GOOD AFTERNOON

LOCAL
ANESTHESIA
DR. JAGRUTI NANDA
PG 1ST YEAR
 CONTENTS
INTRODUCTION
HISTORY
DEFINATION
PROPERTIES OF LOCAL ANESTHESIA
CLASSIFICATION
MECHANISM OF ACTION
COMPOSITION OF LOCAL ANESTHESIA
ARMAMENTERIUM
METHODS OF ADMINISTRATION
TYPES OF NERVE ANESTHESIA
COMPLICATIONS
MANAGEMENT OF SPECIAL PATIENTS
CONCLUSION
 INTRODUCTION
• ANESTHESIA- is the state of controlled, temporary loss of
sensation or awareness that is induced for medical purposes

• GENERAL ANESTHESIA- a temporary loss of sensation or pain

over the whole body with a reversible state of unconsciousness.

• LOCAL ANESTHESIA- a temporary loss of sensation or pain in

one or more part of the body without depressing the level of
consciousness
 HISTORY OF LOCAL ANESTHESIA
1860- Cocaine
- isolated by Nieman
- anesthetic action was demonstrated by Karl Koller-1884

1905- Procaine
- first ester-type of local anesthesia

1943- Lignocaine
- first modern local anesthetic agent KARL KOLLER

- In 1948 lignocaine was used worldwide for dental procedures

 LOCAL ANESTHESIA
Local Anesthesia is defined as a loss of sensation in a
circumscribed area of the body caused by depression of excitation
in nerve endings or inhibition of the conduction process in
peripheral nerves
-Stanley F. Malamed (1980 )
 PROPERTIES

I • It should not be irritating to the tissue to which it is applied

• It should not cause any permanent alteration of nerve structure
N
• Its systemic toxicity should be low.
S • Time of onset of anesthesia should be short.
T • It should be effective regardless of whether it is injected into the
E tissue or applied locally to the mucous membrane.
D • Duration of action should be long enough
CLASSIFICATION
PHARMACOLOGICAL

ESTERS (OF BENZOIC ACID) AMIDES

• COCAINE
• BENZOCAINE • ARTICAINE • LIGNOCAINE
• TETRACAINE • MEPIVACAINE
• BUPIVACAINE
• CHLOROPROCAINE • ETIDOCAINE• PRIOLOCAINE
• PROCAINE
 BASED ON BIOLOGICAL SITE & MODE OF ACTION

Class A---- TETRADOTOXIN, SAXITOXIN

CLASS B---- QUATERNARY AMMONIUM ANALOUGES OF

LIGNOCAINE

CLASS C---- BENZOCAINE

CLASS D---- LIGNOCAINE, MEPIVACAINE, PRILOCAINE

 MODE OF APPLICATION
TOPICAL
SOLUBLE: COCAINE, LIGNOCAINE,
TETRACAINE
INJECTAB
INSOLUBLE: BENZOCAINE
LE
LIGNOCAINE, MEPIVACINE,
BUPIVACAINE
 BASED ON THE DURATION OF ACTION
Ultra short acting:
• Chloroprocaine
• Procaine
Short acting:
• Lignocaine
• Prilocaine
Medium acting:
• Mepivacaine
• Articaine
Long acting:
• Bupivacaine
• Etidocaine
 MECHANISM OF ACTION
Binding of
Displacement
local
of calcium ion Blocking of Decrease in
anesthetic
from sodium sodium sodium
molecule to
channel channel conductance
this receptor
receptor site
site

Failure to
Lack of Depression
Conduction achieve the
developmen of rate of
blockade threshold
t of action electrical
potential
potential polarization
level
++++++++++++++++++++++

-------------------------------------
-
COMPOSITION OF LA

Local anesthetic drug

Vasoconstrictor
Reducing agent
Preservatives
Fungicide
Ringer’s solution
 LOCAL ANESTHETIC DRUG

• 2 % lignocaine/lidocaine/xylocaine

2gms in 100 ml of solution

2000mg in 100ml or 20mg in 1ml of solution
MAXIMUM RECOMMENDED DOSE:

Local anesthetic agents with a vasoconstrictor:

The recommended dose of lignocaine with a vasoconstrictor –

7.0mg/kg body weight (But not to exceed 500mg)

Local anesthetic agents without a vasoconstrictor:

Recommended dose of lignocaine without a vasoconstrictor –

4.4mg/kg body weight (But not to exceed 300mg)
VASOCONSTRICTOR

• Prolong duration  Epinephrine

 Norepinephrine
• Reduces systemic toxicity
 Felypressin
• Decreases bleeding  Levonordefrin
• Dry field in surgical site
• pH of L.A *without vasoconstrictor - 5.5 to 6.0
*with vasoconstrictor - 3.3 - 4.0 (more acidic)
Maximum Recommended doses of Epinephrine
• Healthy adult:- 0.2mg/ per appointment

• Cardiac patient:- 0.04mg/ per appointment

Maximum Recommended doses of Norepinephrine

• Healthy adult:- 0.34mg/ per appointment

• Cardiac patient:- 0.14mg/ per appointment

ANTIOXIDANT/REDUCING AGENT

SODIUM BISULFITE OR SODIUM

METABISULFITE

• Prevents biodegradation of vasoconstrictor

• Sodium bisulfite is oxidized to sodium bisulfate
 PRESERVATIVES

• Methylparaben
• Chlorbutol or Capryl hydrocuprienotoxin (in multidose vials)

OTHERS
 Fungicide – Thymol
 Salts - Nacl Or Ringers’s
Solution
 Vehicle – Distilled Water
 LOCAL ANESTHESIA ARMAMENTARIUM

• Non disposable syringes

• SYRINGE • Disposable syringes
• Safety syringes
• NEEDLE • Computer-controlled local
• CATRIDGE anesthetic delivery system

• OTHERS- TOPICAL ANAESTHETIC

(OINTMENTS, GELS, PASTES, SPRAYS)
METHODS OF ADMINSTRATION
Topical(surface) anesthesia
Local infiltration
Field block
Nerve block
Supplemental Injection
Techniques
Intra ligamentary
Intra septal
Intra pulpal
Intra osseous
TOPICAL ANESTHESIA

• Usually the concentration is greater as compared

to the injectable ones
• Onset of action - 1 minute
• Maximum Recommended Dose for Topical
Anesthesia is 200mg
• Commonly used drugs are:-
Cocaine 4%
Lignocaine 2%, 4%, 5 % ,
10%, 15%
SPRAY OINTMENT GEL

10-15%
5% lignocaine 20% benzocaine
lignocaine
LOCAL
INFILTRATION
• 0.6 – 1.0 ml of solution deposited at the
small terminal nerve endings
• Deposition is done at the apex or above the
apex of the tooth

FIELD BLOCK
• Deposited in proximity to the larger nerve
branches
• Injection deposited sub cutaneously
• Anesthetize the region distal to the site of
injection
NERVE BLOCK
• 1.8 – 2.0 ml of solution is deposited within close proximity to
the main nerve trunk
• Block depends on proximity, concentration, and volume of local
anesthesia
INTRALIGAMENTARY
• 0.2 ml of solution deposited within PDL through the
gingival sulcus.

INTRASEPTAL
• 0.1 ml of solution deposited into the cancellous
bone that supports the teeth
INTRAPULPAL-
• Deposition of solution directly into the pulp
chamber of a pulpally involved tooth

INTRAOSSEOUS-
• Deposition of solution into interproximal bone
between two teeth
 POSTERIOR SUPERIOR
ALVEOLAR NERVE
BLOCK(ZYGOMATIC BLOCK)
NERVES ANESTHETIZED:-
Posterior superior alveolar nerve
AREAS ANESTHETIZED:-
Maxillary molars(except the mesiobuccal root of
first molar)
Buccal alveolar process of maxillary molar
including the periosteum and the connective
tissue
ANATOMICAL LANDMARKS:-
Muco buccal fold and its concavity
Zygomatic process of maxilla
Infratemporal surface of maxilla
Anterior border & Coronoid process
of ramus of the mandible
Tuberosity of maxilla
 INFRAORBITAL NERVE BLOCK/ANTERIOR
& MIDDLE SUPERIOR ALVEOLAR NERVE
BLOCK
NERVES ANESTHETIZED:-
Anterior superior alveolar nerve
Middle superior alveolar nerve
AREA ANESTHETIZED:-
Infra orbital nerve
 Insciors, cuspids, bicuspids and
mesiobuccal root of first molar including its
bony support and soft tissues

 Skin of lower eyelid, lateral aspect of the

nose, skin, and mucosa of upper lip
ANATOMICAL
LANDMARKS:-

Supraorbital notch
Infraorbital notch
Infraorbital foramen
Pupil of the eye
Anterior teeth
 Central Incisor
Bicuspid approach approach
 GREATER PALATINE NERVE
BLOCK/
ANTERIOR PALATINE NERVE
BLOCK
NERVES ANESTHETIZED:-
 Greater palatine nerve
AREAS ANESTHETIZED:-
Posterior portion of the hard palate
Soft tissue upto the first bicuspid area on
the side of the injection
ANATOMICAL LANDMARKS:-
Maxillary second molar and third molar
Palatal gingival margin of second and
third maxillary molars
Midline of hard palate
A line approximating 1cm from the
palatal gingival margin towards the
midline of the palate
 NASOPALATINE NERVE BLOCK/
INSICIVE NERVE BLOCK

NERVES ANESTHETIZED:-
Nasopalatine nerve bilaterally
AREAS ANESTHETIZED:-
Anterior portion of the hard palate
Soft tissues and overlying structures
from incisors to bicuspids
ANTOMICAL LANDMARKS:-
Maxillary central incisors
Incisive papilla in the midline of the palate
 INFERIOR ALVEOLAR NERVE
BLOCK/PTERYGOMANDIBULAR
BLOCK
NERVES ANESTHETIZED:-
Inferior alveolar nerve along with
its terminal branches (mental & incisive )
AREAS ANESTEHSIZED:-
Body of the mandible & inferior portion
of ramus of the mandible
Mandibular teeth
Mucous membrane & underlying tissues anterior to first molar
ANATOMICAL LANDMARKS:-
Muco buccal fold
Anterior border of ramus of mandible
External oblique ridge
Retromolar triangle
Internal oblique ridge
Pterygomandibular ligament
Buccal pad of fat
Pterygomandibular space
 LINGUAL NERVE
BLOCK
The needle is withdrawn about half of its length which was inserted and the
solution is deposited
NERVES ANESTEHTIZED:-
 Lingual nerve

AREAS ANESTHETIZED:-
 Anterior 2/3rd of the tongue, the floor of
the oral cavity and mucoperiosteum on
lingual side of mandible
 LONG BUCCAL NERVE BLOCK

Needle inserted into the muco buccal fold just distal to the most posterior tooth
of that area
NERVES ANESTHETIZED:-
Buccinator nerve branch of anterior div of V3
AREAS ANESTHETIZED:-
Buccal mucous membrane
Mucoperiosteum of mandibular molars
 MENTAL NERVE BLOCK

NERVES ANESTHETIZED:-
Mental nerve
Incisive nerve
AREAS ANESTHETIZED:-
 Lower lip
Mucous membrane in the muco buccal
fold anterior to the mental foramen
 GOW GATES TECHNIQUE

The entire mandibular branch of the trigeminal nerve is anesthetized

NERVES ANESTHETIZED:-
Inferior alveolar nerve along with its terminal branches
Lingual
Mylohyoid
Auriculotemporal
Long buccal
ANATOMICAL LANDMARKS:-
External ear
Inter tragic notch of the ear
Corner of the mouth
Anterior border of the ramus of the mandible
Mesio palatal cusp of the maxillary second molar
 VAZIRANI AKINOSI TECHNIQUE

NERVES ANESTHETIZED:-
Inferior alveolar nerve and its
subdivisions (mental&incisive)
Lingual nerve
Buccinator nerve
AREAS ANESTHETIZED:-
 All mandibular hard and soft tissue to the midline
 Floor of the mouth
 Anterior 2/3rd of the tongue

ANATOMICAL LANDMARKS:-
Occlusal plane of occluding teeth
Mucogingival junction of the maxillary
molar teeth
Anterior border of the ramus
 COMPLICATIONS
LOCAL
• Needle breakage • Hematoma
• Pain • Sloughing of tissues
• Paraesthesia • Facial nerve paralysis
• Trismus

SYSTEMIC
• Toxicity
• Allergic reaction
• Syncope
• Methemoglobinemia
 NEEDLE
BREAKAGE
Rare complication in dental LA injection
CAUSES-
• Sudden unexpected movement of patient
• Small needle size
• Bent needles
• Forceful contact with bone
PREVENTION:-
• Use of long needles
• Do not bend needles when inserting them into soft
tissues
• Donot insert needle till its hub
MANAGEMENT:-
• Remove needle if its visible with help of a small
hemostat or magill forceps
• If not visible locate through panoramic
radiographs
• Refer to an oral surgeon
 PARESTHESIA
It is defined as persistent anesthesia or altered
sensation well beyond the expected duration.
Patient reports feeling NUMB(frozen) for hours or
days
CAUSES:-
• Trauma to any nerve
• Solution deposited near a nerve that
produces irritation and edema to the tissue
• Hemorrhage around the neural sheath
MANAGEMENT:-
• Paresthesia resolves within 8 weeks without treatment.
• Only when damage to the nerve is severe paresthesia will be
permanent
• “Tincture of time” is the recommended treatment
• Dental treatment may continue but avoid administering local
anesthesia into the same region
 SOFT TISSUE INJURY

Self-inflicted trauma to the lips and tongue is

frequently caused by the patient inadvertently
biting or chewing these tissues when anesthetized

CAUSES:-
Most frequently in younger children, mentally
and physically disabled children or adults
PREVENTION:-
• Cotton roll can be placed between lips and teeth
if still anesthetized

MANAGEMENT:-

• Analgesics for pain

• Antibiotics
• Lukewarm saline rinses to aid in decrease swelling
 SLOUGHING OF
TISSUES
Prolonged irritation or ischemia of gingival soft
tissue leading to number of unpleasant
complications, including epithelial desquamation
and sterile abscess

CAUSES:-
• Application of topical anesthesia for a prolonged
period
• Heightened sensitivity to topical or injectable LA
• Use of LA with vasoconstrictor mostly on the hard
palate
PREVENTION:-
• Apply topical anesthesia for 1-2mins to
minimize toxicity
• Avoid the use of over-concentrated LA
solutions

MANAGEMENT:-
• Epithelial desquamation resolved within 7-10
days
 TRISMUS
Defined as prolonged tetanic spasm of the jaw muscles
by which the normal opening of the mouth is restricted

CAUSES:-
• Trauma to muscles – medial pterygoid in
Inferior Alveolar Nerve block
• Contaminated anesthetic solution
• Infection
• Excessive anesthetic volume
PREVENTION:-
• Atraumatic insertion
• Avoid repeated insertion
• Minimal injection and volume
MANAGEMENT:-
• Heat therapy, warm saline rinses, analgesics
• Muscle relaxants if necessary
• Physiotherapy
• Antibiotics should be added to avoid infection
 FACIAL NERVE
PARALYSIS
• Usually occurs in inferior alveolar nerve block
• Loss of motor action of the muscle of facial
expression
• Unilateral paralysis of facial muscles
• Lasts for several hours
• Mostly the patient is unable to
voluntarily close one eye
CAUSES:- MANAGEMENT:-

Induction of LA solution into the An eye patch should be applied to

capsule of the parotid gland (Needle affected eye or manually close the
positioned inadvertently in a lower eyelid periodically to keep
posterior direction) the cornea lubricated
 HEMATOMA

• The effusion of blood into the extravascular

space can be caused by inadvertent nicking of
blood vessels during administration of local
anesthesia.
• Subsequent nicking of an artery and not vein.
• PSA nerve block is the most common followed
by IANB and the mental nerve block
MANAGEMENT:-
• If hematoma is visible, apply direct pressure
immediately
• Once bleeding is stopped, discharge the patient
with instructions followed-
Apply ice intermittently to the site for 6 hrs
Donot apply heat for at least 6 hrs
Use analgesics as required
 TOXICITY
• Due to LOW-MODERATE
systemic absorption of an excessive amount of drug
MODERATE-HIGH

• High blood levels of the drug may be secondary to repeated injections

CONFUSION,RESTLESSNESS,ANXIETY GENERALIZED TONIC CLONIC SEIZURES
or could be a result of a single intravascular administration
FOLLOWED BY

DROWSINESS, DIZZINESS, SLURRED GENERALIZED CNS DEPRESSION

SPEECH
MUSCLE TWITCHING, TREMOR OF FACE DECREASED BP, HR, RR
AND EXTREMITIES

ELEVATED BP, HR, RR

MANAGEMENT:-

• Airway support
• Administration of 100% oxygen
• Supine positioning of the patient
• Protection from injury in the event of seizure activity
• Treating convulsions with benzodiazepines
ALLERGY
• Hypersensitive reactions, initiated by immunological mechanisms
acquired through exposure to a specific allergen; re-exposure to
which produces a heightened capacity to react
• Ester type- more allergic
TESTING OF LA
MANAGEMENT:-

• For mild symptoms, oral or intramuscular

antihistamine diphenhydramine should be
given
• Additionally, hydrocortisone cream may
be prescribed to relieve skin itching or
erythema
• In life-threatening cases basic life
support, intramuscular or subcutaneous
epinephrine should be given.
 SYNCOPE
• It is defined as sudden and transient loss of consciousness due to
inadequate cerebral blood flow
• Most common manifestation of the fear of the injection
• Clinical manifestation- pre syncope, syncope and post syncope

Decrease
circulator
Stress/ Release of y volume/ Decrease
Pooling of
catecholam Syncope in blood
Fear blood Decrease
ines pressure
in cerebral
flow
PRE SYNCOPE SYNCOPE POST SYNCOPE
MANAGEMENT:-
• Procedure should be stopped
• Patient should be placed in a supine position
which legs slightly elevated
• Administer oxygen
• Cold towel compress to forehead “TRENDELENDBU
• Re evaluate vital signs RG POSITION”
METHEMOGLOBINEMI
A
• Methemoglobinemia is a unique dose-dependent reaction where the iron in
hemoglobin is stabilized in the ferric (fe3+) form is unable to attach
oxygen, leading to tissue hypoxia and cyanosis
• Commonly caused by prilocaine and benzocaine
• Treatment- Methylene blue(1 to 2 mg/kg iv for 5 mins)
 LA MANGEMENT FOR SPECIAL PATIETS

UNCOOPERATIVE CHILD:
• The maximum safe dose of lignocaine for a child is 4.5 mg/kg per
dental appointment.
• Local infiltration of anesthesia is sufficient for all dental treatment
procedures even in the mandible
HANDICAPPED PATIENT:
• Choose a shorter needle and/or a larger gauge needle that is
less likely to be bent or broken.
• Better to use general anesthesia
PREGNANCY:
• Lidocaine + Vasoconstrictor: most common local anesthetic
used in dentistry extensively used in pregnancy
• Accidental intravascular injections of lidocaine pass through
the placenta but the concentrations are too low to harm the fetus
PATIENTS RECEIVING ANTICOAGULATION OR
SUFFERING FROM BLEEDING DISORDERS:
Local anesthetic containing a vasoconstrictor should be administered by
infiltration or by intra-ligamentary injection close to the site of surgery

PATEINTS WITH LIVER DISORDERS:

Avoid local anesthesia metabolized in the liver(amide-type)
Ester type of anesthetics should be used
RECENT ADVANCES
 JET INJECTOR
DENTIPATCH DENTAL VIBE
(Needleless)

EMLA
 EUTECTIC
LIGNOCAINE/PRILOCAINE
• Eutectic mixture of lignocaine 2.5% and prilocaine 2.5%
• Oil is emulsified to form cream in a ratio of 1:1 by weight
• Each gram of EMLA cream contains 25mg of lignocaine and
prilocaine each with no preservatives
 CONCLUSION
• Local anesthesia remains the foundation of pain control in dentistry,
especially when combined with moderate – deep sedation for invasive
and painful procedures in surgeries.
• It remains the safest and most effective drug in dentistry to relieve intra
and post-operative pain

IF YOU CAN PROVIDE A NEARLY PAINLESS

SURGICAL PROCEDURE WITHOUT THE USE OF
GENERAL ANESTHESIA THEN YOU HAVE WON HALF
OF THE BATTLE
 REFERENCES
• TEXTBOOK OF ORAL AND MAXILLOFACIAL SURGERY - NEELIMA
ANIL MALIK 4TH EDITION
• MEDICAL EMERGENCIES IN DENTAL CLINIC-STANLEY F. MALAMED
6TH EDITION
• MONHEIM’S LOCAL ANESTHESIA AND PAIN CONTROL IN DENTAL
PRACTICE
• INTECH OPEN ACCESS JOURNALS- COMPLICATIONS ASSOCIATED
WITH LOCAL ANESTHESIA IN ORAL AND MAXILLOFACIAL SURGERY
• HTTPS://WWW.SLIDESHARE.NET/DRPRADNYAWAGH/LOCALANAEST
HESIA