Local Anaesthetic Course

Local Anaesthesia
Course
Frances Zhao
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Frances Zhao
Contents
Part 1: Introduction & Neurophysiology............................................................................................................................ 12
Methods of inducing LA....................................................................................................................................................... 12
First LA ................................................................................................................................................................................. 12
Neurons ............................................................................................................................................................................... 13
Nerve structure .................................................................................................................................................................. 14
Neurophysiology ............................................................................................................................................................... 14
Ionic concentrations ......................................................................................................................................................... 15
Electrophysiology of nerve conduction.............................................................................................................................. 15
Electrophysiology of Nerve Conduction ........................................................................................................................ 15
How does a nerve conduct an impulse? ............................................................................................................................ 16
Modes and action of local anaesthetic .............................................................................................................................. 16
Classification of LA substances according to biologica site and mode of action..................................................... 17
Sequence of mechanism of action of LA ........................................................................................................................... 17
Local anaesthetic molecules ................................................................................................................................................ 17
pKa and pH ............................................................................................................................................................................ 18
Dissociation of LA.................................................................................................................................................................. 18
Actions on nerve membranes.............................................................................................................................................. 18
Membrane action of LA.................................................................................................................................................... 18
Barriers of Diffusion of the Solution ............................................................................................................................... 19
pKa and LA ......................................................................................................................................................................... 19
Why do LA not work well in infected tissues? ............................................................................................................... 19
Induction of Local Anaesthesia ....................................................................................................................................... 20
Blocking process............................................................................................................................................................ 20
Induction time ............................................................................................................................................................... 20
Factors affecting local anaesthetic action ...................................................................................................................... 21
Recovery from LA Block ................................................................................................................................................... 21
Duration of Anaesthesia ................................................................................................................................................... 21
Part 2 : Pharmacology........................................................................................................................................................... 22
Ester-Type ................................................................................................................................................................... 22
Amide-Type................................................................................................................................................................. 22
Pharmacokinetics of Local Anaesthetics ........................................................................................................................ 22
Pharmacokinetics of local anaesthetics .............................................................................................................................. 22
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Pharmacokinetics of local anaesthetics ..................................................................................Error! Bookmark not defined.

Metabolism (Biotransformation) .................................................................................................................................. 23
Metabolism of ESTERS ................................................................................................................................................... 23
Metabolism of AMIDES ................................................................................................................................................. 23
Excretion .......................................................................................................................................................................... 23
Systemic Effects of LA ........................................................................................................................................................... 24
Central Nervous System ............................................................................................................................................ 24
Systemic Effects of LA ...............................................................................................................Error! Bookmark not defined.
Other Systemic Effects of LA....................................................................................................Error! Bookmark not defined.
Vasoconstrictors .................................................................................................................................................................... 25
Chemical structure ................................................................................................................................................................ 26
Mode of action ...................................................................................................................................................................... 26
Vasoconstrictors commonly used ................................................................................................................................... 27
Overdose ................................................................................................................................................................................ 27
Medical Status of Patient ..................................................................................................................................................... 27
Adrenaline maximum doses .............................................................................................................................................. 28
LA commonly used in Australia ........................................................................................................................................... 28
Lignocaine 2% with Adrenaline 1:80,000 ....................................................................................................................... 28
Prilocaine 3% with Felypressin (Octapressin) ................................................................................................................ 29
Articaine 4% with Adrenaline 1:100,000......................................................................................................................... 29
Mepivacaine 3% ................................................................................................................................................................ 30
Bupivacaine 0.5% with Adrenaline 1:200,000 ................................................................................................................ 30
Variability in LA duration ...................................................................................................................................................... 31
variability in LA duration ......................................................................................................Error! Bookmark not defined.
Calculation of maximum dose ......................................................................................................................................... 31
Adrenaline - Maximum doses.......................................................................................................................................... 32
Contraindications of Local Anaesthetics ........................................................................................................................ 32
Anaesthetics for Topical Application .............................................................................................................................. 32
What factors should be considered when selecting a local anaesthetic?.................................................................. 32
Part 3 : Armamentarium ....................................................................................................................................................... 33
Types of Syringes .............................................................................................................................................................. 33
Non-disposable Aspirating Syringes .............................................................................................................................. 33
Non-disposable Self-aspirating Syringes ....................................................................................................................... 34
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Non-disposable Pressure Syringes ................................................................................................................................. 34

Non-disposable Jet Injector .......................................................................................................................................... 35
Disposable Syringes .......................................................................................................................................................... 35
Safety Syringes ............................................................................................................................................................... 35
Computer-controlled LA Delivery ................................................................................................................................... 36
Problems with Syringes .................................................................................................................................................... 36
Needle Parts....................................................................................................................................................................... 36
Needle Gauge and Length ............................................................................................................................................... 37
Needle Gauge and Length ............................................................................................................................................... 37
Problems with Needles..................................................................................................................................................... 37
One-handed Scoop Technique ....................................................................................................................................... 38
Recommended Needles ................................................................................................................................................... 38
Discharging needles ......................................................................................................................................................... 39
Components of a Cartridge ............................................................................................................................................. 39
Cartridge Content ............................................................................................................................................................. 39
Care and Handling ............................................................................................................................................................ 39
Additional Armamentarium ............................................................................................................................................. 40
Preparation of Armamentarium ...................................................................................................................................... 41
Syringe Preparation .......................................................................................................................................................... 41
Placing an additional cartridge ....................................................................................................................................... 41
Part 4: Patient Evaluation and Basic Technique ............................................................................................................... 43
Medical History.................................................................................................................................................................. 43
Medical Questionnaire ..................................................................................................................................................... 43
Common Medical Conditions .......................................................................................................................................... 44
Medical Questionnaire (Cardiovascular) ........................................................................................................................ 44
Categorisation of Drugs in Pregnancy ........................................................................................................................... 44
Physical Examination ........................................................................................................................................................ 45
Adult Blood Pressure Guidelines ..................................................................................................................................... 45
ASA Classification and Dental Modifications................................................................................................................. 46
Physical Examination ........................................................................................................................................................ 46
Stress reduction protocol ................................................................................................................................................. 46
Contra-indications for LA ................................................................................................................................................. 46
Ratings of Drug Interactions ............................................................................................................................................ 47
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Local Anaesthetic Drug Interactions ............................................................................................................................... 47

Vasoconstrictor Drug Interactions .................................................................................................................................. 47
VC and Monoamine-oxidase inhibitors - MAOIs (SR 5)....................................................................................... 48
VC and non-selective -adrenoceptor antagonist (blockers) (SR 1) ................................................................ 48
VC and General Anaesthetic (SR 1) ......................................................................................................................... 48
VC and Cocaine (SR 1) .............................................................................................................................................. 48
VC with antipsychotic or -adrenoceptor blocker (SR 4)..................................................................................... 48
VC with adrenergic neuronal blocker - phenotiazine (SR 4) ............................................................................... 48
VC (epinephrine) with thyroid hormone - thyroxine (SR 4) ................................................................................. 49
Important Facts related to LA Injections ........................................................................................................................ 49
Basic Injection Technique ................................................................................................................................................. 49
Basic injection technique.................................................................................................................................................. 51
Final Recommendations ................................................................................................................................................... 52
Part 5 : anatomy revision I ................................................................................................................................................... 52
Local Anaesthesia Course: Anatomy Revision I ................................................................................................................. 52
Trigeminal Nerve (V) ..................................................................................................................................................... 52
Trigeminal Nerve - Sensory Root .................................................................................................................................... 53
Trigeminal Nerve - Motor Root....................................................................................................................................... 53
Intracranial Part ................................................................................................................................................................. 53
Sensory Root.............................................................................................................................................................. 54
Motor Root ................................................................................................................................................................ 54
Ophthalmic Nerve Branches ............................................................................................................................................ 54
Nasociliary Nerve .............................................................................................................................................................. 56
Maxillary Nerve Branches ................................................................................................................................................. 57
Posterior Superior Alveolar Branch ................................................................................................................................. 58
Anaesthesia Area ........................................................................................................................................................... 59
Middle Superior Alveolar Nerve ...................................................................................................................................... 60
Anterior Superior Alveolar Nerve .................................................................................................................................... 60
Anterior Superior Alveolar Branch .................................................................................................................................. 60
Infraorbital Nerve - Branches in the Face ...................................................................................................................... 61
Anterior Superior Alveolar ............................................................................................................................................... 61
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Pterygopalatine Nerve ...................................................................................................................................................... 61

Palatine Nerves .................................................................................................................................................................. 62
Greater Palatine Nerve ..................................................................................................................................................... 63
Nasopalatine Nerve .......................................................................................................................................................... 63
Part 6: Anatomy Revision II .................................................................................................................................................. 64
Mandibular Nerve ............................................................................................................................................................. 64
Anterior division ........................................................................................................................................................ 64
Posterior division....................................................................................................................................................... 64
Anterior Division - Muscular Branches ........................................................................................................................... 64
Anterior Division - (Long) Buccal Nerve ......................................................................................................................... 65
Innervation ................................................................................................................................................................. 65
(Long) Buccal Nerve and Great Auricular Nerve ........................................................................................................... 66
(Long) Buccal Nerve and Great Auricular Nerve ........................................................................................................... 67
Posterior Division .............................................................................................................................................................. 67
Auriculotemporal Nerve ............................................................................................................................................... 67
Inferior Alveolar Nerve ..................................................................................................................................................... 68
Branches in the Infratemporal Fossa ...................................................................................................................... 68
Branches in the Mandibular Canal .......................................................................................................................... 68
Structures around the IAN area ...................................................................................................................................... 68
Medial ......................................................................................................................................................................... 68
Lateral ......................................................................................................................................................................... 68
Posterior ..................................................................................................................................................................... 68
Mylohyoid Nerve ............................................................................................................................................................... 69
Inferior Alveolar Nerve .................................................................................................................................................. 69
Path ............................................................................................................................................................................. 69
Innervation (after mylohyoid nerve) ....................................................................................................................... 69
Mental nerve ...................................................................................................................................................................... 70
Incisive Branches of the IAN ............................................................................................................................................ 71
Lingual Nerve ..................................................................................................................................................................... 71
Path ............................................................................................................................................................................. 71
Innervation ................................................................................................................................................................. 71
Tongue Innervation........................................................................................................................................................... 72
Overview of Mandibular Nerve ....................................................................................................................................... 73
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Intra-oral Mandibular Innervation Areas know this by heart!!! ....................................................................... 73

Bones Structures of Relevance ........................................................................................................................................ 73
Part 7: Maxillary Techniques ................................................................................................................................................ 74
Overview of Maxillary Nerve ........................................................................................................................................ 74
Supraperiosteal (Buccal infiltration most common injection in the maxilla) ........................................................... 75
Indication ................................................................................................................................................................... 75
Where can we use Supraperiosteal? ............................................................................................................................... 76
Where can we use Supraperiosteal? ............................................................................................................................... 76
Supraperiosteal Technique .............................................................................................................................................. 76
Supraperiosteal Technique .............................................................................................................................................. 77
Intraligamental PDL ....................................................................................................................................................... 77
Intraseptal/Intrapapillary .................................................................................................................................................. 78
Intraosseous ....................................................................................................................................................................... 79
Intrapulpal .......................................................................................................................................................................... 79
Indications .................................................................................................................................................................. 79
Contraindications ...................................................................................................................................................... 79
Advantages ................................................................................................................................................................ 79
Disadvantages ........................................................................................................................................................... 79
Local Infiltrations ............................................................................................................................................................... 80
Indications .................................................................................................................................................................. 80
Technique ................................................................................................................................................................... 80
Anatomy ............................................................................................................................................................................. 80
Maxillary Nerves Anaesthetised ...................................................................................................................................... 81
Maxillary Nerves ................................................................................................................................................................ 81
Posterior Superior Alveolar Nerve .................................................................................................................................. 81
.................................................................. 83
Technique ........................................................................................................................................................................... 83
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Middle Superior Alveolar Nerve ...................................................................................................................................... 84

Anterior Superior Alveolar Nerve .................................................................................................................................... 86
Indications .................................................................................................................................................................. 86
Limitations.................................................................................................................................................................. 86
Alternatives ................................................................................................................................................................ 86
Area anaesthetised............................................................................................................................................................ 86
Branches on the Face................................................................................................................................................ 86
Technique 1 - Central Incisor as Reference ............................................................................................................... 87
Technique 2 - Vertical using the 1PM as Reference ................................................................................................. 88
Greater Palatine Nerve ..................................................................................................................................................... 89
Technique ....................................................................................................................................................................... 90
Nasopalatine Nerve .......................................................................................................................................................... 91
Maxillary Nerve .................................................................................................................................................................. 91
...................................................................................................................... 93
It didnt work!!! .................................................................................................................................................................. 93
Part 8: Mandibular Techniques ............................................................................................................................................ 93
Mandibular Nerves Anaesthetised .................................................................................................................................. 94
Anatomy REMEMBER THIS DIAGRAM!!!! ....................................................................................................................... 94
Inferior alveolar nerve block ............................................................................................................................................ 94
Branches ..................................................................................................................................................................... 95
Inferior Alveolar Nerve Block ........................................................................................................................................... 95
Nerves anesthetised.................................................................................................................................................. 96
Areas anesthetized .................................................................................................................................................... 96
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Advantages ................................................................................................................................................................ 96
Disadvantages ........................................................................................................................................................... 96
Complications / Errors ........................................................................................................................................... 99
Facial Nerve Paralysis in IAN Block (too posterior/deep) .................................................................................... 99
Inferior Alveolar Nerve / Lingual Nerve ......................................................................................................................... 99
Mental Nerve ................................................................................................................................................................... 100
Mental Nerve Block...............................................................................................................Error! Bookmark not defined.
Advantages/Indication ........................................................................................................................................... 101
Disadvantages ......................................................................................................................................................... 101
Incisive Branches of the IAN .......................................................................................................................................... 102
Anatomy ....................................................................................................................................................................... 102
Alternative Technique - Supraperiosteal...................................................................................................................... 103
Lingual Nerve ................................................................................................................................................................... 103
Technique 1 with IAN block ......................................................................................................................................... 104
Technique 2 floor of the mouth .................................................................................................................................. 104
Buccal Nerve ................................................................................................................................................................ 105
Indications/Advantages.............................................................................................................................................. 105
Disadvantages ............................................................................................................................................................. 105
Technique ......................................................................................................................................................................... 106
(Long) Buccal Nerve and Great Auricular Nerve ......................................................................................................... 106
Gow-Gates Mandibular block ........................................................................................................................................ 107
Target area ................................................................................................................................................................... 107
Reference landmarks-maxillary second molar ........................................................................................................ 107
Vazirani-Akinosi Block .................................................................................................................................................... 108
Indications .................................................................................................................................................................... 108
Technique..................................................................................................................................................................... 108
Indication ..................................................................................................................................................................... 109
Area Anaesthetised ..................................................................................................................................................... 109
Part 9: Complications .......................................................................................................................................................... 109
Needle breakage and injuries ........................................................................................................................................ 110
Injury to Patient and Administrator .............................................................................................................................. 110
Nerve Injuries ................................................................................................................................................................... 111
Causes....................................................................................................................................................................... 111
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Management ........................................................................................................................................................... 111

Facial nerve paralysis ...................................................................................................................................................... 111
....................................................................... 112
Facial nerve paralysis ...................................................................................................................................................... 112
Orbital nerves paralysis .................................................................................................................................................. 112
Trismus ............................................................................................................................................................................. 113
Causes....................................................................................................................................................................... 113
Prevention ................................................................................................................................................................ 113
Management ........................................................................................................................................................... 113
Soft tissue injury .............................................................................................................................................................. 113
Causes....................................................................................................................................................................... 113
Prevention ................................................................................................................................................................ 113
Management ........................................................................................................................................................... 113
Hematoma ....................................................................................................................................................................... 114
Cause ........................................................................................................................................................................ 114
Management ........................................................................................................................................................... 114
Pain on Injection.............................................................................................................................................................. 114
Pain on insertion ..................................................................................................................................................... 114
Pain on withdrawal.................................................................................................................................................. 114
Burning on Injection ....................................................................................................................................................... 114
Causes ........................................................................................................................................................................ 114
Management ........................................................................................................................................................... 114
Infection and Edema ....................................................................................................................................................... 114
Infection ................................................................................................................................................................... 114
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Edema ....................................................................................................................................................................... 114

Tissue Vascular Necrosis ................................................................................................................................................ 115
Causes....................................................................................................................................................................... 115
Management ........................................................................................................................................................... 115
Systemic effects of LA..................................................................................................................................................... 115
Classification of Adverse Effects .................................................................................................................................... 115
Overdose - Causes .......................................................................................................................................................... 115
Normal ...................................................................................................................................................................... 115
Liver disfunction ...................................................................................................................................................... 115
Large dose (normal liver) ....................................................................................................................................... 115
Intravascular Injection............................................................................................................................................. 115
Overdose - Predisposing Factors .............................................................................................................................. 115
Dosage of local anaesthetics ...................................................................................................................................... 116
Adrenaline - Maximum doses .................................................................................................................................... 116
Healthy Patients (ASA I) Maximum dose - 200 micrograms ........................................................................ 116
Sick patients (ASA III and IV) Maximum dose - 40 micrograms ................................................................... 117
LA Overdose - Central Nervous System ....................................................................................................................... 117
LA Overdose - CVS and Respiratory ............................................................................................................................. 117
CVS ............................................................................................................................................................................ 117
Respiratory ............................................................................................................................................................... 117
Management of LA Overdose ....................................................................................................................................... 117
Mild overdose .......................................................................................................................................................... 117
Management of LA Overdose ....................................................................................................................................... 117
Severe overdose ...................................................................................................................................................... 117
Epinephrine Overdose .................................................................................................................................................... 118
Management of Epinephrine Overdose ................................................................................................................... 118
Overdose summary ......................................................................................................................................................... 118
Allergy............................................................................................................................................................................... 119
Causes of Allergy ......................................................................................................................................................... 119
Prevention of Allergic reactions ................................................................................................................................ 119
Types of allergic reactions.......................................................................................................................................... 119
Progression of Anaphylactic Reaction ........................................................................................................................... 119
Management of patients with alleged LA allergy.............................................................................................................. 119
Management of patients with allergic reactions .............................................................................................................. 120
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Delayed skin reactions ............................................................................................................................................... 120

Immediate skin reactions .......................................................................................................................................... 120
Management of patients with allergic reactions......................................................................................................... 120
Respiratory Reactions Bronchospasm (Asthma) ....................................................................................................... 120
Anaphylactic Reactions Laryngeal edema ................................................................................................................. 120
Emergency Drugs and Equipment ................................................................................................................................ 120
Emergency Plan ............................................................................................................................................................... 121
Minimum Requirements................................................................................................................................................. 121
Medications.................................................................................................................................................................. 121
Maxillary Techniques ......................................................................................................................................................... 122
It didnt work!!!............................................................................................................................................................. 122
Final Recommendations ................................................................................................................................................. 122
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Part 1: Introduction & Neurophysiology
Handbook of local anesthesia fifth edition
Sensation of pressure which comes from a different pathway will not be fully blocked by LA.
You need to be able to identify if the sensation the patient is experiencing is pressure or sharp pain.
Assure the patient that it is just pressure.
Local anaesthesia is defined as a loss of sensation in a circumscribed area of the body caused by a
depression of excitation in nerve endings or an inhibition of the conduction process in peripheral
nerves without a loss of consciousness
Methods of inducing LA
Mechanical trauma (server the nerve we dont do it! But in some cancer patients the surgeon cut a few
nerves to deal with the pain)
Low temperature
Anoxia (no oxygen)
Chemical irritants
Neurolytic agents such as alcohol and phenol
Chemical agents such as LA
The effect has to be TRANSIENT and COMPLETELY REVERSIBLE.
Desirable properties of a local anaesthetic

1. No local irritation
2. No permanent alternation of nerve structure
3. Low systemic toxicity
4. Effective (complete anesthesia), regardless of whether it is injective or applied locally to mucous
membranes
5. Rapid onset
6. Adequate duration
7. Sufficient potency to give complete anaesthesia without the use of harmful concentrated solutions.
(some drugs have to be used in such high concentrations that it becomes toxic)
8. No allergic reactions (its pretty rare to have allergic reactions to LA these days but sometimes you can
have allergic reactions to the stabilizer in the LA)
9. Stable in solution and readily undergo transformation in the body
10. Sterile or capable of being sterilized.
LA history
Cocaine still used by some EMT surgeons
Procaine -- induces a lot of allergic reactions. One of the metabolites is PABA.
Lidocaine gold standard. Still used today.
Meprivacine
Prilocaine
Bupivacine
Articaine introduced in Europe in the late 60s. Took a while to become in the rest of the world.
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Neurons
Motor Neuron
Neuron 1
o motor cortex
Neuron 2
o Brainstem nuclei
o Reaches muscles
Sensory Neuron
Unipolar
Pseudounipolar
Interneuron
Cell body
Nucleus + Soma
Dendrites (synapse with other neurons)
Myelin sheath
Node of ranvier
Terminal bouton (bulbous axon terminal)
Axon
Peripheral process (Dendrite)

Connects to receptors
Cell body
Located in the Trigeminal Ganglion
Central process (Axon)
Connects to Neuron 2
Anesthesia works on both motor and sensory neurons.
If you go too deep you can hit the facial nerve and cause facial paralysis on that side of the face.
If youre talking about LA you want to stop sensory nerves.
Trigeminal ganglion youre not actually numbing this but the peripheral nerves.
Cell body
Nucleus and soma
Dendrities (synapse with other neurons)
Axons
The nerve is located in the trigeminal ganglion. The peripheral processes will then form the nerve. When were
numbing something, were actually numbing the axons or peripheral processes of the nerve.
Movement is usually bilateral.
Sensory neurons
1. Neuron 1
Trigeminal ganglion
2. Neuron 2
Brainstem nuclei
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3. Neuron 3
Ntalamus
Reaches sensory cortex
Nerve structure (when youre talking about nerves, youre actually talking about collection of axons travelling to
a certain area)
Nerve structure
Myelin sheath
Lipid insulating
Protein
Schwann cells nucleus on the outer layer
Neuron 2
Constrictions every 0.5 to 3mm
Nerve membrane exposed
Myelinated nerves conduct impulses at a much faster rate
Delta nerves are what conduct pain.
Neurophysiology
o
Two layers of lipid
Transport proteins
Sodium channels
Potassium channels
Sodium potassium pump
Sodium extracellular (+)
Potassium intracellular (-)
The resting stage outside of the nerve will be positively charged while inside will be negatively charged.
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Resting state of the neuronal membrane
Ionic concentrations
Ion
Potassium
Sodium
Chloride
Intracellular
110 to 170
5 to 10
5 to 10
Extracellular
3 to 5
140
110
Ratio
27:1
1:14
1:11
Electrophysiology of nerve conduction

Electrical action potentials
Increase permeability to Na+
Delayed increase in perm of K+
Types of impulses
Chemical
Thermal
Mechanical
Electrical
Once an impulse is initiated, the amplitude and shape of that impulse remains constant, regardless of
changes in the quality or strength of the stimulus.
Electrophysiology of Nerve Conduction

Resting potential
-70mV
Exterior +; Interior Slow Depolarization
-50 to -60mV
Na+ channels open
Rapid Depolarization
+40mV (complete reversal from negative to positive)
Repolariazation
-60 to -90mV
K+ channels open
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How does a nerve conduct an impulse?

Sequential neuron cell membrane depolarization from:
Segment to segment: unmyelinated nerves
Node by node (Saltatory conduction): myelinated nerves
Modes and action of local anaesthetic

When? Primary action occurs during the depolarization phase of the action potential
Decrease, particularly in the phase of slow depolarization. An electrical impulse cannot propagate from that
point onwards. The LA will travel inside the nerve and block the Na channels from the inside so the channels
cant open up anymore.
NEED TO UNDERSTAND HOW THESE DRUGS WORK
Where? LA works by blocking sodium channels, thereby preventing nerve cell depolarization and impulse
propagation
LA bind to specific receptors on the sodium channel

LA must to be lipophilicmust be able to penetrate the membrane. The more lipophilic the LA is, the stronger it
is.
LA usually has 2 components cationic and free base components. As soon as you inject the LA into the patient,
they will separate and serve different functions.
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Classification of LA substances according to biologica site and mode of action

Classification
Definition
Chemical substance
Class A
Receptor site on external

surface of membrane
Biotoxins
Class B
Receptor site on internal

surface of membrane
Scorpion venom, ammonium

analogues of lidocaine
Class C
Receptor independent
mechaniams
Benzocaine
Class D
Combination of receptor and

receptor-independent
mechanism
Most clinically used LA

(lidocaine, mepivacine,
articaine, prilocaine)
Sequence of mechanism of action of LA

1. Displacement of calcium ions from the sodium channel receptor site;
2. Binding of the LA molecule to this receptor;
3. Blockade of the sodium channel;
4. Decrease in sodium conductance;
5. Depression of the rate of electrical depolarisation;
6. Failure to achieve threshold potential level; (FULL BLOCKADE AT THIS POINT)
7. Lack of development of propagated action potentials;
8. Conduction blockade
Local anaesthetic molecules

LA are tertiary (majority) or secondary amines
Lipophilic part
Aromatic structure (determine what type of LA you have)
Intermediate Chain
Ester linkage or
Amide linkage
Hydrophilic part
Amine portion
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EACH ANAESTHETIC HAS TWO PARTS HYDROPHILIC PART TO TRAVEL TO THE TARGET AND
LIPOPHILIC TO PENETRATE THE MEMBRANE
Lipophilic
Hydrophilic
Intrinsic potency
Allows diffusion in tissues
Penetrates nerve membrane

Rapid onset
pKa and pH
LA are basic compounds - pKa ranges from 7.5 to 10
Combined with acids form local anaesthetic salts:
Soluble in water and stable
Usually hydrochloride salts, dissolved in water or saline. Need to dissociate for the LA to get into the
membrane and bind to receptor. The pH this happens is called the pKa.
LA with vasoconstrictor are acidified to avoid its oxidation
Tissues normal pH - 7.4
Acidification (inflammatory process) - pH drops to 5 6. The separation of the components of the anesthetic
will not work properly. The anaesthetic will not be effective. YOU SHOULD NEVER INJECT LA INTO
INFLAMMED tissue. You have a better chance of hitting a farther nerve thats not inflamed.
Decreases local anaesthetic effectiveness
Dissociation of LA
pKa is the pH value at which both the Free base (RN) and ionised form (RNH+) are in equilibrium
LA salt is dissolved in water or saline and has:
Free Base form (RN) - uncharged molecules

Cation form (RNH+) - positively charged molecules
Proportion of each varies according to pH of solution or tissues
Low pH - most LA will be in cationic form - RNH+ > RN + H+

High pH - most LA will be in base form - RNH+ < RN + H+
Actions on nerve membranes

Diffusion of the nerve through the nerve sheath
RN (free base form) enters the neuron
RNH+ ions form in excess outside re-equilibrates according to tissue pH and drug pKa - more RN forms
enter until equilibrium the cationic form is the one that will bind to the receptor.
Binding at the receptor site (ion channel)
RN excess in interior re-equilibrates to RNH+ ions
RNH+ ions enter into the sodium channels, and bind to channel receptor from the interior side.
Membrane action of LA
RN (free base form) diffuse through the nerve sheath to reach the interior of the neuron RNH +
(cation form) binds to receptor.
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Takes procaine 18 minutes to work because of its pKa. The more basic the LA is, the more time it takes for it
to work. The pKa determines the speed of onset of action.
You need the free base form to go inside the membrane.
Once you inject LA into a tissue, the LA has to travel through all the barriers of the nerve.
Barriers of Diffusion of the Solution
A lot of tissues to travel through thats why you need a lot of free base form and the LA to be
hydrophilic.
pKa and LA
Why do LA not work well in infected tissues?

pH of extracellular fluid varies, decreases (more acid) in infection or inflammation
much more RNH+ ions form will be present on the outside, and less free base RN form available
Reduced numbers of RN molecules enter the cell, and the remainder outside will be absorbed faster
(increased vascularity)
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Induction of Local Anaesthesia

Diffusion
LA moves from deposition area towards the nerve
Penetration occurs when a drug passes through a tissue that restricts free molecular movement
(perineurium and perilemma)
Depends on the Concentration Gradient
External fasciculi (mantle bundles) are blocked first, inner (core bundles) later
Mantle bundles innervate proximal areas (molars), and core bundles smore distal areas (incisives)
You want to be as close to the nerve as possible. Articaine has a very good diffusion properties so you can
deviate a little. Lidocaine is a little more technique sensitive.
COMPLETE BLOCKADE REQUIRES ADEQUATE VOLUME AND CONENTRATION OF THE LA.
The fibers to be anaesthetized will be the nerves on the periphery. Especially thick nerves e.g. inferior alveolar
nerve. The ones in the middle are further away. The area of the third molar will get numb faster than the ones in
the lip. If the patient starts to get numb in the lip it probably signifies that the LA has reached the entire nerve.
The reverse is the samethird molar loses numbness first.
Whenever youre injecting LA into an area where there are too many blood vessels, it will not work as well as it
will be irrigated quickly.
Blocking process
Solution diffuses in all directions and concentration increases within the nerve as diffusion progress
The part that diffuses away will be:
o
Absorbed by other tissues
Diluted by interstitial fluid
Removed by capillaries and lymphatics
Hydrolyzed (ester-type only)
Induction time
Time between injection and complete blockade
Depends on the concentration of the drug and pH of the LA solution.
Anatomy and diffusion constant cant be controlled by clinician.
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Factors affecting local anaesthetic action
Articaine is more lipophilic works faster and is more potent.

Modern anaesthetic always have vasoconstrictors to limit the blood flowing to the area. You can also decrease
the amount of LA needed. Whenever you use an anesthetic that doesnt have a vasoconstrictor, it will work for a
lot shorter time. You use the vasoconstrictor all the time.
Recovery from LA Block

Same diffusion patterns, but with reverse order
Extraneural concentration is reduced
Diffusion, dispersion, uptake of the drug

Intraneural continues stable initially
When extraneural<intraneural:
Anaesthetic molecules begin to diffuse out of the nerve

Core fasculi recover faster than mantle fasculi**
Recovery is slower than induction
LA is bound to receptor in sodium channel and released slowly

The outside of the nerve will recover much faster than the inside.
Duration of Anaesthesia
Protein binding (the more proteins they bind to, the long they will stay there for)
Long acting LA (Ex: Bupivacaine) are more firmly bound. Bupivacaine can last for up to 10 hours! Not used
much in dentistry but used a lot in surgery where you want patients to stay number for longer.
Shorter action LA (Ex: Lidocaine) not so firmly bound

Vascularity of the Region
Anaesthetic duration is increased in areas with decreased Vascularity

Use of Vasoconstrictors
Addition of vasopressor decreases tissue perfusion, thus increasing duration of block

There are areas where you dont want to use vasoconstrictors extremities of the limb ITS GOING TO KILL
YOUR BLOOD SUPPLY AFTER A FEW HOURS!!!
It can only be done in areas where it is supplied with blood very well. If you inject too much solution for a greater
palatine block, you can cause necrosis of the tissue.
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Frances Zhao
Part 2: Pharmacology
Esters
Amides
Procaine
Lidocaine
Cocaine
Prilocaine
Benzocaine
Articaine
Tetracaine
Etidocaine
Mepivacine
Bupivacaine
Ester-Type
Procaine (2-4%)
Vasodilating effect
Not used today
Tetracaine
Topical use only
High potency (6-8x cocaine)
High toxicity
Amide-Type
Lidocaine
Prilocaine
Articaine
Mepivacaine
Bupivacaine
Pharmacokinetics of Local Anaesthetics

Uptake (Absorption)
Most LA are vasodilators, except Cocaine
This causes increase in rate of absorption, decreasing duration and quality of pain control
Poorly absorbed orally (if at all)
Topical Route - better in tracheal mucosa, less in oral mucosa, skin only if damaged
Injection - IV can reach dangerous toxic concentrations
THESE SOLUTIONS ARE NOT TO BE INJECTED INTO BLOOD VESSELS. BEFORE YOU INJECT LA YOU NEED
TO ASPIRATE AND MAKE SURE YOURE NOT INJECTING INTO BLOOD VESSELS.
Pharmacokinetics of local anaesthetics

Distribution
All body tissues (once in blood) including blood-brain barrier and placenta
Highly perfused have initial high levels: brain, liver, lungs
Skeletal muscle contains greatest percentage of LA (largest mass)
Elimination half-time varies:
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Frances Zhao
Articaine has a shorter half-life so it usually has to be in higher concentrations.
Metabolism (Biotransformation)
Primary process through which clinical actions of LA cease
Relates directly to toxicity (balance between absorption X removal from blood)
Metabolism of ESTERS
Hydrolyzed in PLASMA (pseudocholinesterase)
1 in 2800 persons have an atypical form of this enzyme, and this prolongs its excretion
Transformed into PABA (paraaminobenzoic acid)
The PABA can cause allergies
Metabolism of AMIDES
More complex, bio-transformed in the LIVER
Patients with liver dysfunction or heart failure (ASA IV to V) have relative contra-indication.
Articaine has shorter half-life because part is hydrolysed (cholinesterase) in plasma. Part of its metabolites will
be processed like the ester group (processed in the plasma)
Prilocaine (large doses) produces orthotoluidine that can induce METHEMOGLOBINEMIA. Cant tolerate this
metabolite very well and very often need to be hospitalized.
Excretion
Is mostly done via the KIDNEYS
Procaine is hydrolysed and PABA (90% appears in urine)
Small percentage excreted unchanged
3% lidoc, 2% procaine, 1% mepivacaine
Patients with significant renal disease (ASA IV/V), including patients undergoing renal dialysis represent a
relative contraindication
If you have very sick patients that have significant renal problems, they have difficulties excreting these drugs.
Will not come across patients like these very often because most of the time they will be in the hospital.
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Frances Zhao
Systemic Effects of LA
Central Nervous System
Depress the CNS (IMPORTANT IN OVERDOSES or you accidentally inject into the bloodstream
Low levels - no action
Used IV anticonvulsant properties
Decrease excitability of neurons
Toxic levels (increasing)
1. Excitation
It starts to depress the areas of your brain that control you usually. Works like alcohol. Patients start
becoming more agitated and more talkative than usual.
2. Sedation (rarely)
3. Tonic-clonic seizure
Cardiovascular Effects
More resistant to adverse effects than CNS
1. 1 - Direct action on myocardium - depression, decrease electrical excitability
Used for ventricular disritmias (PVC and ventricular tachycardia)
2. 2 - Peripheral Vasculature dilate blood vessels
Hypotension, only in high levels
Lethal levels - cardiovascular collapse
Because we usually use vasoconstrictors so these effects are evened out by the vasoconstrictors.
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Frances Zhao
Local tissue toxicity

Skeletal muscle damage - trismus. Will not be able to open the mouth well because it will damage the
muscle.
Respiratory system
Unaffected, but in overdose can produce respiratory arrest
Drug interactions
CNS depressants - potentiation of effects
Succinylcholine (muscle relaxant used in GA) - compete for pseudocholinesterase, can cause prolonged
apnea
Barbiturates - induce production of hepatic microsomal enzymes which will increase rate of metabolism
of the LA
If your patient is already on drugs that depress the CNS, be careful.

If you use LA on top of these drugs it can cause prolonged paralysis and numbness.
Vasoconstrictors
LA are vasodilators (except cocaine)
Plain LA are resorbed from the injection site rapidly, resulting in:
Poor anaesthetic depth
Short duration of anaesthesia
Higher LA plasma levels
Increased bleeding
Positive actions
Oppose vasodilatory effects of LA
Constrict blood vessels, decreasing perfusion
Slower absorption of both the LA and epinephrine in the CVS
Lower LA blood levels
Longer durations of anaesthesia
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Frances Zhao
More profound anaesthesia

Reduce bleeding
Reduction in plasmatic peak levels with epinephrine 1:200,000
Chemical structure
Catecholamines
Epinephrine (Adrenalin)
Norepinephrine
Levonordefrin
Dopamine
Non-cathecholamines
Amphetamine
Ephedrine
Phenylephrine
Felypressin (synthetic analogue of vasopressin)
Mode of action
Adrenergic Receptors
Alpha - contraction of smooth muscles (vasoconstriction in skin and mucosas). Ideal vasoconstrictors will only
constrict blood vessels but adrenaline will have other effects as well.
Alpha 1 - excitatory post synaptic
Alpha 2 - inhibitory post-synaptic
Beta - relaxation of smooth muscles
Beta 1 - heart and small intestines (cardiac stimulation and lipolysis)
Beta 2 - bronchi, vascular beds, uterus (vasodilation and bronchodilation)
Increased heart rate.
Increased blood pressure.
Dilate lungs and bronchi.
Increase motility in uterus.
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Frances Zhao
Vasoconstrictors commonly used

Adrenaline
Synthetic, but same effect as endogenous adrenaline
1:80,000 to 1:300,000
Vasoconstriction of vessels (-receptors), pupil dilation, bronchial dilation, skin vessel contraction, syst
BP, beat frequency
Affected by light - store cartridges in cool and dark place (but use at room temperature, or even warm)
Interactions - should not be used in patients taking MAOIs as they can adversely interact
Maximal dose (ASA I) is 0.2mg which is 20 ml in a 1:100.000 solution

Patients with significant CV diseases (III/IV) is 0.04mg (4 ml)
Felypressin
Synthetic analogue of antidiuretic hormone vasopressin

Dose - 0.03 international units/ml
Acts more in veins than in arteries - not recommended when hemostasis is required
No central nervous system effects
No myocardium effects (beta)
Has oxytocic actions - do not use in pregnancy
Overdose
Adrenaline
CNS stimulation: fear and anxiety, tension, restlessness, throbbing headache, tremor, weakness, dizziness,
pallor, respiratory difficulty, palpitation
Cardiac effects: dysrhythmias (ventricular)
Dramatic increase in blood pressure (300 syst; 200 diast mmHg)
Angina in patients with coronary insufficiency
Stimulatory phase of the (toxic) overdose is brief (usually assure the patient that it is okay will help)
Felypressin
Minimal incidence of systemic reactions
Oxytoxic actions, contraindicating its use in pregnant patients
Medical Status of Patient

Adrenaline
ASA I healthy
ASA II has a condition but is managed well
ASA III has a condition but is poorly managed
ASA IV very sick and should be in hospital
Heart diseases (ASA IV)

Unstable angina pectoris
Recent myocardial infarction
Recent by-pass surgery (coronary art)
Refractory arrhythmia
Paroxysmal tachycardia
Highly frequent absolute arrhythmia
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Frances Zhao
Untreated or uncontrolled serious hypertension

Decompensated cardiac insufficiency
Once impaired medical status is improved (ASA IV becomes III), routine LA with vasoconstrictors can be
used
Thyroid dysfunction, diabetis (ASA IV)
MAO inhibitors + tricyclic antidepressants
Felypressin
Pregnancy (can result in contraction of the uterus)
Coronary artery constriction in high doses
Adrenaline maximum doses

Healthy Patients (ASA I)
Maximum dose - 200 micrograms
1:80,000 (12.5 micrograms/ml x 2.2 ml = 27.5 per cartridge)
Maximum - approx 7cartridges
1:100,000 (10 micrograms/ml) x 2.2 ml = 22 per cartridge)
Maximum - approx 9 cartridges
Sick patients (ASA III and IV)

1:80,000 - Maximum - approx 2 cartridges
LA commonly used in Australia

Lignocaine with adrenaline
Articaine with adrenalin
Mepivacaine
Mepivacaine with adrenaline
Bupivacaine with adrenaline (not often available to buy as cartridges but can buy as vials)
Prilocaine with felipressin (octapressin)* --comes as American volume
Lignocaine 2% with Adrenaline 1:80,000

Most commonly used
Good for blocks and infiltrations-very versatile
Rare allergies
Commercial names
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Frances Zhao
Lignospan 2% special (Septodont)

ATO Lidocaine 2% (ATO)
Xylestesin - A (Espe)
Xylocaine (Dentsply)
Should have an idea of the onset and how long it will last (pupal anaesthesia)
and the maximum dose.
Dont have to remember pKa.
2% = 2mg/mL
Prilocaine 3% with Felypressin (Octapressin)

Equipotent to lignocaine, but less toxic
Felypressin has less beta effects / cardiac. Will not affect the heart as well.
NOT to be used in pregnancy
Can produce cyanosis and metahaemoglobinemia at high doses (> 600 mg)
Commercial Names
Citanest with Octapressin (Dentsply) - 1.8 ml!
Articaine 4% with Adrenaline 1:100,000

Suitable for use only in patients 4 years and older
May be an association with neurotoxicity - should not be used in blocks. Has a very high affinity for nerve and
gets into nerve very quickly. Therefore, dont inject too close to the nerve itself so they dont prefer giving blocks
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Frances Zhao
with articaine. Can use for infiltrations but DONT USE FOR BLOCKS. Also gives a false sensation of effectiveness
so it is less technique sensitive than lignocaine. Try to work with lignocaine more.
Good for infiltrations, higher lipid solubility and protein binding rate, becoming popular
Commercial names
Septanest 4% (Septodont) DOUBLE THE CONCENTRATION OF LIGNOCAINE
Ubistesin 1/200,000 (Espe)
Same maximum dose as lignocaine. For patients with same weight, you can only use half of what you use
for lignocaine as it is twice the concentration.
Mepivacaine 3%
Short-acting LA
Less vasodilation than others, can be used without VC. The reason why it can used by itself is that it is not as
vasodilatory as the rest.
Used when vasoconstrictors are contra-indicated
Suitable for use only in patients 3 years or older
Offered with adrenalin as well (with 2%). Only option without vasoconstrictor.
Commercial names
Scandonest 3% Plain (Septodont)
Scandonest 2% Special (Septodont) - with adrenaline 1;100,000
ATO Mepivacaine 3% (ATO)
Mepivastesin (3M)
Bupivacaine 0.5% with Adrenaline 1:200,000

Long-acting LA, but also long onset time
Used for post-op analgesia as well
Suitable for use only in patients 12 years or older
Commercial name
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Frances Zhao
Marcaine with adrenaline (Dentsply)

Not sold in Australia! Used for anaesthetic for the spine because it lasts very long.
Its 8 times as potent as the others.
Variability in LA duration
Normal variation from patient to patient
Accuracy of injection technique
Status of the tissue at injection site
pH
Vascularity
Anatomical variation
Type of injection administered
Block HARDER TO DO
Infiltration
Normal variation from patient to patient

Accuracy of injection technique
Status of the tissue at injection site
pH
Vascularity
Anatomical variation
Type of injection administered
Block
Infiltration
Calculation of maximum dose

Lidocaine 2% + Adr 1:80,000 - Adult with 70 Kg
20mg/ml x 2.2 ml = 44mg per cartridge

Max dose = 7.0 mg/Kg x 70 Kg = 490 mg
490 mg / 44 mg per cartridge = approx 11 cartridges
Lidocaine 2% + Adr 1:80,000 - Child with 20 Kg
20mg/ml x 2.2 ml = 44mg per cartridge

Max dose = 7.0 mg/Kg x 20 Kg = 140 mg
140 mg / 44 mg per cartridge = 3 cartridges
Consider physical status of the patient and also the duration of time over which the
drug is administered.
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Frances Zhao
MUST KNOW THIS TABLE
Adrenaline - Maximum doses

Healthy Patients (ASA I)
Sick patients (ASA III and IV)
Contraindications of Local Anaesthetics

Hypersensitivity to the substances very rare. Used to be common in the ester group which we dont use
anymore.
LA allergy, documented (more in esters), amide usually safe

Bisulfite allergy - LA containing vasoconstrictors - do not use VC
Serious intraventricular conduction defects (AV block)
Decompensated patients (ASA III-IV) with liver, renal and cardiovascular disease - relative contraindication.
Severe hypotension - relative contraindication
Limited plasma cholinesterase activity (articaine only) articaine is partially metabolized in the plasma.
Methemoglobinemia, idiopatic or congenital (prilocaine only)
Anaesthetics for Topical Application

Lidocaine - 2% to 5%
Can be combined with cetrimide, prilocaine

Benzocaine - 0.6% to 20%
Can be combined with tetracaine

Cocaine Hydrochloride
Tetracaine - 0.2% to 1%
What factors should be considered when selecting a local anaesthetic?

Duration of the planned treatment
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Frances Zhao
Need for post-treatment pain control

Possibility of self-mutilation post-treatment
Any medical contraindications (absolute or relative)
Possible need for hemostasis
Part 3: Armamentarium
Types of Syringes
Nondisposable syringes
Aspirating
Self-aspirating
Pressure syringe for PDL injection
Jet injector (needless)
Disposable syringe
Safety syringes
Computer controlled systems
Non-disposable Aspirating Syringes

Advantages
Autoclavable
Visible cartridge
Aspiration with one hand
Long lasting with proper mainteinance
Disadvantages
Weight
Several mechanisms for aspirating, check if it works for you!
Some require a new needle each time to ensure proper aspiration
Positive aspiration can be as high as 10-15%!
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Frances Zhao
Non-disposable Self-aspirating Syringes

Advantages
Introduced to ease aspiration
Use the elasticity of the rubber diaphragm of the cartridge
Pressure on the thumb disk produces positive pressure, when released, negative pressure permits
aspiration
Easy to aspirate with small hands
Disadvantages
Aspiration is not as reliable
Finger must be moved from thumb ring to thumb disk to aspirate
Non-disposable Pressure Syringes

Advantages
Designed for Intraligamentary injections (PDL) injection
Can be used instead of block
Careful, can damage PDL
Should be used only in extractions to compliment if needed
Disadvantages
Cost - PDL injection also works with conventional syringe
Easy to inject too fast
2 places where you feel pain mucosa and bone. Always make sure the bevel is facing the bone.
Short needles are what we usually use. Long needles (more than 3cm) are used for the blocks. For inferior
alveolar block, infraorbital block, posterior superior alveolar block.
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Frances Zhao
Non-disposable Jet Injector

Advantages
Does not require needle
High pressure (2000 psi)
Small volumes (0.01 to 0.2 ml)
Used for topical anaesthesia or palate
Disadvantages
Expensive
Easy to inject too fast
Disposable Syringes
Advantages
Disposable, single use
Sterile until opened
Lightweight
Disadvantages
Does not accept pre-filled dental cartridges
Aspiration requires two hands
Not commonly used in Dentistry
Use 2-3 ml syringes with 25 gauge needles
Safety Syringes
Advantages
Disposable, single use
Sterile until opened
Lightweight
Less risk of needle-stick injuries
Disadvantages
Cost
May feel awkward to a first time user
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Frances Zhao
Computer-controlled LA Delivery
Advantages
Precise control of flow rate and pressure - more comfort
Some handpieces are lightweight - increased tactile feeling
Automatic aspiration
Injects LA slowly less painful
Known for being pain-free injection main reason is speed.
Disadvantages
Cost
Requires additional armamentarium
Problems with Syringes

Leakage during injection
Off-centre perforations of the rubber diaphragm when reloading
Broken cartridge
Old syringes, bent harpoon
Plastic ones are cheaper but wont slide as well as glass
Bent harpoon / aspiration device
Must be sharp and straight
Disengagement of the harpoon from the plunger during aspiration
Surface deposits
Ultrasonic (cleaning should usually get rid of this)
Needle Parts
Bevel always make sure the bevel is facing the bone. If you dont do that you might touch periosteum
when you touch bone.
Shaft
Hub
Syringe adaptor
Cartridge penetration
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Frances Zhao
What should you do to ensure minimal pain?

Dont change needle direction
Dont bend needle
Avoid 30 gauge needles
Pain on withdrawal needle forced to bone producing fishhook barbs on tips. When the needle hits the
bone it can bend slightly and when you withdraw it can tear tissues.
Avoid recapping needles, if needed use one-handed scoop technique
Needle Gauge and Length

Gauge = internal (lumen) diameter
30 gauge: thin (<aspiration, > deflection)
27 gauge: medium
25 gauge: thick
(>aspiration)
Thinner needles = less painful but easier to break for longer needles
The one we have = 27 gauge
Bi-rotational insertion technique (BRIT) minimises needle deflection.

Needle Gauge and Length
Length
Extra short: 10-16 mm
Short: 21-25 mm - routine use (what we use daily)
Long: 30-41 mm - used for blocks (IAN, PSA)
Needles should not be inserted into tissues to their hubs unless it is absolutely
necessary for the success of the injection - THEY CAN BREAK!
Problems with Needles
Pain on insertion
Use topic anaesthesia before
Use good brand/sharp needles
Not sharp enough
Breakage
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Frances Zhao
Do not bend needle, no dental technique requires this!

Do not change needle direction while embedded in tissues
Avoid 30 gauge needles (59 out of 60 breakage - Malamed, 2004)
Pain on withdrawal
Needle forced to bone producing fishhook barbs on tip
Injury to Patient and Administrator
One-handed Scoop Technique

1. Place needle on flat surface
2. Hold syringe with dominant hand
3. Scoop the needle cap onto the needle
4. Tip syringe vertically to slide cover over needle

5. Secure needle cap by grasping it near the hub
Non dominant hand should be distant! DO NOT hold

onto needle cap with this hand while scooping
Recommended Needles
27 gauge - Short
Most LA injections
25/27 gauge - Long
Inferior alveolar
Gow-gates mandibular
Akinosi mandibular
Infraorbital
Maxillary nerve block
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Frances Zhao
Discharging needles
Recap needle using scoop technique
Remove needle
Check that you did not remove the metal adaptor from the syringe
Place needle into sharps container
Components of a Cartridge
Glass tube (some are plastic)
US - 1.8 ml
UK, Australia - 2.2 ml
Colour code varies by country
Stopper (plunger)
Check if design fits your LA syringe for proper aspiration

Aluminium cap
Diaphragm
Cartridge Content
Plain
Local Anaesthetic: blocks nerve conduction

Sterile water: volume
Sodium chloride: isotonicity of the solution
With vasoconstrictor
Vasopressor: > depth and duration; < absorption

More acidic pH - slower onset of action and more burning on injection
Sodium (meta) bisulfite: antioxidant

Allergies and pain in injection as it oxidises when it gets older
Shelf life for plain LA = 36 months. With vasoconstrictor = 18 months
Care and Handling

Blister packs - not sterile, but very clean
Glass cartridges should not be autoclaved

Store in original package at room temperature (21oC) and in dark place
Light accelerates deterioration of the vasopressor)

Diaphragm can be wiped with gauzes moistened with 70% ethyl alcohol, but should NOT be immersed in it
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Frances Zhao
Bubble in cartridge
Small bubble with nitrogen is normal

Large bubbles caused by freezing - do NOT use, sterility not assured
Extruded stopper
If bubble, caused by freezing

If not, caused by prolonged storage in disinfectant diffused into cartridge (such as alcohol) - do NOT use,
alcohol is neurotoxic and can cause long term anaesthesia

Leakage during injection
Incorrect needle/cartridge preparation

Excessive force in PDL injections (more in plastic cart)
Burning on injection
Normal response to pH of the drug

Cartridge with sterilising solution
Overheated or too cold cartridge
Cartridge with vasopressor
Sticky stopper - more with plastic cartridges

Corroded cap - if immersed in disinfectants
Rust on cap - from the container if there is a leaking cartridge
Broken cartridge
Storage, cracked glass, bent harpoons, extruded plungers
Additional Armamentarium
Topical Antiseptic (optional)
Optional
Povidone-iodine or Chlorhexidine
Topical Anaesthetic
Dry mucosa, apply for 1 minute

Gel better than spray
Benzocaine (ester - allergy)
Lidocaine/Prilocaine (amide)
Mai contain methylparaben as preservative allergy
Applicator sticks
Cotton swabs for topic application

Can be used to compress palatal mucosa
Cotton gauze
Used to dry mucosa for topic LA

Aid in tissue retraction
Haemostat
Not essential, but should be readily available to remove broken needles from tissue
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Frances Zhao
Preparation of Armamentarium
Syringe Preparation
Retract piston fully
Some models are loaded sideways, retracting the piston creates space for the cartridge
Others are loaded by folding the syringe after retracting the piston
Insert cartridge
Side loading - while piston is fully retracted, rubber plunger first

Back loading - insert the cartridge, aluminium end first
Engage harpoon
Gentle push - do not hit, may break glass

In twisted harpoon system, twist clock-wise 1/2 turn
Attach needle to syringe
Remove small protective cap

Screw needle onto syringe
Remove cover and expel a few drops of solution
Placing an additional cartridge

Recap needle using scoop technique
Remove needle
Retract the piston
Remove used cartridge
Insert new cartridge
Embed harpoon
Reattach needle
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Frances Zhao
Some dentists replace the cartridge without removing the needle.

This option can only be used if the system they are using still
permits aspiration.
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Frances Zhao
Part 4: Patient Evaluation and Basic Technique

Medical History
Read the medical history form that patients fill in
Dialogue with patient confirming, checking all relevant information
Record significant medical history in patients electronic or paper file
Update the medical history on a regular basis, at least every 6 months
Has there been any changes in your health since last visit?
Are you now taking any drugs or medications?
Medical Questionnaire
1. Are you having pain or discomfort at this time?
2. Do you feel very nervous about having dental treatment?
3. Have you ever had a bad experience in the dental office?
4. Have you been in the hospital during the past 2 years?
5. Have you been under the care of a medical doctor during the past 2 years?
6. Have you taken any medicine or drugs during the last 2 years?
7. Are you allergic (e.g.itching, rash, swelling of hands or eyes) to penicillin, aspirin, codeine or any
medications?
8. Have you ever had excessive bleeding requiring treatment?
9. What medical condition you have had or have at present?
10. When you walk up stairs or take a walk, do you get very tired or have to stop because of pain in your
chest?
11. Do your ankles swell during the day?
12. Do you use more than 2 pillows to sleep?
13. Have you lost or gained more than 5 Kg in the past year?
14. Do you ever wake up from sleep short of breath
15. Are you on a special diet?
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16. Has your medical doctor ever said you have a cancer or tumour?
17. Do you have any disease, condition or problem not listed?
18. WOMEN: Are you pregnant now? Are you practicing birth control? Do you anticipate becoming
pregnant?
Relative contraindication for LA
Avoid treatment in 1st and 3rd trimesters
Do NOT use Felypressin
Common Medical Conditions

Heart failure
Anaemia
Heart attack
Stroke
Angina pectoris
Kidney trouble
High blood pressure
Asthma, hay fever, sinus trouble, allergies
Heart murmur, rheumatic fever, congenital heart
Diabetes
lesions
HIV, Hep B, Hep C, liver disease, jaundice, drug
Artificial heart valve
addition, haemophilia
Heart pacemaker
Thyroid disease
Implant cardioverter/defibrillator
Pain in jaw or joints
Heart operation
Epilepsy or seizures
Fainting, dizzy spells,
Psychiatric Treatment
Bruise easily
nervousness
Medical Questionnaire (Cardiovascular)

Categorisation of Drugs in Pregnancy
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Physical Examination
Visual inspection
Vital signs
Blood pressure
Pulse
Respiratory rate
Temperature
* Weight/height
E/O Exam
I/O Exam
Adult Blood Pressure Guidelines
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Frances Zhao
ASA Classification and Dental Modifications
Physical Examination
Determination of Medical Risk
Can the patient tolerate both physiologically and psychologically the stresses involved in the proposed
treatment?
Does the patient have a greater risk (morbidity/mortality) than normal?
If patient has increased risk, what modifications are necessary in the planned treatment to minimise this
risk?
Is the risk too great for the patient to be managed safely in the dental office?
Stress reduction protocol

1. Sedation: evening before (E.g. Valium 5mg) Benzodiazepine 5mg
2. Sedation: intra-operative. (can only be done in hospital setting)
3. Effective pain control
4. Morning appointment
5. Time factor: do not exceed patients tolerance. Dont try to do too many things in one appointment.
6. Avoid hot, humid weather
7. Postoperative prescriptions. Call them the following day and make sure theyre happy.
8. Postoperative phone call
Contra-indications for LA
Relative
Malignant hyperthermia or malignant hyperpyrexia
Atypical plasma cholinesterase particularly if youre using articaine. Dont use it. Use lignocaine instead.
Idiopathic or congenital Methemoglobinemia. Use prilocaine.
Absolute
Allergy. If patient told you they had a crisis after an injection last time and had to be hospitalized dont do
it.
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Ratings of Drug Interactions
Local Anaesthetic Drug Interactions

Combination of Local Anaesthetics (Significance Rating 1) e.g. mixing lignocaine and articaine. Its additive!
Toxicity is additive, check maximum recommended doses
Opioid sedation (SR 1) the sedative effects of all the drugs that are sedative will be enhanced by LA.
Increases risk of LA overdose, significant in children
Amide LA with H2- receptor blockers (SR 5)
Cimetidine modifies biotransformation of lidocaine by competing with it for binding to hepatic oxidative
enzymes. These drugs will decrease the function of the liver and make the metabolism of lignocaine
harder.
In ASA III + congestive heart failure - increased risk of LA overdose
Sulfonamides and Esters (SR 5)
Procaine and others may inhibit bacteriostatic action of sulphonamides.
LA induced Methaemoglobinemia (SR 4)
May result from high doses of prilocaine, not likely in normal doses
Prilocaine should not be given to patients with congenital MH since it can lead to significant MH, < oxygen
blood levels
Clinical signs - lethargic, respiratory distress, cyanotic nails, skin pale gray
Treatment - slow IV administ of 1% methylene blue, or ascorbic acid
Vasoconstrictor Drug Interactions

VC and Tryciclic antidepressants (SR 1)
These drugs enhance cardiovascular actions of the VC
There might be some exacerbation of the vasoconstricting effects of the LA more tachycardia etc
More significant in nor-epinephrine, less with adrenalin, but max dose should be reduced to approx 2
cartridges only
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Frances Zhao
VC and Monoamine-oxidase inhibitors - MAOIs (SR 5)

Used for major depression, phobic-anxiety states and obsessivcompulsive disorders
Potentiate actions of VC by inhibiting their biodegradation by the enzyme monoamine oxidase (MAO)
Historically was a contra-indication with VC
Today only phenylephrine remains a contra-indication
Have a chat with the GP and ask for his opinion.
VC and non-selective -adrenoceptor antagonist (blockers) (SR 1)

Increases likelihood of serious elevation of BP
Monitor vital signs, BP/pulse, check before and 5-10min after LA -adrenoceptor Antagonists (-blockers)
Might trigger a serious crisis of high blood pressure
VC and General Anaesthetic (SR 1)

Halogenated gases used in GA can cause cardia dysrhythmias if they receive epinephrine - discuss with
anaesthetist before!
Sometimes you would inject LA to patients already on GA (because you want to limit the bleeding just
want the effects of the adrenaline)
VC and Cocaine (SR 1)

Cocaine stimulates norepinephrine release and inhibits reuptake, producing catecholamine hypersensitivity
This patient will be very sensitive to adrenalineeffects will be obvious
Potentially myocardial ischaemia, lethal dysrhythmias, anginal pain, myocardial infarction or cardiac arrest
Postpone treatment if patient had cocaine within 24 hrs
Do NOT use gingival retraction cord impregnated in epinephrine.
VC with antipsychotic or -adrenoceptor blocker (SR 4)

Hypotension as a result of antipsychotic overdose may be intensified, use VC with caution
VC with adrenergic neuronal blocker - phenotiazine (SR 4)

Used for serious psychiatric disorder
Sympathomimetic effects may be enhanced, if IV injection can cause hypotension. Not contraindicated, but
use small volumes
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VC (epinephrine) with thyroid hormone - thyroxine (SR 4)

Summation effects, use with caution if signs and symptoms of hyperthyroidism are present
Thyroxine will have similar effects to adrenaline.
Important Facts related to LA Injections

54.9% of emergency situations happen during or in the first 5 minutes after LA (Japan)
Over half of the emergencies in America were vasodepressor syncopes (common faint), usually associated
with LA injections. More related to anxiety and stress.
LA administration becomes increasingly traumatic to patient the longer the dentist has been out of school
LA should not be painful
Empathy is the most important skill a dentist must have
USE LESS VASOCONSTRICTOR IF YOURE NOT SURE
Basic Injection Technique

1. Use sterile sharp needle
Check for fishhook-type barb (rare): draw needle back over gauze. If its not going in smoothly you can
already feel that something is wrong.

Change needle after 3-4 penetrations. If you touch bone get another one because its going to be bent.
Patients cannot differentiate between 25-27-30 gauge (23 too thick). 27 is what we usually use.
2. Check the flow of LA solution
After harpoon is embedded, expel a few drops
Self-aspirating systems are not as reliable.
3. Determine whether or not to warm cartridge or syringe
No need to warm if kept at room temperature (21-22oC)
Metal can be warmed by holding in hand for 30s before injection
4. Position the patient
Supine position if possible (head and heart parallel to the floor) with feet elevated slightly. Horizontal
position will be more comfortable for the patient.

Prevents vasodepressor syncope (common faint)
5. Dry the tissue
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Use sterile gauze to dry saliva

Sterile gauze can also be used for retraction
6. Apply topical anaesthetic
Small quantity
Only 2-3mm deep
Ideally 3 minutes
will not numb deeper tissues
(Therapeutic Guidelines), minimum 1 minute
7. Establish a firm hand rest
Patients face, chin
Hard tissues such as teeth, palate
Never have a loose hand on the end.
Patients chest (caution females)
Do NOT rest on arm or shoulders as they may move and cause injuries
8. Make the tissue taut
Stretch tissues, needle will cut with low resistance
The injection is much less painful if the mucosa is really stretched.
Provides better visibility and atraumatic needle insertion
Americas/Europe - fingers
Australia - dental mirror is recommended
9. Keep the syringe out of the patients line of sight
Behind patients head OR
In front, but below line of sight
10. Insert the needle into the mucosa (watch and communicate with patient)
Make sure the bevel of the needle is oriented toward bone
Insert gently but firmly
Watch and communicate with patient
I dont expect you to feel this
Avoid This will not hurt
Should have the arrow pointing towards the bone. If not youll lacerate the periosteum if you
push too hard.

11. Inject several drops of LA solution (optional)
12. Slowly advance the needle toward the target
In patients apprehensive about injections, continue injecting a few drops of LA, wait 2-3 seconds
advance the needle and repeat
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This is NOT needed in most patients as they do not feel pain between the mucosa and the periosteum
usually
13.Deposit several drops of LA solution before reaching the periosteum
Controversial. You might inject into blood vessels.
Periosteum is richly innervated.
Develop you tactile sense, some techniques require bone contact
14.Aspirate
Mandatory before injecting large volumes of LA
Blood in the cartridge is a positive aspiration
If positive, remove syringe and change cartridge.
If you hit an artery youll usually feel it very quickly. If theres a drop of blood theres not too much
problem just reposition the needle. But if theres too much blood throw out the cartridge because blood
is irritating to connective tissues.
15.Slowly deposit the LA solution
Communicate with the patient
Slow = no pain = 1ml/min
1 cartridge = 2 minutes
More realistic: 1 cartridge/minute
Its easy to move your hand if its a huge injection so the best way is to stop midway and reaspirate.
Every time youre in an area of lots of connective tissues the injection should go quite easily (lots of
fatty tissues) e.g. IAN block. For others, if youre injecting into the hard palate its going to be
harder to inject and you need to go really SLOWLY.
At least 1 aspiration during injection - if positive:
Only small volume was injected
Reposition needle, aspirate twice and continue
16. Slowly withdraw the syringe
Discard or recap immediately
When youre injecting its easy to bend the needle you can slowly rotate the needle.
If recapping - One handed scoop technique
If you hit the nerve (especially when youre doing the blocks) withdraw the needle immediately.
Assure the patient.

Nowadays there is no need to place the cartridge in the sharps container, just the needle.
Basic injection technique

1. Observe the patient
Most adverse reactions occur in the first 5-10 minutes after a LA injection
Patients should never be left unattended after a LA
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2. Record the injection on the patients chart/notes

LA name, dose, VC used, needle used, injection given, patient reaction
Volume of LA used ideally put it in ml rather than number of cartridges.
Ex: R-IANB, 25-long, 2% ligno + 1:80,000 adr, 44mg. Tolerated well
Final Recommendations
Good History/Examination
Know the anatomy!
Aspiration
Inject slowly
Observe the patients reaction
Dosage as low as possible
Use anaesthetics with low toxicity
Be prepared for emergencies - equipment and knowledge
Part 5 : Anatomy Revision I

Trigeminal Nerve (V)
Ophthalmic
Maxillary
Mandibular
Most of the patient's face is innervated by the trigeminal nerve. It has both sensory and motor functions.
Huge nerve. Leaves the brain near the pons. The motor component of this nerve will travel with mandibular
nerve only.
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Trigeminal Nerve - Sensory Root

Stereoceptive
Face, nasal cavity, oral cavity, paranasal sinuses, eye bulb, meninges
Proprioceptive
TMJ, teeth, PDL, palate,
Proprioceptive nerve usually work very fast and it's unconscious. They are not well anaesthetized.
Trigeminal Nerve - Motor Root

Masticatory muscles
Masseter
Temporalis
Medial pterygoid
Lateral pterygoid
Other muscles
Anterior belly digastric (whenever you're doing a block you're paralysing this. otherwise we're not usually
blocking these nerves)
Tensor tympani
Tensor palate
Intracranial Part
Origin from CNS
Pons (laterally)
Two nerves
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Sensory root (thick)

Motor root (thin)
Sensory Root
Trigeminal ganglion
Ophthalmic Nerve
o
Maxillary Nerve
o
Superior orbital fissure

Foramen rotundum
Mandibular Nerve
o
Foramen ovalis
Motor Root
No connections to the ganglion
Joins the Mandibular Nerve (Mixed)
Ophthalmic Nerve Branches

Meningeal branch
This branch goes back into the meninges and innervate the dura mater - any pain you have inside your head is
usually because of this nerve.
Lacrimal Nerve (lateral nerve)
Frontal Nerve (intermediate nerve)
Nasociliary Nerve (medial nerve)
Lacrimal Nerve
Branch
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Communicant with zygomatic nerve

Innervation
Skin/mucosa around the lacrimal gland (lateral part of upper eyelid)
Gland innervation is provided by Facial nerve (VII)
Frontal Nerve (travels all through the orbit and innervates the skin around the frontal region.)
Branches
Supraorbital
Suprathrochlear
Innervation
Skin in frontal area
Upper eyelid skin and conjunctiva
Frontal sinus
Frontal bone
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Nasociliary Nerve
Nasocillary nerves that will innervate the eye. Pain around the eye area comes from this nerve. Optic nerve only
innervates the retina.
Branches
Communicans with cilliary ganglion
Long and short cilliary
Posterior and anterior etmoidal
Internal and external nasal
Infratroclear
Innervation
Eye globe
Medial area of eyelid
Nose bridge/tip
Etmoidal sinuses
Superior/anterior area of nasal cavity
Nasocillary nerve innervates all the anterior portion of the nose
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Maxillary Nerve Branches

Meningeal branch also innervates the dura mater
Zygomatic Nerve (lateral)
Infraorbital Nerve and Post Sup Alveolar (intermediate nerves) and its branches which will be all the alveolar
nerves
Pterigopalatine Nerve (medial nerves)
Zygomatic Nerve exits through pterygopalatine fossa
Branches
Zygomaticotemporal
Zygomaticofacial
Innervation
Skin over zygoma, side of forehead and anterior part of temporal fossa
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Posterior Superior Alveolar Branch

Travels inside the maxilla until it reaches teeth - innervates all upper molars except MB root. Teeth, pulp, soft
tissues, bone are innervated by these nerves. Palate and palatal gingiva are NOT innervated by these nerves.
Direct branch from the Maxillary nerve in the pterygopalatine fossa before the nerve enters the orbit
Innervation
Teeth 8 to 6 (not MB root)
Adjacent buccal mucosa and gingiva
Maxillary bone in this area
Mucous membrane of maxillary sinus

Avoid injecting too posterior risk of damaging pterygoid venous plexus
Infratemporal fossa - covered by connective tissues, fat and this mass of blood vessels. In this region there's a
high risk of injecting into blood vessels.
In Australia, dentists tend to only do buccal infiltrations - buccal infiltrations only works well with buccal roots.
PSA blocks work better as it will anaesthetize all the roots
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Anaesthesia Area
Infraorbital Nerve
Branches in the Infraorbital canal
Changes name to infraorbital nerve after getting into the orbit. hit the face via the infraorbital foramen. While
travelling on the floor of the orbit it branches into 2 more branches - MSA and ASA. MSA - premolars and mesial
roots. ASA - canines and central incisors.
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Middle Superior Alveolar Nerve

Variable, leave the infraorbital nerve within the infraorbital canal helping to form the superior dental plexus
It can be absent in some people. Teeth, bone buccal soft tissue, maxiallry sinus except palatal side
Innervation
Teeth 4, 5 and MB of 6

Mucous membrane of maxillary sinus
Anterior Superior Alveolar Nerve

Leaves the Infraorbital Nerve while in the canal, approx 6-10mm before the foramen
Innervation
Teeth 3, 2, 1
Mucous membrane of nasal cavity and sinus
Anterior Superior Alveolar Branch
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Infraorbital Nerve - Branches in the Face

Innervation
Inferior Palpebral lower eyelid skin and conjunctiva
Lateral Nasal lateral skin of nose
Superior Labial upper lip, skin and mucosa
Anterior Superior Alveolar

Infraorbital Nerve - Branches in the Face
Pterygopalatine Nerve
Short nerve located in the pterygopalatine fossa immediately attaches to a ganglion - pterygopalatine ganglion
and then divide into several branches.
Branches
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Orbital, Pharyngeal
Palatine Nerve
Greater palatine nerve
Lesser palatine nerve
Sphenopalatine Nerve
Posterior nasal branches
Nasopalatine nerve
Palatine Nerves
Divides into 2 nerves - greater palatine nerve and lesser palatine nerve. One goes into the soft palate and other
goes into the hard palate. We're numbing the greater but because they're close together we're essentially
numbing both nerves. Patient will feel uncomfortable - they can't feel air flowing through and they might
complain there's something at the throatthats their tonsils.
Greater Palatine
Innervation mucosa of hard palate and gingiva from teeth 8 to 4
Lesser Palatine
Innervation mucosa of soft palate
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Greater Palatine Nerve
Nasopalatine Nerve
Path
Sphenopalatine foramen nasal septum nasopalatine foramen - hard palate
Incisive canal and then gets to the mouth and innervates the anterior part of the palate
Innervation
Nasal septum
Mucosa of anterior hard palate and palatal gingiva from teeth 3 to 1
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Part 6: Anatomy Revision II

Mandibular Nerve
Mixed nerve-has both sensory and motor functions
Anterior division
Muscular branches
Buccal nerve (is sensory)
Mostly motor nerves
Branches forward immediately after foramen ovale
Posterior division
Auriculotemporal (lateral)
Inferior Alveolar (intermediate)
Lingual nerve (medial)
Mainly sensory but there is one branch that is motor
Anterior Division - Muscular Branches

Branches and Innervation
Medial pteygoid nerve (direct from the mandibular nerve)

Masseteric nerve
Deep temporal nerves
Lateral pterygoid nerves
We usually dont numb as high as the foramen so dont expect these muscles to be paralyzed.
Facial nerve innervates the buccinator.
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Anterior Division - (Long) Buccal Nerve

Provide sensation over a little part of the cheek but mainly sensation of the inner mucosa of the cheek.
Innervation
Skin of cheek
Mucosa of cheek
Buccal gingiva of lower molars (need to numb before you do extractions of the lower molars)
The motor innervation of the buccinator muscle is provided by the Facial Nerve (VII )
Crosses the anterior border of the mandible (you can feel that in some people)
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Yellow line where the nerve travels. Over the anterior border of the ramus
Great auricular nerve comes from the cervical plexus. (might need some local infiltrations to cover that nerve)
(Long) Buccal Nerve and Great Auricular Nerve

Buccal nerve area can overlap with the great auricular nerve area
Therefore usually additional injections are needed for the mandibular buccal soft tissues
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Posterior Division
Meningeal Branch (supplying dura mater)
Auriculotemporal (lateral nerve)
Inferior Alveolar to teeth and jaw (intermediate nerve)
Lingual (medial nerve)
Auriculotemporal Nerve
Path
Goes posteriorly contours mandibular neck - parotid bed - zygomatic arch preauricular area - temporal
region
Supplies innervation to TMJ (any pain related to TMJ will be from this nerve)
Travels posteriorly after the foramen goes behind the TMJ and behind the ear and goes up to the
temporalis region. Travels through the parotid gland. Rare to have to anaesthetize it. Need to do an
external injection to numb this nerve.
Innervation
TMJ, parotid area (sensory), meatus, tympanic membrane and temporal region skin
The secretory innervation of the parotid gland is provided by the Glossopharyngeal Nerve (IX)
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Inferior Alveolar Nerve
Branches in the Infratemporal Fossa
Mylohyoid nerve (anterior belly of the diagastric and the geniohyoid muscle)
Branches in the Mandibular Canal
Dental branches
Osseous branches
Mental nerve
Incisive nerve
Base and of the skull and the point where it enters the mandible you can only anaesthetize it in this region.
Once it reaches the mandible, it travels below teeth and will supply bone, PDL and pulp.
Mentalis nerve when it exists the mandible.
Structures around the IAN area

The needle stays behind the mandible and medial pterygoid muscle and not too close to the muscle (will
cause trismus).
Medial
Medial pterygoid muscle
Lateral
Mandibular ramus
Posterior
Parotid gland
External carotid artery
Retromandibular vein
Facial Nerve (VII)
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If you go too far back, the needle will enter the parotid gland and youll enter up with facial paralysis.
Mylohyoid Nerve
Path
Leaves the IAN before it enters the mandibular canal
Innervation
Motor for anterior belly of diagastric
Motor for geniohyoid muscle
?? Pulp mesial root lower 6
Skin under mental protuberance
Inferior Alveolar Nerve

Path
Enters mandibular canal and divides into mental nerve and incisive nerve in the 4-5 area
Innervation (after mylohyoid nerve)
Bone branches - mandibular bone
Teeth branches - all inferior teeth

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Mental nerve - skin and mucosa of lower lip and mental area
Incisive branch - Teeth 4 to1, bone and buccal gingiva from 4-1
Mental nerve
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Incisive Branches of the IAN
Lingual Nerve
Path
Infratemporal fossa - anterior to IAN - over mylohyoid muscle flor of mouth - tongue
Innervation
Sensory anterior 2/3 tongue
Floor of mouth
Soft tissues/gingiva on lingual side of teeth 8-1
The Lingual Nerve carries secretory fibres to the submandibular and sublingual glands, as well as
gustatory fibres from the anterior 2/3 of the tongue - All from the chorda tympani branch of the Facial
Nerve (VII)
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Tongue Innervation
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Overview of Mandibular Nerve
Intra-oral Mandibular Innervation Areas know this by heart!!!
Bones Structures of Relevance

Remember the differences in bone thickness around each tooth
Buccal
Palatal/lingual
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Apical
Correlate skull, particularly maxilla and mandible to the nerves studied
Foramen
Fissures
Grooves
Canals
Fossae
Part 7: Maxillary Techniques

Overview of Maxillary Nerve
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Terminal injections
Supraperiosteal (Buccal infiltration most common injection in the maxilla)
Aiming at the apex of the tooth or slightly higher than the apex of the tooth.
Indications
Pulpal and buccal tissues

Mostly used in maxilla
Contraindications
Infection
Dense bone over apices
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For extractions need palatal/ lingual complement

Only numbs the buccal soft tissues and the pulp but NOT the palatal soft tissues
Need a very thin buccal plate and the roots of the tooth to be close to the buccal. Palatal roots of the first
molar buccal infiltration might not work.
Where can we use Supraperiosteal?

Superior Incisors/Canines
YES
Superior Premolars
YES
Superior Molars
YES for Buccal Roots

Palatal roots NO
Where can we use Supraperiosteal?

Not generally in mandible
Inferior Incisors / Canines YES

Inferior Premolars NO (cortex too thick)
Inferior Molars NO (cortex too thick)
Supraperiosteal Technique
Introduce the needle parallel to the long axis of the tooth into the area where the buccal mucosa folds.
Dont have to touch periosteum. Technique doesnt require the needle to touch bone. Works well in the maxilla
apart from the central and lateral incisors not much space to expand into.
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Supraperiosteal Technique
Needle
27 short
Entry point
Mucobuccal fold above apex
Target area
Apical region of the tooth, close to the bone
Technique
Syringe parallel to tooth long axis
Depth
Usually a few millimetres
Volume
1/3 of cartridge over 20 secs
Risks
Pain if touches bone, withdraw
Anaesthetised area
Pulp, root area(bone), buccal soft tissue
Intraligamental PDL very painful!! Not used routinely.
Indications
Extractions (compliment) when other techniques fail

Avoid using for other procedures, supraperiosteal is better
If blocks should not be given
Can damage PDL
Contraindications
Infection
Painful, do not use as main injection
Primary teeth (can damage permanent tooth)
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Needle
27 short or 30 extra-short
Entry point
PDL, gingival groove
Target area
PDL
Technique
Syringe parallel to tooth long axis, if available use pressure syringe
Depth
Volume
0.2ml over 20secs
Risks
Painful, can damage PDL, needs buccal and lingual infiltrations, solution not
retained
Anaesthetized
area
Pulp (not always), root area (bone), soft tissues in the area of injection
Intraseptal/Intrapapillary
Indications
Deciduous teeth or local injectiononly when a little gingiva needs to be anaesthetized.

Applied on the mesial and distal papillae of the selected tooth
Same injection from buccal to palatal, slowly inserting deeper
More painful than supraperiosteal
Contraindications
Infection
Needle
27 short
Entry point
Centre of interdental papilla
Target area
PDL
Technique
Needle 90 degrees to gingival (45 to tooth)
Depth
Volume
0.2-0.4mL over 20s ischemia noticeable, resistance of injection
Risks
More painful than supraperiosteal, short duration
Anaesthetized
area
Soft tissues and bone in the area of injection
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Intraosseous
Indications
Rarely used, only if other techniques have failed

Can be used in posterior mandible
Technique
Mucosal anaesthesia
Bone drilled towards apex of tooth with slow speed
Needle inserted in the trabecular bone area
Injects directly into bone. Creates a hole using a bur in the bone and then inject the anaesthesia.
Intrapulpal
Indications
Radical Root Canal Therapy

Tooth sectioning in extractions
Provides anaesthesia by LA action and pressure
Used if other techniques fail
Contraindications
None
Sometimes only technique
Very painful so do it very quickly
Advantages
Lack of lip/tongue anaesthesia

Immediate onset of action
Disadvantages
Need small opening in chamber

Traumatic - brief pain
Bending of needle may be needed
Could kill the pulp!
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Needle
27 short
Entry point
Pulp chamber
Target area
Pulp
Technique
Deposit under pressure, may leak, may need to bend needle
Depth
Volume
0.2-0.3 ml under pressure, 20s
Risks
Solution not retained in tissue advance needle further into chamber or root canals
Anaesthetized
area
Pulp
Local Infiltrations
Indications
Used in areas with mixed innervation

Can be applied distant from an infected area
Skin procedures
Technique
Several peripheral injections to numb central area

Introduce needle trough previously numbed area
Commonly used in skin
Palatal infiltrations if not using greater palatine block. Can do two small injections
Can be used in conjunction with supraperiosteal to anaesthetise the palatal soft tissues
Local Infiltrations - Buccal nerve
Buccal side of the lower molars. Local Infiltrations - Buccal nerve
Anatomy
Posterior Superior Alveolar

Middle Superior Alveolar
Anterior SA (Infraorbital)
Greater Palatine
Nasopalatine
Maxillary Nerve
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Maxillary Nerves Anaesthetised
Anatomy
Maxillary Nerves
Posterior Superior Alveolar Nerve
Travels from pterygopalatine fossa downloads
Done on posterior side of the maxilla
Indications
Treatment in 2+ molars
Palatal roots (while sometimes buccal infiltration will not)
If supraperiosteal has failed
Contraindication
If risk of haemorrhage is too high

Injecting close to the plexus of veins need to be very efficient with aspiration. Can tear small
blood vessels in that plexus while introducing the needle a small hematoma will develop
immediately. If this happens, stop immediately. The hematoma will develop in the patients face.
Advantages
High success rate (>95%)

Reduced number of injections
Minimizes volume of LA
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Disadvantages
Risk of hematoma
Technique arbitrary - no bony
Avoid injecting too posterior risk of damaging pterygoid venous plexus
Second injection needed for BL(MB?) root of upper 6 (28% of patients)
Anaesthetised Area
Pulps of upper molars except MB root of upper 6

Bone and max sinus in the area
Buccal soft tissue
Complications
Haematoma (too far distally)

Possibility of numbing maxillary (V2) and Abducent (VI) nerves(too high)
Possibility of numbing mandibular (V3) nerve (too lateral)
Too far back will numb the whole infraorbital nerve
Too high up can hit abducens nerve patient will start to have double vision
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Technique
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Needle
27 short
Entry point
Mucobuccal fold above the upper second molar
Target point
PSA posterior, superior and medial to posterior border of maxilla
Technique
Mouth semi-opened, syringe 45 inward, 45
Depth
Average 15-16mm, close to PSA, no need to touch bone (covex surface of maxilla)
Volume
to 1 cartridge over 30-60secs
Risks
Haematoma, other nerves anaesthethized such as v/2, v/3, and orbital nerves (VI)
Anaesthetized
area
Upper molars except MB root of the 6, buccal bone and soft tissues in the area, maxillary
sinus
Anatomy
Infraorbital Nerve
Middle Superior Alveolar
Branches on the Face

Superior Labial
Lateral Nasal
Inferior Palpebral
Premolars, MB root of the first molar.
Dont have a specific technique.
Injection above the premolar region (like a buccal infiltration)
MSA starts all the way from the orbit so hard to reach.
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Present in 28-54%. When MSA is absent, the ASA supplies the area
Indications
Procedures in premolars and to compliment MB of first molar
Contraindications
Infection
Area anaesthetised
Upper premolars and MB root of first molar, buccal bone and soft tissue
Upper lip may get numb
Technique
Like a supraperiosteal injection above the second premolar, but higher
Needle
27 short
Entry point
Mucobuccal fold above the upper second premolar
Target area
Bone above apex of 2nd premolar
Technique
Like supraperiosteal, syringe parallel to tooth, check bevel (close to bone)
Depth
Around 10mm, can touch bone, but should retract to avoid injecting under periosteum
Volume
1/3 to cartridge over 30-40 secs
Risks
Haematoma, other nerves anaesthetized such as v/2, v/3 and orbit (VI)
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Anaesthetized
area
Upper molars except MB root of the 6, buccal bone and soft tissues in the area maxillary sinus
Anterior Superior Alveolar Nerve

Usually buccal infiltrations work well with anterior maxilla but if you want to do procedures in more than
one tooth you can block the ASA.
Indications
Dental procedures in more than 2 maxillary teeth

When supraperiosteal is ineffective due to dense cortical bone
Limitations
Some dentists are afraid to damage the eye

Difficult anatomical landmarks
Very painful injections close to the nose which is very sensitive
Alternatives
Supraperiosteal
Alternative: Supraperiosteal above the canine area
Area anaesthetised
Branches on the Face

Immediately anaesthetised: lower eylid, upper lip, nose laterally
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Anaesthetised later: because the nerve is located approx. 1 cm deep into the canal - needs massage.
Midline to premolars (72%) or to canine (28% when MSA present), pulp, bone and buccal soft tissues
ASA - Infraorbital Foramen
Technique 1 - Central Incisor as Reference

Mesio-incisal corner to disto-cervical corner of the tooth
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Technique 2 - Vertical using the 1PM as Reference

Closer to the lip than to the gingiva a little more distal
Needle
27/25 long (short in smaller patients)
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Entry point
Mucobuccal fold above the upper first premolar, but more towards the lip than in
supraperiosteal
Target area
Infraorbital foramen (below IO notch)
Technique
Syringe parallel to 1PM, avoid premature bone contact, check bevel, keep finger over
foramen, massage/pressure area for 1-2 minutes after injection.
Depth
Average 15-16mm (1/2 long)
Volume
cartridge over 30-40 secs, feel LA solution beneath finger
Risks
Pain if touches bone, shock sensation
Anaesthetised area
Midline to premolars (canines if MSA), buccal bone and soft tissue, upper lip, lower eyelid,
nose
Greater Palatine Nerve
Areas anaesthetised
Posterior part of hard palate up to premolars

Palatal gingiva 8-4
Problems
All palatal injections can be painful but a great palatine nerve block done properly is the least
painful of all palatine injections.
Apply pressure with cotton stick/topic
Ischemia and necrosis may happendont overdo it.
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Technique
Doesnt go through the foramen itself dont have to touch bone
Needle
27 short
Entry point
Mucosa over greater palatine foramen-palpate depression over 2nd molar area, between
gingival border and midline, just in front of soft/hard palate junction
Target area
Greater palatine foramen
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Frances Zhao
Technique
After topical, apply pressure with cotton swab over foramen 30sec, needle inserted 90
Depth
Less than 10mm
Volume
of a cartridge over 30 secs minimum
Risks
Necrosis if too much ischaemia
Anaesthetized area
Hard palate and palatal gingival from 8 to 4
Nasopalatine Nerve
Needle
27 short
Entry point
Palatal mucosa just lateral to the incisive papilla
Target area
Incisive foramen beneath the papilla
Technique
Injection 45
Injection straighten needle until bone is touched
Depth
Around 5mm
Volume
1/5 to of a cartridge over 30sec
Risks
Painful, injection slowly, risk of ischaemia/necrosis
Anaesthetized area
Nasopalatine nerves bilaterallyhard palate and palatal gingival from 14 to 24
*Nasopalatine numbing both sides as both nerves are joined together at this junction. Sometimes from canine
to canine.
Maxillary Nerve
Technique 1 - High-Tuberosity (like a PSA block but high up to hit the maxillary nerve)
Approach
Via the maxillary tuberosity, similar to a high PSA block
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Technique 2 - Greater Palatine
Approach
Via the greater palatine foramen until the pterigopalatine fossa is reached
Great risk off damaging GP nerve
Technique 3 - Extra-oral
Approach
Under zygomatic arch, needle aims corner of eye

Very dangerous, risk of braking needle if patient opens mouth (goes through several masticatory
muscles)
Should not be used
Will be going through all the muscles of mastication and can potentially damage them
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It didnt work!!!
How do I know if it worked?
Tingling (know your target nerve distribution)

Using probe (gentle at first)
Cutting into tooth
Patient will feel touch and pressure, not pain, double check and reassure
Analyse the problem - dont just re-give
Check anatomy (usual cause of failure)
Check other factors
Part 8: Mandibular Techniques

Buccal infiltrations usually work as well as the block.
Buccal side of molars need to numb the buccal area (buccal nerve)
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Mandibular Nerves Anaesthetised
Anatomy REMEMBER THIS DIAGRAM!!!!
Inferior alveolar nerve block
Heightreference the occlusal plane of the mandible. The nerve lies about a 1cm above the occlusal plane of
the mandible.
Common mistake inject it too low.
Not a big problem if you inject it too high.
The nerve lies resting on the median pterygoid nerve and lingual nerve.
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Frances Zhao
You need to puncture the buccinators to reach the area. You dont want your needle to go through the median
pterygoid muscle. Initially insertion point should not be too medial. If the initial insertion point is too close to the
pharynx. Pterygoid mandibular raphe marks where the buccinators starts and where the anterior border of the
median pterygoid muscle is.
Branches
Mylohyoid nerve
Dental branches
Osseous branches
Mental nerve
Incisive branch
Inferior Alveolar Nerve Block
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Frances Zhao
Nerves anesthetised
IAN
Mylohyoid
Incisive
Mental
Lingual
Areas anesthetized
Mandibular teeth
Body of mandible, inferior part of ramus
Buccal soft tissues anterior to first molar, lower lip, chin (mental nerve)
Anterior 2/3 of tongue (lingual nerve)
Lingual soft tissues and floor of mouth (lingual nerve)
Advantages
One injection, wide area anesthesia

Can be a disadvantage especially for kids who could accidentally hurt their tongue, cheeks etc
Disadvantages
Wide area of anesthesia

15-20% failure
Intraoral landmarks not consistant
Positive aspiration (10-15% highest of all IO techniques). There are lots of blood vessels in there as well.
Tongue and lower lip anesthesia discomfiting for many patients
Check on the OPG where the foramen is particularly the height of the foramen.
Final position of the needle will be in the middle between the mandible and the median pterygoid muscle. If
youre not hitting the mandible, it can mean that youre closer to the muscle than to the bone or youre too far
back.
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Frances Zhao
Lateral to the raphe, theres a depression (where you put the needle in) and go more laterally youll feel
the anterior border of the mandible.
Keep the syringe parallel to the lower occlusal plane. You should use at two-thirds of the long needle
before you hit bone. Second, youre going to put it closer to the canine, more posteriorly.
Ideal position syringe over inferior premolars
If bone resistance: withdraw slightly and bring syringe over canine-incisive
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Complications / Errors
Early bone contact - withdraw slightly and rest syringe anteriorly over canine/incisive
Overinsertion, no bone contact - risk of injecting into parotid, facial nerve paralysis
Needle inserted too medially - risk of perforating the medial pterygoid muscle trismus post-op
Needle too low - below the foramen willlead to failure of the block - inject higher next time
Facial Nerve Paralysis in IAN Block (too posterior/deep)
Inferior Alveolar Nerve / Lingual Nerve

Because the Lingual Nerve runs anteriorly and very close to the IAN, usually both are anaesthetised at the
same time
2/3 of the needle in and 1/3 of the needle out.

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Needle
25/27 long
Entry point
1cm above occlusal plane, between pterygomandibular raphe and anterior border of ramus
Target area
IAN before it enters the mandibular foramen
Technique
Wide opened mouth, rest syringe over corner of mouth or lower premolars on opposite side,
bone contact needed
Depth
20-25mm (2/3 to ) of long needle
Volume
to 1 cartridge if lingual nerve as well
Risks
Aspiration essential
Facial nerve (too deep)
Medial pterygoid (too medial)
Anaesthetized
area
IAN: mandibular teeth, mandibular, buccal soft tissues from 5 to 1, lower lip.
Lingual nerve: anterior 2/3 tongues, floor of the mouth, lingual soft tissues/gingiva
Mental Nerve
Mental Nerve Block

Area anaesthetised
Mental nerve - lower lip, chin, buccal mucosa from 5 to 1 (quickly obtained as it leaves the mandible)
Incisive nerve - premolars,canine and incisives, bone in the area (this branch is anesthetised slowly as the
LA enters the mental canal reaching the mandibular canal)
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Advantages/Indication
Dental procedures in anterior mandible

When IANB is not indicated
No lingual anaesthesia
High success rate
Up to the first premolar
Disadvantages
Requires injection for lingual soft tissues (need to do a lingual nerve block as well)
Midline can require complimentary injection
Shock sensation when nerve is touched (if it happens withdraw slightly)
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Incisive Branches of the IAN

Anatomy
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Alternative Technique - Supraperiosteal
Lingual Nerve
Can numb anywhere along where the lingual nerve travels doesnt have to do it with the IAN.
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Technique 1 with IAN block
Technique 2 floor of the mouth
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Frances Zhao
Buccal Nerve
You need to do a separate injection for the buccal nerve. Very superficial (only need to penetrate 2-3mm.
same angulation as the IAN.
Indications/Advantages
Buccal anaesthesia in lower molars area

Good success rate, easy
Disadvantages
Potential pain if periosteum touched

Possible innervation from Greater Auricular Nerve
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Technique

Buccal nerve area can overlap with the great auricular nerve area
Therefore usually additional injections
Neede
27 short
Entry point
Mucous membrane distal and buccal to last molar
Target area
Buccal nerve as it crosses an border of ramus
Technique
Syringe parallel to occlusal plane but buccal to it
Depth
Usually a few mm, just perforate buccinators
Volume
0,3ml over 10s
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Risks
Few, haematoma?
Anaesthetized area
Buccal soft tissues lower molar area, cheek mucosa
Gow-Gates Mandibular block

Described in 1973 (Australian!)
Supposedly high success rate
Anaesthesia of the entire Mandibular nerve, including the IAN, Lingual N, and Auriculotemporal N
Less positive aspiration (2% over 10-15% with regular block)
Steep learning curve, could be used if block fails
Target area
Neck of condyle
Below Lateral
Reference landmarks-maxillary second molar
Corner of mouth
Tragus
Intertragic notch
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Frances Zhao
Needle
25/27 long
Entry point
Mucous membrane medial to mandibular ramus, just distal to the maxillary second molar, much
higher than in the normal IAN block (10-25mm above mandibular occlusal plane)
Target area
Lateral side of condylar neck, below lateral ptergygoid muscle
Technique
Syringe parallel to the line from the intertragic notch to the corner of the mouth, resting over PM,
but can go to incisives
Depth
Average 25mm, similar to IANB, bone contact needed
Volume
1 cartridge over 60-90 secs
Risks
Check bone contact, VII nerve paralysis
Anaesthetized
area
Entire mandibular nerve, including auriculotemporal
Vazirani-Akinosi Block
Mandibular Block - Extra-oral
Indications
Patients with trismus, since it will also anaesthetise the motor fibres for these muscles
Technique
Under zygomatic arch
Through masseter and sigmoid notch

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Aims foramen ovale
NOT used regularly

Described in 1960 (Vazirani) and 1977 (Akinosi)
Indication
Closed mouth, trismus
Alternative to extra-oral techniques in these cases
Area Anaesthetised
Mandibular nerve, including the IAN, lingual nerve, auriculotemporal nerve and muscular
branches (masticatory muscles)
Needle
25/27 long
Entry point
Mucous membrane medial to mandibular ramus, directly adjacent to the maxillary tuberosity,
at the height of the mucogingival junction adjacent to the upper third molar
Target area
Soft tissues medial to mandibular ramus (pterygomandibular space), above IANB and below
Gow-gates
Technique
Closed mouth, syringe parallel to maxillary occlusal place, bevel away from mandibular ramus
(needle deflects towards the ramus), NO bone contact
Depth
Average 25mm, similar to IANB, bone contact needed
Volume
cartridge over 60secs
Risks
Same as with Gow-gates
Anaesthetized
area
Entire mandibular nerve, including auricolutemporal
Part 9: Complications
Most common complications are related to anatomical ortechnique problems
Incomplete or failure of LA effect - Example - IANB
Overdose and toxicity usually related to intravascular injections
Particularly with Vasoconstrictors

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Common faint is the most common systemic complication

Dentists should be able to manage these complications
Proper equipment
Staff and personal training
Needle breakage and injuries
Persistent anaesthesia or paraesthesia
Facial and orbital nerves paralysis
Trismus
Soft tissue injury
Hematoma
Pain and Burning on injection
Infection and Edema
Tissue vascular necrosis
Needle breakage and injuries

Breakage
Do not bend needle, no dental technique requires this!

Do not change needle direction while embedded in tissues
Avoid 30 gauge needles (59 out of 60 breakage - Malamed, 2004)
Do not embed too deep into tissues, you should be able to grab it if it breaks - artery forceps
IAN Block
33/34 litigation cases with broken needles in the US
Injury to Patient and Administrator

1. Place needle on flat surface
2. Hold syringe with dominant hand
3. Scoop the needle cap onto the needle
Non dominant hand should be distant! DO NOT hold onto needle cap with this hand while scooping
4. Tip syringe vertically to slide cover over needle
5. Secure needle cap by grasping it near the hub
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Nerve Injuries
Neuropraxia 10-12 days
Axonotmesis 6 weeks
Neurotmesis unlikely to recover
Causes
Trauma from needle

Injection with LA contaminated with alcohol
LA solution: articaine and prilocaine > lidocaine
Hyperesthesia worse
Management
Usually recovered in 8 weeks, permanent if severe damage

Reassure patient, examine every 2 weeks
If over 1 year send to Oral surgeon or neurologist
Facial nerve paralysis

Causes
Injections IANB and Mandibular blocks too deep, posterior, no bone contact
DONT USE ARTICAINE FOR BLOCKS. Just for buccal or local infiltrations.
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Facial nerve paralysis

Management
Reassure patient, back to normal after LA stops

Remove contact lenses, cover eye with patch, record incident
Orbital nerves paralysis
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Frances Zhao
Management
Test eye movement in all directions
Reassure patient, back to normal after LA stops
Trismus
Causes
Usually injections through thick muscles such as the medial pterygoid

Intramuscular injections - LA is toxic can cause muscular necrosis
Haemorrhage and infection - tissue irritation, muscle disfunction
Excessive volumes of LA
Medial Pterygoid muscle
Shouldnt have trismus after LA (if it happens, thats usually because youve hit the median pterygoid
muscle. the way muscles recover from injury is by contracting trismus
Prevention
Sharp disposable needles, correct technique, atraumatic insertion

Avoid repeated injections
Use minimum effective volumes of LA
Management
Heat therapy (20min/hour), warm saline rinse

Analgesic/antiinflamatory, Diazepan (as muscle relaxant)
Physiotherapy (open/close/lateral movements)
Examine patient
If more treatment needed with trismus, use Vazirani-Akinosi technique
Improvements usually within 48-72 hours
If no improvement in 2-3 days consider infection - antibiotics
Refer to specialist if it does not improve in 5-7 days
Soft tissue injury

Causes
Bites or injuries on lips, tongue, cheek while still anaesthetised
Prevention
Inform patient, avoid eating and drinking while numb

Use LA with proper duration
Management
Analgesics, saline rinses, petroleum jelly (lubricant)
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Hematoma
Cause - puncture of vein or artery
Management
Immediately - stop procedure, apply pressure at least 2 minutes

Subsequent - discharge once bleeding stops, advise of risk of trismus, discoloration of mucosa/skin
Heat after 24 hours. Lasts for 7-14 days, follow up!
Pain on Injection
Pain on insertion
Use topic anaesthesia before

Use good brand/sharp needles, inject SLOWLY
Pain on withdrawal
Needle forced to bone producing fishhook barbson tip
Burning on Injection
Causes
Normal response to pH of the drug (more with VC)

Normally due to temperature
Solution injected too fast
Cartridge with sterilising solution
Overheated or too cold cartridge
Neurotoxicity of the LA
Management
Transient effect, reassure patient
Infection and Edema

Infection
Causes - contaminated needles, injecting LA in an area with infection, lack of sterile technique, storage
problems
Management - treat as for trismus, may require drainage and antibiotics - check oral surgery lectures
Particularly if youre going through an area of infectionwill bring the infection to the other areas.
Edema
Causes - infection, allergy, haemorrhage

Management - usually not a problem, BUT: if swelling is due to allergy: angioneurotic edema may
compromise airway, see systemic complications (ABC, adrenalin, corticosteroid, antihistamine)
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Tissue Vascular Necrosis

Causes
Excessive volume / VC
Occurs usually 2 days after injection - ulcer
Differentiate from aphtous stomatitis and Herpes simplex
Management
Symptomatic, topic anaesthetics

Lasts for 7-10 days with or without treatment
Applying too much pressure and introducing air into the tissue.
Systemic effects of LA
US - 300 million of cartridges a year
LA are safe drugs
Drug Administration:
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 toxicity of a drug rests in the hands of the user
Classification of Adverse Effects

Allergy X overdose
Allergy
Overdose
Dose
Non-dose-related
Dose-related
Signs and symptoms
Similar, regardless of allergen
Related to pharmacology of the

drug
Management
Similar (epinephrine, histamine

blockers)
Different, specific for drug

administered
Overdose - Causes
Normal
Constant absorption
Constant removal
Liver disfunction
Constant absorption
Removal slower
Large dose (normal liver)
Constant absorption
Liver cannot remove fast enough from CVS
Intravascular Injection
Increased absorption in CVS in very short time
Overdose - Predisposing Factors

Patient Factors
Drug Factors
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Age
Vasoactivity
Weight
Concentration
Other drugs
Dose
Gender
Route of administration
Presence of disease
Rate of injection
Genetics
Vascularity of the injection site
Mental attitude and environment
Presence of vasoconstrictors
REMEMBER THE DOSAGES PARTICULARLY ADRENALINE
Dosage of local anaesthetics remember

Mg/ml
2.2ml
=1cartidge
Max dose
(mg/kg)
Max 2.2ml
cartridge
(adult)
Max 2.2ml
cart (20kg)
Mepivacaine
3%
30
66mg
AUS NS
AUS 3
1-2
US 6.6
US 6
Mepivacaine
2% + epi
1:100,000
20
AUS NS
AUS 3
US 6.6
US 6
Lidocaine 2%
+epi
1:80,000
20
4.4 (2007)
11
Articaine 4%
+epi
1:100,000
40
88mg
1.3
Prilocaine 3%
felypressin
30
66mg
6(2007)
Bupivicaine
0.5% +epi
1:200,000
44mg
44mg
1-2
7(2012)
9(2012)
11mg
1.3
Adrenaline - Maximum doses

Healthy Patients (ASA I) Maximum dose - 200 micrograms
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Frances Zhao
Sick patients (ASA III and IV) Maximum dose - 40 micrograms

LA Overdose - Central Nervous System
LA Overdose - CVS and Respiratory

CVS
Myocardial depression
Bradycardia
Peripheral vasodilation
Hypotension
CV collapse
Cardiac Arrest
Respiratory
Respiratory depression
Respiratory Arrest
Management of LA Overdose
Mild overdose
Position patient comfortably (supine, feet elevated)

Check ABC if needed
Reassure patient
Administer oxygen (nasal cannula)
Monitor/record vital signs
IV line (if trained)
Wait for patients recovery
Management of LA Overdose
Severe overdose
Position patient in supine position, feet elevated

Check ABC, CPR if needed
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Frances Zhao
If convulsions:
Protect patients head, arms, legs
Request medical emergency assistance
Continue CPR
Seizures last usually 1-3 min
If > 5 min, consider anticonvulsants (IV diazepam 5mg/min, or IM midazolam 5mg) - medical help!
Post seizure phase - patient drowsy or unconscious, breathing shallow, low BP, low heart Frequency may require CPR and epinephrine
Epinephrine Overdose
Management of Epinephrine Overdose

Terminate the procedure, and:
Position patient comfortably (supine, feet elevated)

Check ABC if needed
Reassure patient, anxiety and restlessness are common signs
Administer oxygen (nasal cannula)
Monitor/record vital signs
Wait for patients recovery
Overdose summary
Local anaesthetic
Epinephrine
Stop treatment
Stop treatment
Place patient supine elevate feet
Place patient supine elevate feet
Basic life support ABCD
Basic life support ABCD
Administer oxygen
Administer oxygen if not hyperventilating
Give IV anticonvulsants if trained
Reassure patient
Reassure patient
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Allergy
Causes of Allergy
Esters
Drug itself
Preservatives (methylparaben)
Amides
Rare
Vasoconstrictos
Usually due to antioxidant: Sodium (meta) bisulfite
Positive skin testing to one local anaesthetic does not provide any information about other drugs
Prevention of Allergic reactions

Medical questionnaire
Known allergies, asthma, serious anaphylactic episodes
What treatment was given, hospitalisation needed?
What position was the patient?

-
upright LA may have caused vasodepressor syncope, not allergy
Contact the GP
Types of allergic reactions

Type
Mechanism
Time of reactions
Clinical examples
Anaphylactic (immediate)
Seconds minutes
Anaphylaxis, angioedema,
urticarial, hay fever
II
Cytotoxic
--
Transfusion reactions,
haemolytic anaemia,
certain drug reactions
III
Immune complex
6 to 8 hours
Serum sickness, acute viral

hepatitis, lupus nephritis
IV
Cell-mediated
48 hours
Allergic contact dermatitis,

infectious granulomas (TB),
chronic hepatitis
Progression of Anaphylactic Reaction

1. Early phase - skin reactions
Feeling sick, itching, flushing, giant hives (urticaria) over face and chest, conjunctivitis, vasomotor rhinitis,
pilomotor erection
2. GI an genitourinary reactions - smooth muscle spasms
Nausea and vomiting, sever abdominal cramps, diarrhea, fecal and urinary incontinence
3. Respiratory reactions
Chest pain, cough, wheezing (bronchospasm), dyspnea, cyanosis, possible laryngeal edema
4. Cardiovascular reactions
Pallor, lightheadedness, palpitations, tachycardia, hypotension, cardia dysrhytmias, unconsciousness
Management of patients with alleged LA allergy

Assume that allergy exists
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Frances Zhao
Elective care
Postpone until thorough evaluation of the allergy
Emergency dental care

Option 1 - no invasive treatment, maybe nitrous sedation, send to GP
Option 2 - send to GA
Option 3 - if allergy was from ester LA, use amide LA
Management of patients with allergic reactions

Delayed skin reactions
ABC if needed
Oral histamine blocker (50mg diphenhydramine 6/6hr for 3-4 days)
Observe for 1 hour before discharge
If drowsiness from anti-histamine, should not leave unescorted
Immediate skin reactions
ABC if needed
Administer epinephrine 0.3 mg IM or SC
Administer IM histamine blocker
Obtain medical advice (000) before patient leaves
Management of patients with allergic reactions

Depends on how soon the allergic reactions developif they develop immediately, seek help immediately!!
Respiratory Reactions Bronchospasm (Asthma)
ABC if needed
Stop treatment
Oxygen 5-6 L/min
Administer aerosol inhaler (salbutamol or albuterol)
Observe for 60 min, consider epinephrine IM or SC
Medical help (000)
Anaphylactic Reactions Laryngeal edema
ABC - call 000 immediately

Epinephrine, repeat every 10 min if no improvement
Oxygen
Check vital signs
Histamine blocker IM
Hydrocortisone
Maintain airway, cricothyrotomy last resource
Emergency Drugs and Equipment

Dental Practices have a wide range of setups:
From no equipment ?? to full emergency doctors bag
Medical emergencies are uncommon

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Risk that medications will expire before needed

Easily overlooked or expensive
All dental practitioners have an obligation to ensure that they are properly trained and are up to date with
emergency management (including staff, DAs should have at least a basic first aid and CPR certificate)
Emergency Plan
Every practice needs to have an established plan for emergencies
Numbers 000 and next medical facility should be prominently placed
Consider time to get to your practice

More time / distance needs more equipment and staff training
Location of equipment known

Training staff and YOU!!!!
Minimum Requirements
Oxygen
Easily transportable to the patient

Via a bag, mask or nasal 6-8L/min
Disposable plastic airway (Guedel)

Adrenaline
Pre-loaded vials (1:1,000 or 1:2,000) for tongue or anterolateral thigh injections

Enough in the office for at least 2 doses
Dental practitioners should carefully consider their emergency equipment needs and staff training, relevant to
their location, patient population and practice type

Second Level of desirable
Medications
Glucose - hypoglicemia
Glyceryl trinitrate tablet or spray angina crisis
Salbutamol (bronchodilator) and spacer - asthma crisis
Aspirin - suspected myocardial infarction
Hydrocortisone for injection Addisonian crisis and also for management of anaphylactic Reactions

Other Equipment
Blood pressure monitor - assess BP, monitor collapsed patients

Blood glucose monitor diabetes patients
Pulse oximeter - essential if doing IV sedation, desirable for oral sedation
Laryngeal airways - airway protection, facilitate ventilation
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Frances Zhao
Automated external defibrillators part of any modern ABC protocol, available in our emergency kit for
VF
Maxillary Techniques
It didnt work!!!
How do I know if it worked?
Tingling (know your target nerve distribution)
Using probe (gentle at first)
Cutting into tooth
Patient will feel touch and pressure, not pain, double check and reassure
Analyse the problem - dont just re-give
Check anatomy (usual cause of failure)
Check other factors
Final Recommendations
Good anamnesis
Know the anatomy!
Aspiration
Inject slowly
Observe the patients reaction
Dosage as low as possible
Use anaesthetics with low toxicity
Be prepared for emergencies - equipment and knowledge
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Local Anaesthetic Course

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Local Anaesthetic Course

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Local Anaesthesia

Pharmacokinetics of local anaesthetics ..................................................................................Error! Bookmark not defined.

Non-disposable Pressure Syringes ................................................................................................................................. 34

Local Anaesthetic Drug Interactions ............................................................................................................................... 47

Pterygopalatine Nerve ...................................................................................................................................................... 61

Intra-oral Mandibular Innervation Areas know this by heart!!! ....................................................................... 73

Middle Superior Alveolar Nerve ...................................................................................................................................... 84

Management ........................................................................................................................................................... 111

Edema ....................................................................................................................................................................... 114

Delayed skin reactions ............................................................................................................................................... 120

Part 1: Introduction & Neurophysiology

Handbook of local anesthesia fifth edition

Assure the patient that it is just pressure.

Anoxia (no oxygen)

Neurolytic agents such as alcohol and phenol

Chemical agents such as LA

The effect has to be TRANSIENT and COMPLETELY REVERSIBLE.

Desirable properties of a local anaesthetic

Cocaine still used by some EMT surgeons

Procaine -- induces a lot of allergic reactions. One of the metabolites is PABA.

Lidocaine gold standard. Still used today.

Peripheral process (Dendrite)

Anesthesia works on both motor and sensory neurons.

If youre talking about LA you want to stop sensory nerves.

Nucleus and soma

Dendrities (synapse with other neurons)

Reaches sensory cortex

Nerve membrane exposed

Myelinated nerves conduct impulses at a much faster rate

Delta nerves are what conduct pain.

Two layers of lipid

Sodium potassium pump

Sodium extracellular (+)

Potassium intracellular (-)

Resting state of the neuronal membrane

Electrophysiology of nerve conduction

Electrophysiology of Nerve Conduction

How does a nerve conduct an impulse?

Modes and action of local anaesthetic

LA bind to specific receptors on the sodium channel

Classification of LA substances according to biologica site and mode of action

Receptor site on external

Receptor site on internal

Scorpion venom, ammonium

Combination of receptor and

Most clinically used LA

Sequence of mechanism of action of LA

Local anaesthetic molecules

Allows diffusion in tissues

Penetrates nerve membrane

Free Base form (RN) - uncharged molecules

Low pH - most LA will be in cationic form - RNH+ > RN + H+

Actions on nerve membranes

Barriers of Diffusion of the Solution

Why do LA not work well in infected tissues?

Induction of Local Anaesthesia

Absorbed by other tissues

Diluted by interstitial fluid

Removed by capillaries and lymphatics

Hydrolyzed (ester-type only)

Time between injection and complete blockade

Depends on the concentration of the drug and pH of the LA solution.

Anatomy and diffusion constant cant be controlled by clinician.