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Local Anesthesia Checklists
Transcript of Local Anesthesia Checklists
Deposit several drops of local anesthetic before touching the periosteum
Slowly withdraw the syringe
Apply Topical Anesthetic
Small quantity of topical LA placed on cotton applicator stick and applied directly on injection side
Communicate with The Patient
Avoid 'injection, shot, pain and hurt'
Use Sterilized Sharp Needle
Check the Flow of Anesthetic Solution
Determine whether to warm the anesthetic cartridge or syringe
Position the Patient
Dry the Tissue
Apply Topical Antiseptic (OPTIONAL)
Establish a Firm Hand Rest
Make the tissue taut
Keep the syringe out of patient's sight
Inject several drops of anesthetic solution
and slowly advanced the needle toward the target
Slowly deposit the local anesthetic solution
Ideal slow injection 1mL >60 seconds
Malamed: aspiration 2x -> deposit 1/4 -> reaspirate -> deposit 1/4 -> so on
Observe the patient
Adverse drug reactions develop drug injection or within 5 to 10 minutes of its completion
Twice with the orientation of the bevel changed
Adequate stabilization in mandatory
Do not move the tip of the needle, neither pushed farther into nor pulled out
Supine position: Head and Heart parallel to the floor with the feet slightly elevated
Cerebral ischemia secondary to inability of hte heart to supply the brain with adequate volume of oxygenated blood
Anesthetic Consideration in Dental Specialities
Pulpal and periapical inflammation or infection cause decreased in tissue pH in the affected region (pH pus 5.5 to 5.6) and increased vascularity --> incomplete anesthesia, delay onset anesthesia
Blood vessel in region of inflammation become dilated -->rapid removal of anesthetic
Use of vasopressor to provide hemostasis.
Use long duration LA
Preparing a tooth for full coverage, pain control might not be difficult at initial visit
Subsequent visit may be harder:
1. Overly high provisional restoration --> TFO --> sensitivity after a day
2. Poorly adapted gingival margins develop microleakage --> sensitivity
The longer these source of irritation are present --> >> trauma --> >>difficult to achieve adequate anesthesia.
Use regional nerve block. Infiltration will provide adequate pain control but shorter duration of anesthesia
Long duration anesthetic for longer procedures (>2 hours) --> nerve block with bupivacaine
For Incision and drainase of the abscess, anesthesia with block technique together with infiltration at some distance from inflamed area in order to avoid the risk of existing microbes spreading into deep tissue
Some persons, inferoposterior border of the mandible is not innervated by the trigeminal nerve. Any type of mandibular nerve blocks provide only partial anesthesia in this situation. PDL injection will corrects this.
Attaining profound pain control in teeth requiring extirpation
Administer LA at a site distant fro area of inflamation. DO not inject anesthetic solutions into infected tissue --> the infection will spread to uninvolved regions.
Use a buffered local anesthetic solution
Method of acvihieving anesthesia
Local infiltration --> severe inflammation or infection is not present
Regional Nerve Block --> effective because solution is deposited at a distance from inflammation
Intraosseous injection (CV absorption >>)
PDL injecton--> severe inflammation or infection is not present (0.2 mL each root).
Intrapulpal injection --> pharmacologic and applied pressure
A sensitivity may accompany the injection.
Needle does not fit snugly --> no increased pressure --> anesthesia produced only by pharmacologic action of the drug (no pressure anesthesia). Instrumentation begin 30s
Few ocassions when all techniques discussed fail to provide pain control and intrapulpal anesthesia cannot be attempted until the pulp is exposed:
1. Use slow speed high torque which is less tramautic
3. Pulp chamber approached --> direct pulpal anesthesia
If high level of pain persist and still not possible to enter the pulp chamber:
a. place a cotton pellet saturated with LA loosely on pulpal floor
b. wait 30s; then press pellet more firmly in dentinal tubulus or the area of pulpal exposure. This area may be sensitive initially but become insensitive within 2 to 3 minutes.
c. Remove pellet and continue use of slow speed until pulpal access is gained; then intrapulpal injection
Patients may respond unfavorably to instrumentation even canal have been thoroughly debrided:
Infiltration/ intrapulpal or topical anesthetic
Apply small amount of topical anesthetic ointment onto the file before inserting it into the canal --> helps to desensitize the periapical tissue during instrumentation
Local Anesthetic Overdose
Overdose from a drug occurs when its blood level in a target organ (e.g., brain and myocardium) become excessive.
CNS depression (mild tremor to tonic-clonic convusions) or CVS system depression (slight decrease in BP and cardiac output to cardiac arrest)
Self-inflicted soft tissue injury
Self-inflicted soft tissue injury- accidental biting or chewing of lip, tongue or cheek is a complication of residual soft tissue anesthesia. Soft tissue anesthesia lasts longer than pulpal anesthesia
Maxilla: Infiltrasi. Few indication for PSA or ASA nerve block.
Great palatine nerve block technique
equal dose (mg) of LA, a healthy adult patent with larger body weight and greater blood volume will have a lower blood level of anesthetic than the child with lesser weight and smaller blood volume. Blood volume relates to body weight (except in obesity)
Different anatomy, Smaller volumes of LA provide the depth and duration of pain control
1. Select a LA with duration of action that is appropriate (mepivacaine 3%- 20-40 minutes)
2. Phentolamine mesylate. Approved for use in 6 years or older and weighing more than 15kg
3. Advise patient and adults.
Alpha-adrenergic antagonist, when injected into the site where LA with vaspressir was deposited, produces vasodilation, increaing bloood flow thereby increasing speed with which LA diffuses out of the nerve. Duration of residual soft tissue anesthesia is reduced.
Density << and smaller so decreased penetration of needle
IANB: average depth 15mm
Buccal nerve block
Incisive nerve block provide pulpal anesthesia to 5 mandibular teeth in a quadrant. Deposition of anesthetic solution outside the mental foramen (between the 2 molars) with application of finger pressure for 2 minutes.
PDL injection is not recommended for use on primary teeth --> enamel hypoplasia in developing permanent tooth
Soft tissue manipulation and surgical procedures are associated with hemmorage especially when the tissues involved are not healthy. LA without vasopressors counterproductive because vasodilating property of LA. Vasopressor produce arterial smooth muscle contraction through direct stimulation of alpha receptors located in the wall of the blood vessel. LA with vasopressors must be injected directly into the region where the bleeding is to occur.
Unpleasant childhood experience --> adults acutely dental phobia--> behavior management
Self-inflicted soft tissue injury
Mepivacaine 3% 20-40 minutes
Multiple quadrant: AL + vasopressor
>> risk of soft tisue injury but << LA overdoses
Pain control for entire primary dentition can be achieved by 2 cartridge LA
Osseous and soft tissue anesthesia and hemostasis for periodontal curettage and flap
Obtaining profound anesthesia in pulpally involved tooth is a problem esp for mandibular molars.
Deposition of LA directly into coronal portion of pulp chamber provides effective anesthesia for pulpal extirpation and instrumentation
Moderate to severe discomfort using high-pressure syringe techniques
1. Infection or Inflammation at the site of injection
2. Primary teeth
+ No anesthesia of lip, tongue
+ Minimum dose of LA (0,2 mL per root)
+ Alternative to partially successful regional nerve block
+Rapid onset (30s)
- Leakage of LA solution into mouth
- Excesive presure or overly rapid injection may break cartridge (conventional syringe)
- Administration with conventional or PDL syringe is painful.
- Post injection discomfort
- Potential for extrusion if excessive pressure (too rapid injection) or volume are used
1. 27-gauge short needle
2. Insert needlein mesial or distal root or lingual or buccal surface as close to long axis as possible. Bevel toward the root
3. Advance the needle apically until resistance is met
4. Deposit 0,2 mL in a minimum 20S
5. Indicators of success: resistance to deposition of LA (noticeable with conventional syringe), LA should not flow back into mouth. Happens --> repeat from different angle.
Do not inject too rapidly (20S for 0,2 mL)
Do not inject too much solution (0,2 mL per root)
Do not inject into infected or inflamed tissues
CI: infection or severe inflammation
+ Lack of lip and tongue anesthesia
+ Minimum volume of LA
+ Useful on periontally involved teeth (avoids infected pockets)
+ Rapid onset <30s
- Bitter taste if leakage
2. Insert in the center of interdental papilla adjacent to the tooth to be treated. 2mm below interdental. bevel toward apex
3. Right angle to the soft tissue and 45 degrees to the long axis of the tooth
4. Slowly inject a few drops of LA as needle enters soft tisse and advance until contact with the bone
5. Push the needle slighly deeper (1-2mm) into interdental septum
6. Deposit 0,2 mL not less than 20S
7. Indication of success: Significant resistance, solution not come back into mounth (occurs --> repeat with needle slighlt deeper), ischemia of soft tissue
Do not inject too rapidly (20S for 0,2 mL)
Do not inject too much solution (0,2 mL to 0,4 mL per site)
Do not inject into infected or inflamed tissues
Intrapulpal injection provide pain control through pharmacologic LA and applied pressured
-Intrapulpal injection has a brief period of pain as anesthetic is deposited
1. 25 or 27 G short or long needle into pulp chamber
2. Wedge the needle firmly. If does not snug, deposit in the chamber. Anesthesia in this case is produced only by pharmacologic action of LA. no pressure anesthesia
3. Deposit 0,2-0,3 mL
When intrapulpal injection is performed properlu, a brief period of sensitivity is felt
STA System precisely regulated flow rate and controlled low pressure injection to perform PDL. STA provides continuous audible and isual feedback to the clinician as the dental needle is introduced into the tissue duting injection.
Orange : minimal pressure
Yellow: mild to moderate
Auditory: ascending tone --> pressure is rising.
When PDL is identified, "P-D-L'
Transforms blind syringe approach into an objective method
1. Place slowly into gingival sulcs as if it is a probe, simultaneously intiacting ControlFlo (press foot control --> 3 beeps --> "CRUISE"
2. Advance the needle until resistance
3. Minimize movement as DPS is analyzes. Illumination and ascending tones
4. 20-30 s "P-D-L" and 2 longer beeps
Technique of Mandibular Anesthesia
Inferior Alveolar Nerve Block
Indication: buccal soft tissue anesthesia (curretage)
CI: Infection or inflammation
Buccal Nerve BLock
Buccal mucose anterior to mental foramen to the midline and skin of the lower lip and chin
Pulpal nerve fibers from P to I
Mental Nerve Block
Insisive Nerve Block
Pulpal anesthesia limited to 1/2 teeth
Soft tissue anesthesia
Treatment involves 2 or more maxillary molars
CI: Risk of hemmoraghe is too great
Posterior Superior Alveolar Nerve Block
Middle Superior Nerve Block
For many patients, palatal injections prove to be a very traumatic experience
Indication: Palatal soft tissue anesthesia for more than 2 teeth.
Pain control involving soft and hard tissue
Inflammation or infection
Greater Palatine Nerve Block
Metal foramen : Apical P2
Technique of Maxillary Anesthesia
- Not recommended for large area
Insert the needle in mucobuccal fold over the second molar.
Advanced needle in 3 direction at once.
Upward: 45 to occlusal plane
Inward: 45 to midline
Backward: 45 to axis of M2
Penetrate to 16 mm for adult or 10/14 mm for smaller skull
SHORT needle (20mm)
Anterior Superior / Infraorbital Nerve Block
However, palatal anesthesia can be achieved atraumatically (or least painful than they had ever recieved)
Step in atraumatic administration of Palatal Anesthesia:
1. Topical Anesthesia (remain in contact at least 2 minutes. Hold the cotton swab)
2. Use pressure anesthesia at the site before and during needle insertion and deposition of solution (firm object , such as cotton applicator stick previously used to apply topical anesthetic/ handle of mirror. Press till Blanch. Dull and tolerable not sharp and painful)
3. 27 G needle
4. Maintain control over needle (secure a handrest)
4. Deposit the anesthetic solution slowly. (Rapid injection produces high tissue pressure, tears palatal soft tisssue)
5. Trust yourself
Junction of alveolar bone and palatal bone. Palpate from M1 to posterior
NasoPalatine Nerve Block
Highly traumatic injection --> soft tissue is dense, firmly adherent to bone and sensitive
Lateral Papila Incisive
All LA are vasodilator, leading to:
1. Increased rate of absorption of LA
2. Higher plasma level of LA. increase risk to toxicity
3. Decrease depth and duration of anesthesia because LA diffuses away rapidly
4. Increased bleeding
Drugs that constrict blood vessels and thereby control tissue perfusion
Few CI for administration in concentrations in dental LA if administered slowly and negative aspiration ensured.
1. Patient with CV disease
2. Thyroid dysfunction, diabetes, sulfite sensitivity (asthma)
3. Patients receiving antidepressants
1. Constricting blood vessels, decrease blood flow to the site of drug administration
2. Absorption of LA is slowed --> blood levels are lowered --> decreasing the risk of toxicity
3. Increasing the duration of LA
4. Decrease bleeding at the site of administration
How LA works?
Place the needle tip against the grauze and draw the needle backward
Disposable needles are sharp on first insertion. Succeeding penetration, sharpness diminishes. Changed after 3-4 tissue penetration
Do not use needle larger than
25 gauge (orange)
Anxiety: Blood flow increasing directly towards skeletal muscle. No muscular movement --> increased volume of blood in skeletal muscles remains --> decreasing venous return to heart and brain.
wipe with gauze to dry
and remove debris
Produce anesthesia 2mm-3mm
Remain in contact with the tissue for 2minutes for maximum effectiveness. Minimum 1 minute
Patient's Face or elbow rest
Complete control of injection
Stretch before needle insertion permit insertion with minimal resistance
Loose tissues are pushed and torn by needle insertion
Observe patient's face.
deposit --> 2-3 seconds --> advanced --> deposit --> until reach target
Buffered LA will be more comfortable
small amount and no need aspiration
Periosteum richly innervated
Carried out before large volume of LA is deposited
Minimize possibility of IV injection
Prevents tearing the tissue and for safety reason
27 G; bevel towards bone
Buffered Local Anesthetic
Idea behind it:
-Pain on injection esp vasopressor contained anesthesia
-LA does not work as reliably in the presence of infection and inflammation
Phentolamine mesylate is a short acting, competitive antagonist peripheral Alpha-adrenergic receptors, so BLOCKING the actions of circulating EPINEPHRINE and norepinephrine.
Clinical effects: peripheral vasodilation and tachycardia. When injected into the site where LA with vasopressor was deposited, produces vasodilation, increasing blood flow thereby increasing speed with which LA diffuses out of the nerve. Duration of residual soft tissue anesthesia is reduced.
Idea behind it:
- Patient demands painless injections.
- The inability to obtain consistently profound anesthesia in mandible esp when infected teeth are involved. Higher failure rate for mandibular anesthesia is related to thickness of cortical plane in adult mandible.
Intranasal Local Anesthesia
Idea behind it:
- Nares are extremely vascular, so most drugs instilled into them will be absorbed rapidly and distributes sytemically.
- Intranasal instillation of LA has been employed in ENT procedures. Tetracaine receiver commented on their upper teeth felt numb
For dental application, vasoconstrictor oxymetazoline was added.
Studies states success to achieve adequate pulpal anesthesia from P2 to P2.
Computer-Controlled Local Anesthetic Delivery (C-CLAD)
Idea behind it:
RN (lipid soluble) and RNH+ (not lipid soluble)
Only lipid soluble can cross the nerve membrane.
Relative amounts depends on pH of the solution.
At pH 3,5, 99,996% lidocaine HCl exists in RNH+, only 0,004% in RN form. Once within the nerve RN picks up an H+with the resultant RNH+ entering an Na+ channel to block nerve conduction. Only after the body buffers the injected anesthetic solution to a pH closer to physiologic range (7.35-7.45) anesthetic enter into the nerve and block nerve conduction. Transformation --> anesthetic latency (5 to 10 minutes onset)
Infection lowers tissue pH
Anesthetic buffering effect:
1. greater patient comfort during and post injection
2. more rapid onset
3. Independent anesthetic effect of carbon dioxide
LA containing vasoperessor have a pH of 3.5
Without 5.9. Low pH means more soft tissue injury
Future Trends in Pain Control
NaHCO3 interacts with HCl in LA to create water and CO2. CO2 potentiate the action of lidocaine HCl by
1. providing a direct depresant effect of CO2 on the axon
2. concentrationg LA inside the nerve trunk through ion trapping
Changing the charge of LA inside the nerve axon.
CO2 possesses an independent anesthetic effect and caused a sevenfold potentiation in anesthetic action.
Comfortable= 72%: 17%:11%
Painless (VAS=0)= 44%:6%
Onset of Anesthesia= 2 minutes : 8 minutes.
Duration of soft tissue anesthesia is longer than pulpal anesthesia.
Residual STA is inconvenience or embarrasing to the patient.
Functional: diminished ability to speak, smile, drink, and to control drooling
Sensory: lack of sensation
Perceptual: distorted perception (e.g. swollen lips)
Self-inflicted injury most commonly lip or tongue in younger children.
When a LA is deposited close to a nerve, it diffuses into the nerve.
Dental drill stimulates, a nerve impulse is propagated. This impulse travels only so far as the area of the nerve where the LA has been deposited. The nerve impulse then dies out, never reaching the patient's brain
LA stop working when the volume of LA within the nerve is greater than the volume of LA outside the nerve. The process of diffusion reverses, and the drug begins to leave the nerve and move into the soft tissues. Nerve fibers are gradually unblocked. As the drug exits the nerve, it is absorbed into capillaries that carry LA away via venous circulation. the GREATER the volume of blood flowing this area, the more rapidly diffusion OUT of the nerve.
Plain LA is vasodilators --> increase vascular perfusion at the injection site --> lesser volume of LA enter the nerve and more rapid diffusion of the drug back out of the nerve.
LA with vasopressor diminished blood flow into the site of LA deposition --> greater volume of LA to diffuse into the nerve and less blood flows throng that area allows LA to remain within the nerve in higher concentration for a longer time.
Increasing blood flow through the site of LA injection facilitates more rapid diffusion of LA from nerve into CVS, decreasing residual STA.
Idea behind it:
Administration of PM should be a treatment option whenever prolonged STA presents a potential risk or negatively impact the patient's lifestyle. PM is indicated for reversal of soft tissue anesthesia. NOT reccomended for use in younger than 6 years or weighing less than 15kg.
Recommended dose is based on the number of cartridges of LA + vasocontrictor.
Administered in an equal volumes, up to a maximum of two cartridges at the same location and by the same technique.
Difficulty of IANB is an absence of consistent landmarks.
Benefits of ability to provide localized area of anesthesia by infiltration injection without the need for nerve block injection:
2. comfortable for patients
3. can provide hemostasis when needed
4.avoids the risk of potential damage to nerve trunks
5. lesser risk of intravascular injection
Failure of anesthesia IANB --> development alternative technique of nerve block, PDL injection --> Articaine HCl by infiltration.
Studies show greater success of infiltration of 4% articaine HCl compared to Lidocaine HCl.
Administer a full cartridge of articaine 4% with epinephrine 1:100.000 or 1:200.000 in mucobuccal fold adjacent to mandibular M1 when treating molars or premolars in adult mandible
C-CLAD provide the ability to control the rate of delivery of LA.
C-CLAD introduced the concept of using a disposable handpiece weighing less than 10g, allowing the clinician to hold like a pen, greatly increasing tactile control.
As a result of new technology, several new injection techniques were introduced:
AMSA nerve block (anesthesia of multiple maxillary teeth from a single palatal injection)
P-ASA nerve block (dental and soft tissue anesthesia of I1 and I2 from a single palatal injection)
STA-Single Tooth Anesthesia allows dentist to perform a dental injection with real-time feedback, indicating when the needle tip is in the correct location when a dental injection is performed. The system incorporates the safety of using dynamic pressure-sensing technology, allowing low-pressure administration of LA.
Allows easy administration of traditional injection and dental injections that were developed using C-CLAD.
PDL injection with the use of a low-pressure C-CLAD injection instrument, STA-System with DPS, did not produce damage to the underlying developing permanent tooth bud.
DPS (dynamic pressure-sensing)
Pressure transducers, allowing instantaneous real time measurement of fluid exit-pressure at the tip of the needle. DPS provide visual and audible feedback that helps to:
identify tissue types for health care provider and ensure injection of drugs occurs at the precise targeted location
Studies showd A measurable reduction in pain-disruptive behavior in children receiving a C-CLAD injection. C-CLAD instrument provided a benefit in treatment of pediatric patient. C-CLAD effectively reducing subjective pain perception compared with traditional syringe when IANB is performed.
Allen and coworkers studied 40 preschool patients and concluded C-CLAD demonstrated significantly fewer disruptive behaviors compared with those given a traditional injection regimen. Even with increased duration of the injecetion, slower rate of anesthetic delivery of C-CLAD reliably reduce pain-related behavior in children. Reducing disruptive behavior in preschool-aged children is important because it creates a more positive experience for the child.
STA-System device resulted in more predictable, more reliable, and more comfortable anesthesia than the high pressure mechanical syringe and/or the conventional dental syringe.
C-CLAD devices have been shown to enable the dental practitioner to administer a more COMFORTABLE and less anxiety-provoking injection.
The Wand (1997), CompuDent, Midwest Comfort Control Syringe, STA-System
STA-system with DPS proves continuous real-time injection feedback and identification of specific patient tissues and enhance the predictability of PDL injection. MORE POSITIVE EXPERIENCE for patients and doctor
RNH+ <=> RN + H+
DO NOT EXCEED MRD
Pediatric treatment: 30 minutes. LA + Vasocontrictor considered unnecessary
Let's make a painless dentistry
Do not administer LA more than MRD
For multiple quadrant, Nerve block is recommended and use of vasocontrictor
Dental Treatment requiring LA (topical or injection) should be postponed
Emergency : Inhalation sedation, GA, HIstamin blockers used as LA (Diphenhydramine HCl 1% with 1:100.000 ephinephire for 30 minutes pulpal anesthesia
Sign and Sysmptoms
Generalized anaphylaxis: skin reaction, smooth muscle spasm, respiratory distress, cv colllapse
Procedures recommended to minimize systemic complication
1. Medical evaluation
2. Anxiety, fear should be recognize
3. Dental injection supine or semi-supine.
4. Topical anesthesia minimum 1 minute
5. Weakest concentration of LA at the minimum volume
6. Vasoconstrictor should be included unless CI
7. Neddle should be disposable, sharp, capable of reliable aspiration
8. Aspirate in at least 2 planes
9. Inject slowly
10. Observe patiect during and after LA.
Clinical signs and symptoms of overdose appear whenever the blood level in that drug's target organ becomes overly high, in this situation include CNS and CVS. CVS less sensitive comapred to CNS
LA exert a depressant effect on all excitable membranes. LA is applied to a specific region of the body and produce reversible depression of peripheral nerve conduction. LA is absorbed into circulation and its subsequent actions is depress excitable membrans, including smooth muscle , myocardium and CNS.
Blood/plasma level of drug: the amount absorbed into the circulatory system and transported in plasma throughout the body. (ug/mL).
Following intraoral administration of 40-160 mg of lidocaine, blood level rises to a maximum 1ug/mL.
D: Mild or Severe
Topical Anesthetic Allergy
Ester --> Amida
Amida --> Amida
Histaminen bockers as LA
Deposit LA in capsular parotid gland
Nicking to artery or vein. Most common in PSA NB and IANB
Will stop when EV pressure is higher than IV pressure or when clotting
May lead to trismus
Pressure on site
Warm water on the day after
Trauma to muscle, deposition of LA intramuscular of supramuscular, hemorrage
Transient until LA is absorbed
Heat therapy, warm saline, analgesics, muscle relaxant, physiotherapy