGE
• glass cylinder containing the local anesthetic drug, among other ingredients
• Most commonly contain 1.8ml of Solution

PARTS
The prefilled 1.8-mL dental cartridge consists of four parts:

1. CYLINDER
• Can be made of glass of plastic
• Hold the anesthetic solution
• Volume: 2 mL of solution
• Today, most dental cartridges are made of glass and contain
• approximately 1.8 mL of local
• anesthetic solution.

2. STOPPER/PLUNGER/ BUNG
• located at one of the ends of the cartridge that receives the harpoon of the aspirating syringe.
• Occupies approx. 0.2ml of cartridge volume.
• Treated with silicone

remember:
An intact dental cartridge the stopper is slightly indented from the lip of the glass cylinder.

Cartridges whose plungers are flush with or extruded beyond the glass of the cylinder should
not be used.

3. ALUMINUM CAP WITH DIAPHRAGM

Aluminum cap
• located at the opposite end of the cartridge from the rubber plunger.

• It fits around the neck of the glass cartridge, holding the thin diaphragm in position.

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• It is silver colored on most cartridges.

Diaphragm
• Semipermeable membrane through which the needle penetrates into the cartridge.
• When properly prepared, the perforation of the needle is centrically located and round,
forming a tight seal around the needle.
Remember:
1. Improper preparation of the needle and cartridge can produce an eccentric puncture with
ovoid holes leading to leakage of the anesthetic solution during injection.
2. The diaphragm is a semipermeable membrane that allows any solution in which the dental
cartridge is immersed to diffuse into the cartridge, thereby contaminating the local anesthetic
solution

Possible Problems and Trouble shooting

1. Bubble in the cartridge
2. Extruded stopper
3. Burning on injection
4. Sticky stopper
5. Corroded cap
6. “Rust” on the cap
7. Leakage during injection
8. Broken cartridge
Component Component
Function Function
L.A. Agent Blockade of nerve
conduction
Sodium Isotonocity of
chloride (NaCI) solution
Sterile water Volume
Vasoconstrictor vasoconstriction
(Increase depth
and duration,
Sodium Antioxidant/
bisulfite preservative
Methylparaben Bacteriostatic

COMPONENTS OF LA SOLUTION

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 COMPONENTS OF LA SOLUTION: LOCAL ANESTHESIA
• The local anesthetic drug is the raison d’être for the entire dental cartridge.
• It reversibly blocks sodium channels and interrupts the propagation of nerve impulse,
preventing it from reaching the brain.
• It is stable and capable of being autoclaved, heated, or boiled without breaking down.
• Vasodilators
• Fat- soluble drugs
• Exists as water-soluble hydrochloride salts (hydrophilic) in the cartridge
• Must be NON-IONIZED FREE-BASE FORM in the body (lipophilic)

• Once the local anesthesia is injected, the buffering capacity and the pH of the body tissue
(usu. pH 7.4) shifts the equilibrium in favor of free- base formation.

• At physiological pH of 7.4 approx. 5-20% of the local anesthetic is in free-base form which is
enough to penetrate and cause anesthesia
ONCE LA IS INJECTED, PH OF BODY TISSUE IS IN NON-IONIZED FREE BASE (7.4); 5-20 % LA IS IN
FREE BASE ENOUGH TO CAUSE ANESTHESIA
CONTRAINDICATIONS OF LOCAL
 CASES OF INFECTION/ ABSCESS
• If there is an infection or abscess present, the pH of tissues may be acidic and there is a
significant reduction in the concentration of the free-base form.
• In this situation, the local anesthesia may not be effective.
• Note: Injection of lidocaine (pKa = 7.8) into tissue that has pH of 7.8, the lidocaine will exist in
an equal mixture of ionized and non-ionized forms which will be more than enough to produce
anesthesia

order of sensations lost due to local anesthesia: PaTe ToPS

1. Pain ß first to go!
2. Temperature
3. Touch
4. Pressure (proprioception)
5. Skeletal Muscle Tone

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CALCULATIONS OF MILLIGRAMS PER CARTRIDGE

COMPUTATION FOR SOLUTION:

Given:
Volume of Cartrodge : 1.8 ml
2% anes
Solution: 2% = 0.2; 1.8 mL

Another Example:

Given: 0.5% anes

Solution:
0.5% = 5
1.8ml = 1.8
5 x 1.8 = 9
Answer = 9 mg Marcaine
MAXIMUM RECOMMENDED DOSAGES (MRDS) OF LOCAL ANESTHETICS
AVAILABLE IN NORTH AMERICA

Computation:

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 Shortcut for Max Dose Anes/ kg
LPAB
• Lido and mepi 4.40
• Prilo at 6
• Arti at 7
• Bupi at 1.30

•Ligo and Make-up at 4:40am

•Pasok at 6
•Arrive at 7
•Break at 1:30pm

Memorize:
• Color-Coding of Local Anesthetic Cartridges
• From the American Dental Association Council on Scientific Affairs

COMPONENTS OF LA SOLUTION: VASOPRESSOR:

• A vasopressor drug is included in most anesthetic cartridges to enhance safety
and the duration and depth of action of the local anesthetic.
• The pH of dental cartridges containing vasopressors is lower (more acidic) than
that of cartridges not containing vasopressors (pH of 3.5 [3.3 to 4.0] vs. pH 6.5
without epi).
• Because of this pH difference, plain local anesthetics have a somewhat more
rapid onset of clinical action and are more comfortable (less “burning” on
injection).

Catecholamines:

COMPONENTS OF LA SOLUTION: EPINEPHRINE

• A vasoconstrictor
• Included dental local anesthesia preparations for 3 reasons:
1. It PROLONGS THE DURATION of the local anesthesia (main reason)
2. Provides hemostasis such that local bleeding is controlled or reduced
3. To delay the absorption of anesthetic into the systemic circulation thus
reducing the chance of systemic toxicities.
NOTE: Epinephrine has no effect on the pH or the amount of free base
form of the
local anesthetic

DILUTION OF VASOPRESSOR
• The dilution of vasoconstrictors is commonly referred to as a ratio (e.g., 1 to
1000 [written 1:1000]). Because maximum doses of vasoconstrictors are
presented in milligrams, or more commonly today as micrograms (μg)

• A concentration of 1:1000 means that 1 g (1000 mg) of solute (drug) is contained

in 1000 mL of solution.

• Therefore, a 1:1000 dilution contains 1000 mg in 1000 mL or 1.0 mg/mL of

solution (1000 μg/mL).

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• To produce a more dilute, clinically safer, yet effective concentrations, the
1:1000 dilution must be diluted further. This process is described here:

To produce a 1:10,000 concentration, 1 mL of a 1:1000 solution is added to 9

mL of solvent (e.g., sterile water); therefore 1:10,000 = 0.1 mg/mL (100 μg/mL).

To produce a 1:100,000 concentration, 1 mL of a 1:10,000 concentration is

added to 9 mL of solvent; therefore 1:100,000 = 0.01 mg/mL (10 μg/mL).

Warning
• Intravascular administration of vasoconstrictors and their administration to
sensitive individuals (hyperresponders), or the occurrence of unanticipated
drug–drug interactions, can however produce significant clinical manifestations.

• Intravenous administration of 0.015 mg of epinephrine with lidocaine results in

an
increase in the heart rate ranging from 25 to 70 beats per minute, with elevations
in systolic blood from 20 to 70 mm Hg.

NOTE: Phenoxybenzamine is the drug for “epinephrine-reversal”

Epinephrine is deactivated in the body by catechol-o-methyltransferase

Computation for solution

Exercise 2: Compute for the milligrams of Vasoconstrictor per Cartridge

 Given:
1:200,000
1.8 ml cartridge
Solution:
1: 50,000 = 0.02
1: 100,000 = 0.01
1: 200,000 = 0.005
0.005 x 1.8ml = 0.009

Answer = 0.009 mg epi/ car

Recommended Maximum Doseges of Epinephrine

COMPONENTS OF LA SOLUTION: ANTIOXIDANT

• Most often sodium (meta Sodium bisulfite)

• Prevents oxidation of the vasopressor by oxygen, which can be trapped in the

cartridge during manufacture or can diffuse through the semipermeable
diaphragm (or the walls of a plastic cartridge) after filling.

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• Sodium bisulfite reacts with oxygen before the oxygen is able to destroy the
vasopressor

• When oxidized, sodium bisulfite becomes sodium bisulfate, having an even

lower pH.

- The clinical relevance of this lies in the fact that increased burning (discomfort)
is experienced by the patient on injection of an “older” cartridge of anesthetic
with vasopressor compared with a fresher cartridge.

REMEMBER: Allergy to bisulfites must be considered in the medical

evaluation of
all patients before local anesthetic is administered

COMPONENTS OF LA SOLUTION: SODIUM CHLORIDE

➢ Added to the cartridge to make the solution isotonic with the tissues of the body.

COMPONENTS OF LA SOLUTION: DISTILLED WATER

➢ used as a diluent to provide the volume of solution in the cartridge.
DIS - DILUTED

COMPONENTS OF LA SOLUTION: BACTERIOSTATIC AGENT

• A significant change in cartridge composition in the United States (after 1984)
and in many other countries was the removal of methylparaben, a bacteriostatic
agent.

• Reasons for removal:

➢ Dental local anesthetic cartridges are single-use items meant to be discarded

and not reused. Therefore, inclusion of a bacteriostatic agent is unwarranted.

➢ Second, repeated exposure to parabens has led to reports of increased allergic

reactions in some persons.

SKIN TESTING
PURPOSE: to determine allergenicity to local anesthetic used
 PROCEDURE
1. Disinfect skin
2. Aim with bevel up and angulate (5-15°)
3. Insert needle underneath the skin (about the past the length of the bevel)
4. Deposit anesthesia until a bleb is seen
5. Draw outline with ballpen
6. Time results for 1 hr
7. Check results

SKIN DISINFECTION TECHNIQUE

1) Start at the planned injection site and rub disinfectant from inner to outer in an
overlapping clock-wise (or counter clock-wise) motion.

2) TAUT SKIN FOR EASIER PENETRATION

3) AIM, ANGULATE (5-15 DEGREE) AND INSERT BEVEL SIDE UP

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4) BLEB

5) DRAW OUTLINE WITH BALLPEN