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Local Anesthetic Review Local Anesthetic Review 8 Homestudy Credit Hours Anthony S. Mennito, D.M.D. The Academy of Dental Learning is an ADA CERP Recognized Provider. Table of Contents Table of Contents ........................................................................................................................ 9 Objectives .................................................................................................................................. 10 Introduction ............................................................................................................................... 11 History of Local Anesthetics ................................................................................................... 12 Neurophysiology ....................................................................................................................... 13 Pharmacology ........................................................................................................................... 14 Anesthetic Action ..................................................................................................................... 15 Uptake, Distribution, and Elimination ..................................................................................... 16 Systemic Effects of Local Anesthetics ..................................................................................... 16 Pharmacology of Vasoconstrictors ........................................................................................ 17 Topical Anesthetics .................................................................................................................. 19 Selection of Anesthetics .......................................................................................................... 21 Toxicity ...................................................................................................................................... 23 Epinephrine Overdose ............................................................................................................. 25 Armamentarium ........................................................................................................................ 26 Syringes ................................................................................................................................... 26 Needles.................................................................................................................................... 27 Cartridge .................................................................................................................................. 28 Preparation of the Syringe ....................................................................................................... 28 Patient Evaluation ..................................................................................................................... 29 Injection Techniques ................................................................................................................ 31 General Injection Technique .................................................................................................... 31 Maxillary Anesthesia ................................................................................................................ 33 Mandibular Anesthesia ............................................................................................................ 36 Other Mandibular Nerve Block Anesthetic Techniques ........................................................... 38 Complications ........................................................................................................................... 42 Pain on Injection ...................................................................................................................... 42 Paresthesia .............................................................................................................................. 42 Hematoma ............................................................................................................................... 42 Trismus .................................................................................................................................... 43 Infection ................................................................................................................................... 43 Facial Nerve Paralysis ............................................................................................................. 44 Broken Needles ....................................................................................................................... 44 Latest Updates in Local Anesthesia ....................................................................................... 45 Electronic Dental Anesthesia ................................................................................................... 45 Lidocaine Patch ....................................................................................................................... 45 9 Objectives Upon completion of this course, the student will be able to: • Explain the action of a nerve. • Explain the action of local anesthetic drugs on nerves. • Describe different techniques of local anesthe tic administration, and what teeth are affected by each injection. • Identify the toxicity level for all anesthetic medications used. • Identify symptoms of complications that may result from administration of local anesthesia and the treatment for each. • Understand the rationa le behind th e use of a lternative forms of anest hesia, including sedation and electronic dental anesthesia. 10 Introduction Pain control is the fo undation of successful dental pat ient management. Go od injection technique is essential f or consistent anesthesia. Dental professionals licensed to administer local anesthesia (Dentists and some Dental Hygieni sts) must use the medications available to them with caution and confidence. The patient's psychological state must be evaluated before the administration of any anesthesia. A relaxed, confident pati ent will respond better to local anesthesia. An anxious or phobic dental patient may require some type of intervention strategy to relieve the stress before administering anesthesia. Other co nsiderations such as th e health of the tissue ( presence or absence of infection) and deviation from normal anatomy must be assessed as well. This course is a review of currently accepted practices for dental local anesthetic administration. This course will not lead to licensur e of local anesthetic ad ministration. The student should be knowledgeable about head and neck anatomy and basic emergency medical proced ures for the dental office, including CPR. 11 History of Local Anesthetics 1500's Accounts referring to Peruvian Indians chewing on leaves of the coca plant are found. 1884 Carl Koller demonstrated the usefulness of the extract from these leaves (cocaine) as a topical anesthetic for the eyes, and earned distinction as the "Father of Local Anesthesia". 1884 William Halsted used cocaine in the first nerve block (an inferior alveolar nerve block). The use of cocaine for anesthesia produced several unwanted side effects including cardiac problems and addiction. 1885 James Corning demonstrated the use of a tourniquet to slow absorption of cocaine. 1901 Heinrich Braun demonstrated the use of epinephrine to retard local anesthetic absorption from the site of injection. 1904 Alfred Einhorn introduced procaine (proprietary name novocaine) which had far fewer side effects. Epinephrine was needed to constrict the vessels in the area of administration to lengthen the duration of anesthesia. It was common to see a 1:50,000 % concentration for many years. 1943 Nils Lofgren introduced lidocaine (proprietary name xylocaine), a synthetic anesthetic with far fewer allergic responses and faster onset of action. 1947 Novocol company made the dental aspirating syringe available. 1959 Disposable sterile needles made available by Cook-Waite, Roehr Company. (Information from: Malamed, 1994: JADA and Yagiela, 1991: Anesthesia Progress) 12 Neurophysiology Nerves are groups of cells that a ct together to be a communication system for the Centra l Nervous System (CNS). The neuron is the cell responsible for transmitting messages from the periphery of the body to the CNS a nd from the CNS to the periphery of the body. Afferent or sensory nerves conduct impulses to the C NS while efferent or motor neurons condu ct messages from the CNS to the periphery. The sensation of pain is first felt at the skin, tissue, or mucosa and the dendritic zone (made up of free nerve endings) starts the impulse. This impulse follows along an axon to the brain where it is interpreted. After the sensory nerve stimulates the CNS, the CNS decides the best action to take and sends its decision via impulse b ack through motor neurons to activate muscles. The cell body is invol ved in this return transmission as well as being responsible for the metabolism of the whole nerve. The axon is a long nerve fiber that runs the wh ole length o f the nerve. It's enca sed in a nerve membran e called an axolemma. Inside the membrane is a gelatinous substance called axoplasm. Most axolemmas are surrounded by a myelin sheath. The most widely held theory on nerve transmission attributes conduction of the nerve impulse to changes in the axolemma, not necessarily the axoplasm or the cell body. In a resting nerve, the electrical resistance keeps sodium, potassium
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