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Local Anesthesia

Local Anesthesia Manual

Loma Linda University School of Dentistry

2011/2012

Barry Krall DDS 1

Local Anesthesia Manual

Local Anesthesia

able of

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Course Objectives History of Anesthesia and Sedation Armamentarium Fundamentals of injection technique Pharmacology of local anesthetics Pharmacology of vasoconstrictors Patient evaluation Dosages Complications of local anesthetic injections Supraperiosteal injection IA, lingual and buccal nerve blocks Infratemporal fossa Posterior superior alveolar nerve block Pterygopalatine fossa Greater palatine and nasopalatine nerve blocks Mental/Incisive nerve blocks ASA “field block” injection Supplemental injections Miscellaneous injections Bacterial endocarditis prophylaxis regimen Table of blocks Dosage guidelines References

LOCAL ANESTHESIA MANUAL COURSE OBJECTIVES

To learn how to administer local anesthetics effectively, safely and painlessly.

To do this you need to know how and be able to do 5 things: 1. What you’re giving?

Therefore we will discuss the pharmacology of local anesthetics.

2. Who you’re giving it to?

We will discuss how to evaluate patients physically and emotionally. This will involve some physiology. Emergency prevention is emphasized.

3. Where to place it?

The anatomy of respective nerves and adjacent structures must be learned.

4. How to place it there?

Painlessly, in the right amount at the proper rate (slowly). The technique is both an art and a science.

5. How to handle emergencies?

Some may occur in your office or elsewhere. As health professionals we should know what to do, especially if we precipitated the event!

Local Anesthesia

HISTORY & DEVELOPMENT OF ANESTHESIA & SEDATION

BEGINNINGS 1. Genesis 2:21 2. For centuries man had only alcohol and opium (morphine) to control pain. 3. Compression of arteries and/or nerves. 4. Refrigeration 5. Bleeding 6. Hypnosis - Anton Mesmer, 1786 1772 1789 1823 1841 1842 1844 1846 1847 1853 1868 1884 1884 1905 1943 1945 1945 1948 1958 1965 1983 2000

Joseph Priestley prepared O2 and N2O. He was a priest in England. Humphrey Davy observed the analgesic effect of N2O on his own painful erupting “wisdom tooth”. Henry Hill Hickman anesthetized dogs with CO2, thus demonstrating anesthesia with a gas. He was a physician in England. Jayne patented his syringe with a nozzle tapering to a sharp point eliminating the necessity of making a skin incision first. Crawford Long - a physician in Georgia. Removed a tumor after the patient “smelled” ether. He did not publish this. Horace Wells DDS. Inhaled N2O for extraction of his aching “wisdom tooth”. He is credited with the discovery of general anesthesia. W.T.G. Morton DDS administered ether for a patient at Massachusetts General Hospital surgeon Dr. Warren. Simpson - Chloroform for childbirth in Scotland. Used on Queen Victoria. Pravez of France first employed a separate needle with a slip joint. Andrew, Chicago added O2 to N2O. Better and safer. Showed N2O effect was not due to hypoxia. Karl Koller a Viennese Ophthalmologist demonstrated the analgesic effect of cocaine. Halstead blocked the inferior alveolar nerve with cocaine. This showed that the injection of a nerve trunk in any part of its course is followed by local anesthesia in its entire peripheral distribution. Einhorn synthesized procaine (Novocaine). Lofgren synthesized lidocaine (xylocaine). Braun added adrenaline to the procaine solution. Jorgensen began using pentobarbital for IV sedation. Xylocaine available (First amide) Mepivacaine (Carbocaine) Prilocaine (Citanest) Bupivacaine (Marcaine) in dental cartridges Articaine (Septocaine)-FDA approved

Local Anesthesia

ARMAMENTARIUM The basic setup for delivery of local anesthetic requires 3 basic items: 1. a sterile, disposable needle 2. aspirating syringe 3. local anesthetic cartridge A. Needle Significant improvements have been made to the local anesthetic needle since its development. In dentistry today, needles used for local anesthesia delivery are: 1. sterile 2. disposable 3. manufactured out of stainless steel. This reduces the risk of: 1. cross contamination 2. needle breakage 3. tissue trauma. Needles are manufactured in various diameters and lengths. There are 3 diameters commonly utilized in dental intraoral injections: 1. 25 gauge (red) 2. 27 gauge (yellow) 3. 30 gauge (Blue) A smaller gauge number represents a larger diameter needle, whereas a larger gauge number reflects a finer needle. There are 3 lengths of needles commonly used for intraoral injections in dentistry. 1. The first is a long needle, which depending on the manufacturer, may vary in length from 30 to 35 mm. 2. Secondly, a short needle ranges from 20 to 25 mm in length 3. And lastly, a seldom used ultrashort needle, which averages about 10 mm in length. There is considerable variation in the preference of dental practitioners when selecting the length and gauge of a needle for local anesthetic administration. However, to simplify the selection of the proper needle diameter and length, two considerations should be addressed: 1. The depth of needle penetration necessary 2. And whether block or infiltration anesthesia is to be performed. Most intraoral injections can be administered using a short needle. The length must be sufficient to reach the target area and at the same time allow for adequate exposure of the needle shaft in the event of a broken needle, which allows for the easy retrieval of the fragmented needle. The infraorbital, Gow-Gates and Akinosi injections are exceptions to the above and almost always require selection of a long needle. Successful local anesthesia relies on the ability to deposit local anesthetic in close approximation to the nerve or nerves to be anesthetized. Therefore, when performing block anesthesia, it must be appreciated that a 27 or 30 gauge needle will result in significant deflection from the intended target area than the more rigid 25 gauge needle. The advantages of a 25 gauge needle are the following:

Local Anesthesia

1. it is rigid enough to be guided directly to the target without deviation. 2. it is less likely to penetrate the smaller vessels. 3. aspiration is much easier and certain through the larger lumen. 4. it is safer, as breakage is less likely to occur. A common misconception is that a larger diameter needle will result in more discomfort to the patient. However, this has not been demonstrated clinically when proper injection technique is utilized. Therefore, a 25 gauge needle is suggested for all block injections. With the exception of palatal nerve blocks, the use of a 30 gauge needle is discouraged. When performing multiple injections on the same patient, the needle must always be inspected for integrity and imperfections. This is especially important if bone has been contacted with the tip of the needle. Penetration of tissues with a barbed needle results in significant tissue damage and patient discomfort. A barbed needle is easily discovered by pulling the needle through a sterile 2x2 gauze pad. The imperfection is easily noted as the barb will catch on the fibers in the gauze. The barbed needle should be discarded and a new needle placed before proceeding with the planned injection. B. Syringes There are multiple varieties of syringes on the market today. However, there are certain criteria which must be met when selecting a syringe: 1. the syringe must either be disposable or autoclavable 2. must have aspiration capabilities and designed so that blood can be easily observed in the cartridge There are two basic types of syringes available for the delivery of local anesthetic: a. cartridge type 1. breech-loading 2. self aspirating 3. peripress or ligmaject 4. needleless (Syrjet) 5. CCLAD b. luer-lok 1. used in medicine 2. used for IV sedation A typical dental syringe consists of: 1. the barrel which holds the cartridge of anesthetic 2. the hub which serves to attach the needle to the syringe 3. and the piston which engages the plunger of the anesthetic cartridge C. Cartridge Local anesthetic is delivered in single dose cartridges that are constructed of either glass or plastic. Each cartridge consists of a tube with a rubber stopper on one end and a metal cap enclosing a rubber diaphragm on the other. The harpoon on the plunger of the aspirating syringe engages the rubber stopper located at one end of the cartridge. The rubber diaphragm allows for the penetration of the needle into the anesthetic cartridge. Surrounding the cartridge is a thin plastic mylar strip which protects the patient in case of glass rupture and also provides information regarding cartridge contents. Local anesthetic cartridges should be stored at room temperature in the dark. Exposure of the cartridge to heat and light results in degradation of the vasoconstrictor. The term Carpule is frequently used interchangeably with cartridge: However, Carpule is a registered trade name by Cook-Waite. A dental cartridge in the USA. has a volume of 1.8 ml. 1. Advantages of dental anesthetic cartridges compared to multi-dose vials a. convenient to use

Local Anesthesia

b. maintain sterility c. constant dosage d. does not contain parabens (antimicrobials) 2. Disadvantage - more expensive Contents: a. local anesthetic b. NaCl to make solution isotonic c. distilled H2O d. pH adjusted with NaOH or HCL e. sodium bisulfite/metabisulfite - antioxidant to stabilize vasoconstrictor (anesthetics containing vasoconstrictor) f. vasoconstrictor (anesthetics containing vasoconstrictor) i. the least stable component ii. acid medium required for stability iii. broken down by heat, light, O2, alkalinity Care of Cartridges: a. They are considered clean as they come from the container (don’t autoclave) b. Wipe diaphragm end with alcohol before loading syringe (optional). c. Do not soak in alcohol - it will penetrate diaphragm. d. Store at room temperature in a dark place. e. Avoid freezing. D. Assembly Assembly of the anesthetic syringe: 1. retract the syringe piston 2. place the anesthetic cartridge into the syringe with the rubber stopper being placed first 3. gently engage the harpoon into the rubber stopper. The harpoon should remain embedded in the stopper when the piston is pulled back gently. 4. attach the needle to the syringe, remove the cap and express a few drops to test for proper assembly. Changing the cartridge while needle is in place. 1. Make sure needle is recapped. 2. Pull back the plunger. 3. Remove and replace cartridge. 4. Engage harpoon. Unloading the cartridge. 1. Pull back the plunger. 2. Remove cartridge. 3. Remove needle. NOTE: CARTRIDGE MUST BE REMOVED BEFORE NEEDLE IS REMOVED TO PREVENT CARTRIDGE FROM IMPLODING. E. Recapping the needle/discarding sharps After injection is complete, the needle should be recapped immediately to avoid the unfortunate “needle stick injury”. Although there are multiple devices available for this maneuver, the accepted technique at Loma Linda University School of Dentistry is the single handed “scoop” technique. The needle cap is placed on the tray and the uncapped needle is slipped back into the sheath. Only after the needle has fully entered the cap should the free hand be allowed to grasp the cap and secure it more tightly. When unloading the syringe pull back on the piston until the harpoon disengages from the rubber stopper. The cartridge can then be removed from the syringe and along with the needle be placed directly into the sharps container.

Local Anesthesia

FUNDAMENTALS OF INJECTION TECHNIQUE There are 6 basic techniques for achieving local anesthesia of the structures of the oral cavity: 1. Nerve block

4. Topical

2. Field block 3. Infiltration/Supraperiosteal

5. Periodontal ligament (PDL) 6. Intraosseous

Fig 8-1 Local anesthesia of the oral cavity: Jastak, Yagiela and Donaldson, 1995 W.B. Saunders

Nerve block- Nerve block anesthesia requires local anesthetic to be deposited in close proximity to a nerve trunk. This results in the blockade of nerve impulses distal to this point. It is also important to note that arteries and veins accompany these nerves and can be damaged. To be effective, the local anesthetic needs to pass only through the nerve membrane to block nerve conduction Field block/Infiltration/Supraperiosteal - Field block, infiltration and supraperiosteal injection techniques, rely on the ability of local anesthetics to diffuse through numerous structures to reach the nerve or nerves to be anesthetized: sPeriosteum sCortical bone sCancellous bone sNerve membrane Topical - Topical anesthetic to be effective requires diffusion through mucous membranes and nerve membrane of the nerve endings near the tissue surface. PDL/Intraosseous - The PDL and intraosseous injection techniques require diffusion of local anesthetic solution through the cancellous bone (spongy) to reach the dental plexus of nerves innervating the tooth or teeth in the immediate area of the injection. The local anesthetic then diffuses through the nerve membrane to halt neuronal impulses. A. Needle selection

Local Anesthesia

Needle length and gauge selection is dependent on a number of variables. The trend in dentistry today is the selection of smaller gauge needles in the hope that injection trauma to the patient will be lessened. However, this has been unsubstantiated in a multitude of clinical experiments. Listed below are suggestions for needle selection for the various injection techniques. Nerve blocks: Inferior alveolar- 25 G short (LLU technique) PSA- 25 G short Mental/Incisive- 25 G short Palatal- 27/30 G short/ultrashort Gow-Gates/Akinosi- 25 G long Infraorbital- 25 G long Field Block: ASA 25/27 short Infiltration: Infiltration/SP 25/27 short PDL/Intraosseous PDL 27/30 short Intraosseous 30 short/ultrashort B. Local anesthetic selection The selection of a local anesthetic requires knowledge of the type and duration of the planned procedure as well as the medical history of the patient. Ideally, selection of a local anesthetic that will provide profound local anesthesia for the duration of the procedure and then diminish rapidly after completion of the treatment would be desirable. However, this is impossible to achieve as soft tissue anesthesia outlasts pulpal anesthesia even when utilizing short acting local anesthetics. Local anesthetics are typically divided into 3 main categories: short, intermediate and long acting local anesthetics. Taking into account the duration of the procedure and the duration of the individual agents described below, selection of the appropriate local anesthetic is not difficult.

Infiltration

Nerve block

Pulpal

Soft tissue

Pulpal

Soft tissue

Short

30 min

2-3 hrs

45 min

2-3 hrs

Intermediate

60 min

2-3 hrs

75-90 min

3-4 hrs

Long

40 min

5-6 hrs

3-4 hrs

6-8 hrs

Short acting agents 1. Mepivacaine 3 % 2. Lidocaine 2% Intermediate acting agents 1. Lidocaine 2% 1:100000 epi 2. Lidocaine 2% 1:50000 epi 3. Mepivacaine 2% 1:20000 neocobefrin 4. Prilocaine 4% 5. Articaine 4% 1:100000 epi Long acting agents 1. Bupivacaine 0.5% 1:200000 epi C. Patient positioning The most common medical emergency encountered in the dental office setting is syncope. The physiologic response to the stress and anxiety of dental procedures (e.g. intraoral injections) is pooling of blood in skeletal

Local Anesthesia

muscle. This leads to a drop in blood pressure which results in cerebral ischemia which leads to the undesirable symptoms of lightheadedness, pallor and possible loss of consciousness. With this in mind, it is always appropriate to place patients in the supine or semi-supine position to improve venous return and cerebral blood flow provided that the position is tolerated by the patient and is appropriate for their medical condition. D. Tissue preparation The preparation of tissue involves the removal of debris, excess saliva and placement of topical anesthetic. Preparation of the injection site with an antiseptic is not necessary due to substantial bacterial flora present in the mouth. The tissue however, should be cleaned with a 2x2 gauze to remove debris. Before topical is placed the tissue is dried to prevent dilution and mobilization of the topical anesthetic by the patient’s saliva. Topical anesthetic should remain in contact with the tissues a minimum of 1-2 minutes. E. Operator position/Finger rests Most dental injections can be administered from one of two operator positions. For the right-handed operator, the 8 and 10 o’clock position and for left-handed operators, the corresponding 2 and 4 o’clock position almost always allows for optimal visualization of the injection field. Finger rests should be established to allow for stabilization of the syringe and back support for the operator. Finger rests are unique for each injection and will vary with practitioners depending on individual preference and hand size. It is appropriate to use some parts of the patient’s anatomy for finger or elbow support (i.e. chin, shoulder) but discretion should be used. F. Injection Before the initiation of the injection, a thorough understanding of anatomy is essential. A mental picture of the nerve or nerves to be anesthetized in relationship to identifying landmarks is crucial to the success of the injection. Proper orientation of the syringe before penetration of the tissue is important to avoid multiple reorientations of the syringe once the needle has entered the tissue. This lessens the amount of damage to the tissue and leads to less post-op discomfort as well as trauma to important structures such as muscles and nerves. 1. Topical anesthetic is placed for 1-2 minutes 2. The anesthetic syringe, needle and selected local anesthetic are then prepared and a drop of anesthetic is expressed to assure proper assembly. 3. The needle is then aligned so that the bevel is oriented towards the periosteum (if applicable for the injection). 4. The tissue should be retracted taut but gently and is oftentimes accomplished with 2x2 gauze. This allows for a more comfortable needle insertion and also decreases the depth of tissue penetration to the target area. 5. Initial penetration of the mucosa should be done expeditiously, but with control, to a depth of a few millimeters. At this point, the operator should pause and deposit a few drops of local anesthetic. 6. After pausing 5-10 seconds, the needle is then advanced in incremental steps toward the target area. The needle should only be advanced into tissue that has been anesthetized ahead of the needle by the advancing pool of anesthetic. 7. When the final target area has been reached, aspiration is performed to ensure that the tip of the needle is not located in a blood vessel. If blood enters the cartridge, the syringe should be reoriented and aspiration performed again. It is also good practice to aspirate several times as the anesthetic is deposited to avoid inadvertent intravascular administration of local anesthetic. 8. The anesthetic solution should be administered slowly at a rate of 1 ml/min or less. This is especially true when injecting into dense palatal tissues and for the apprehensive patient. Slow administration of local anesthetic is equally important for avoiding complications in case of inadvertent intravascular injection. Rapid injection into a blood vessel results in transiently high plasma levels of local anesthetic leading to systemic toxicity. 9. In most cases deposition of 1 milliliter (or less) of local anesthetic at the final target area is all that is

Local Anesthesia

necessary for profound anesthesia to be obtained. 10. When the injection has been completed, the needle is withdrawn carefully and the needle is recapped using proper technique. 11. Profound anesthesia can be expected in 3-5 minutes for most conventional injection techniques. The Gow-Gates and Akinosi are examples of injection techniques that require 5-10 minutes for profound anesthesia due to the extensive diffusion that is necessary to reach the nerves to be anesthetized. 12. After completion of the local anesthetic injection, the local anesthetic and amount given should be recorded in the chart. It is very important to never leave the patient alone after local anesthetic administration. A majority of medical emergencies in the dental office occur either during or shortly after the delivery of the local anesthetic injection

PHARMACOLOGY OF LOCAL ANESTHETICS A. Desirable Characteristics 1. Block axon conduction (nerve impulse) when applied locally in appropriate concentrations. 2. Local anesthetic action must be completely reversible; however, the duration of the anesthetic block should be of sufficient length to allow completion of the planned treatment. 3. Produce minimal local toxic effects such as nerve and muscle damage as well as minimal systemic toxic effects of organ systems such as the cardiovascular and central nervous system. B. Source 1. Cocaine - 1st local anesthetic - isolated in the 1860’s from leaves of Erythroxylon coca plant. 2. Hundreds of local anesthetics have been synthesized in the laboratory but few have been marketed due to toxicity, irritation, insolubility and unstable properties. 3. Local anesthetics used in dentistry today are synthetic: sCOMMONLYUSEDLOCALANESTHETICS - Articaine, bupivacaine, lidocaine, mepivacaine and prilocaine. C. Chemistry 1. Major features

a. Lipophilic aromatic group - Enhances the ability of the local anesthetic molecule to penetrate various anatomical structures between the site of injection and the target site - the sodium channel in the nerve axon. b. Intermediate chain Important for two main reasons: s3EPARATESTHEHYDROPHOBICANDTHEHYDROPHILICPORTIONOFTHE local anesthetic molecule. s$ETERMINESTHEBIOTRANSFORMATIONMETABOLISM COURSE s3ERVESASACONVENIENTWAYOFCLASSIFYINGCONVENTIONALLOCAL anesthetics into two groups: amides and esters c. Hydrophilic amino group - Imparts water solubility to the molecule ensuring that on injection into the tissue, the local anesthetic will not precipitate.

Local Anesthesia

2. Classification a. Esters 1. Formed from an aromatic acid and an amino alcohol. 2. Examples of ester type local anesthetics: Procaine Chloroprocaine Tetracaine Cocaine Benzocaine- topical applications only b. Amides 1. Formed from an aromatic amine and an amino acid. 2. Examples of amide type local anesthetics: Articaine Mepivacaine Bupivacaine Prilocaine Etidocaine Ropivacaine Lidocaine

3. Chemical Properties

Local Anesthesia

a. All commonly used local anesthetics are weak basic tertiary amines (acceptors of hydrogen ion). Synthesized in the laboratory, anesthetic bases are of little use, as the compound is poorly soluble in water and unstable when exposed to air. This amine (local anesthetic base) is a weak base and therefore readily binds with acids to form a salt. Example RN + HCL base

RNH+s#L salt

This local anesthetic salt is quite soluble in water and relatively stable. Because of this property, local anesthetics are dispensed as salts (HCL) for injections dissolved in sterile water or saline. In sterile water or saline, the local anesthetic salt ionizes to form a quaternary amine cation and an acid anion. Example RNH+s#, salt

RNH+ cation

Cl– acid anion

The cation [ionized] then, is in an dissociation equilibrium with the base[non-ionized]. Example RNH+ cation

RN base

+ H+

The proportion of the ionized form (RNH+), to the free base (nonionized) form (RN) in any given solution depends upon the pH (H+ concentration) of the solution and the surrounding tissues as well as the pKa (dissociation constant) of each specific local anesthetic. In the presence of a high concentration of hydrogen ions (low pH), the equilibrium shifts to the left and most of the anesthetic molecules are found in the ionized form. E.G.

RNH+

> RN + H+

As the hydrogen ion concentration decreases (higher pH) more of the free base form of the anesthetic is formed. E.G.

RNH+ < RN + H+

pKa (dissociation constant), simply put, is the affinity of a compound for hydrogen ions (H+). When the pH of a solution and the pKa of a particular local anesthetic are the same, 50% of the anesthetic drug exists in the ionized (cation) form and 50% in the nonionized (base) form. Henderson-Hasselbach equation cation Log ( –––––– ) = pKa - pH base

Local Anesthesia

The pKa of amides ranges from 7.6 to 8.1. At physiologic pH (7.4), most of the local anesthetic is in the ionized state (a charged base). For example, lidocaine has a pKa of 7.9. The above formula determines that at physiologic pH, lidocaine exists in a ratio of 3:1 ionized to non-ionized: log [ionized/non-ionized]= 7.8 - 7.4 log [ionized/non-ionized]= 0.4 ionized/non-ionized = 100.4 3 Ionized ~ — = —————— 1 non-ionized

To expand the example, the ester procaine has a pKa of 8.9. The higher pKa value means that at physiologic pH, procaine exists in a ratio of approximately 32:1, ionized to non-ionized. Because lidocaine has a relatively greater proportion of the non-ionized form than does procaine, it could therefore be expected to have a more rapid onset of action. This expectation is confirmed clinically, where lidocaine has been shown to have an onset range of 2 to 3 minutes and procaine to have an onset range of 6 to 12 minutes. Daniel Haas DDS Septodont 2002

Since the pKa is a constant for any given local anesthetic, it can be determined from the above equation that the base/cation ratio is solely determined by the pH. When the pH and pKa coincidently happen to be equal, the ratio of base (nonionized) to cation (ionized) is 1:1. Because most local anesthetics have pKa values that range from 7.7 to 9.0, it is immediately apparent that the ionized form of the local anesthetic molecule is more abundant than the nonionized form at physiologic pH.

Dissociation constants Local anesthetic

pKa

% of base(RN) at pH 7.4

onset of action(min)

Lidocaine

7.8

2-4

Bupivacaine

8.1

5-8

Mepivacaine

7.7

2-4

Prilocaine

7.9

2-4

Articaine

7.8

2-4

Procaine

9.1

14-18

Benzocaine

3.5

100

D. Mechanism of Action When a local anesthetic is injected, it is the ionized [cation] form of the local anesthetic that actually binds to anionic channel receptors in the sodium channel, thus blocking the influx of sodium ions which are responsible for lowering the -70mv resting potential towards the firing threshold of -55mv which then results in depolarization of the nerve membrane. However, only the lipid soluble nonionized [base] form of the local anesthetic can penetrate the various barriers [e.g., nerve membrane, fibrous tissue] between the site of injection and the targeted destination which is the sodium channel.

Local Anesthesia

E. Entry Into Nerve Fibers 1. Entry into nerve fibers of injected local anesthetic is strongly influenced by the ratio of the nonionized to the ionized form since the nonionized form readily crosses the lipo-proteins of the

nerve sheath and axon membrane while the ionized form does not. a. Events involved in injection and entry are illustrated below. b. The injected solution of pH 6 has only 1% nonionized lidocaine but when mixed with the buffered tissue fluid at pH 7.4 the nonionized form will rise to 26%, provided adequate buffering (bicarbonate) is present. Initially in some cases the proportion of nonionized form will be less (e.g. 1 ml of pH 6 solution could temporarily lower the pH of 1 ml of ECF to 7.1, thus decreasing the nonionized form to 15%). As fresh bicarbonate and other buffers diffuse from the blood and adjacent tissues the pH will rise back to 7.4 and the percent of nonionized form will rise. c. Injection of relatively large volumes of acidic local anesthetic solution into a small area may lower pH of tissue so much that the anesthesia will be less effective than with smaller volumes (e.g. infiltration of 2-3 ml over the roots of the anterior or premolar maxillary teeth). d. Reduction in the pH of ECF by infection will also reduce the percent of nonionized form and thus the effectiveness of anesthesia. e. Both alkalinization and carbonation of local anesthetic solution may enhance onset as well as be less irritating on injection. 2. Topical Anesthetics a. Uses 1. Anesthetize soft tissue before needle insertion. 2. Helpful in reducing gag reflex; e.g., x-rays, impressions. 3. Helpful in management of alveolar osteitis [dry socket]. 4. Reduces sensitivity during periodontal probing, gingival curettage and orthodontic

Local Anesthesia

band placement. b. Most injectable local anesthetics are inappropriate candidates for topical anesthetic preparations. In order to be effective as topical agents, the concentrations would have to be so high that overdosage and local tissue toxicity would be of concern. c. Local anesthetics in solution as HCL salt do not penetrate intact skin appreciably. Small amounts spilled on hands, etc. in course of use are not likely to cause toxic effects but may induce the allergic state. d. Spray preparations applied to membranes of the oropharynx may be rapidly and extensively absorbed. These preparations are potentially hazardous due to toxic overdose and should not be used without metered valve dispensers. These are considered no more effective than application by a cotton applicator. F. Neurophysiology 1. Nerve fibers exhibit wide range of sensitivity to nerve blockade-in order of increasing resistance to block are the sensations of pain, cold, warmth, touch, pressure, proprioception and motor function. Nerve Fibers: Types Size Speed (M./Sec.) A ( ) 20 µm 80 - 120 ( ) 8 - 15 µm ( ) 4 - 8 µm ( ) 3 - 4 µm 10-15 B 4 µm 10-15 C 1-2 µm 1-2 Myelinated = faster conducting Unmyelinated = slower conducting

Occurrence Myelinated (Primarily for muscular activity). Myelinated (Touch and pressure) Myelinated (Muscle spindle tone) Myelinated (Pain and temperature sensation) Myelinated (Preganglionic autonomic) Unmyelinated (Pain and temperature sensation)

2. Small non-myelinated fibers (C- pain fibers) and smaller myelinated pre-ganglionic B fibers are more readily blocked than are larger myelinated fibers responsible for muscle activity and touch [A-alpha and A-beta]. Clinically, a person would notice complete lack of sensation to a pinprick, while at the same time still be able to move their fingers. 3. The clinical phenomenon of differential nerve block is thought to result from the differences in the internodal distance seen between nerve fibers of varying sizes. It is generally accepted that to halt neuronal traffic, 3 successive nodes must be bathed with the local anesthetic solution. The internodal distance of small A fibers ranges from 0.3-0.7mm whereas the internodal distance of the larger A fibers range from 0.8-1.4mm. Knowing this, the “pool” of anesthetic covering the 3 nodes of the larger A nerve fiber would need to be at least twice the size of the “pool” covering the three smaller nodes of the A fiber. It therefore seems that differential sensitivity of fibers results from variations in the “critical length” that must be exposed to a local anesthetic for conduction to be blocked. G. Effects and Toxic Actions on Organ Systems 1. Local anesthetics (dose dependent) interfere with transmission in any excitable tissue (e.g. CNS and CVS). 2. CNS effects a. Central neurons very sensitive. b. Excitatory-dizziness, visual and auditory disturbances, apprehension, disorientation and muscle twitching more common with ester type agents. c. Depression manifested as slurred speech, drowsiness and unconsciousness more common with amide type agents (e.g. lidocaine). d. Higher concentrations of local anesthetic may eventually produce tonic-clonic[grand mal]

convulsions. e. Very large doses may produce respiratory depression which can be fatal. Artificial respiration may be life-saving.

Local Anesthesia

3. CVS effects a. Local anesthetics have direct action on the myocardium and peripheral vasculature by closing the sodium channel, thereby limiting the inward flux of sodium ions. b. Myocardium usually depressed both in rate and force of contraction. Depression of ectopic pacemakers useful in treating cardiac arrhythmias. c. Concentrations employed clinically usually cause vasodilation in area of injection. d. Vasoconstrictors such as epinephrine may counteract these effects on myocardium and vasculature. 4. Local Tissue Responses a. Occasionally focal necrosis in skeletal muscle at injection site, decreased cell motility and delayed wound healing. b. Tissue hypoxia may be produced by action of excessive amounts of vasoconstrictors. H. Pharmacokinetics [Absorption, Distribution, Metabolism, Elimination] 1. Absorption a. Ideally, local anesthetic molecules would remain at the neural target interrupting neural traffic. The local anesthetic molecule, having both hydrophilic and hydrophobic properties, does not remain confined to the injected site for long. A significant portion of the injected local anesthetic diffuses away from the injection site and is absorbed into the circulation. b. In order to localize the site of action and decrease absorption, transport and/or destruction in the blood stream following injection, vasoconstrictor agents are sometimes used in conjunction with local anesthetics. (See pharmacology of vasoconstrictors for further information). 2. Distribution a. Some agents such as procaine and lidocaine are active vasodilators and may enhance their own absorption into the blood. b. Most agents once absorbed into the circulation are readily distributed from blood to well perfused tissues (e.g. brain, heart, liver, etc.) c. As time progresses, local anesthetic partitions into less well perfused tissues[i.e. muscle, fat] as well as into clearance organs[i.e., liver and kidney] e. Can cross placenta and occasionally may depress heart of fetus. 3. Metabolism a. Esters inactivated by hydrolysis in blood and/or liver by pseudocholinesterase; products may be conjugated and/or excreted. Individuals with genetically based defects in pseudocholinesterase are unusually sensitive to procaine and other esters. b. Amides metabolized in liver by oxidation (e.g. N-demethylation), and hydrolysis by liver amidase; products conjugated and excreted. Inactivation of prilocaine, a secondary amine, is relatively rapid because dealkylation not required before hydrolysis. Severe hepatic disease may reduce metabolism and lead to toxic reactions. Some metabolites of amides still have pharmacologic activity (e.g. metabolites of lidocaine are sedative). 4. Excretion a. Both esters and amides are excreted in the urine mainly as metabolites with only a few percent as the unchanged agent.

Local Anesthesia

I. Characteristics of Individual Agents 1. Procaine (Novocaine) - Not available in North America a) Classic Ester type agent, first synthetic injectable local anesthetic. b) Slow onset and short duration of action. c) No longer available in North America 2. Tetracaine (Pontocaine) - Not available in North America[injectable] a) Ester type agent--ten times as potent and toxic as procaine. b) Slow onset but long duration of action. c) Available in injectable and topical applications. 3. Propoxycaine (Ravocaine)- Not available in North America a) Ester type agent–five times as potent and toxic as procaine. b) Often combined with procaine to increase duration of action. 4. Lidocaine (Xylocaine) Most widely used and versatile local anesthetic a) Versatile widely used amide type agent. b) Two - three times as potent and toxic as procaine. c) Rapid onset and relatively long duration of action. d) Good agent for topical application. 5. Mepivacaine (Carbocaine) a) Amide type agent similar to lidocaine. b) Without vasoconstrictor has only short duration of action. 6. Prilocaine (Citanest) a) Amide type agent — less potent than lidocaine. b) Without vasoconstrictor has only short duration of action. c) Metabolized to o-toluidine which can cause methemoglobinemia — significant only with large doses of prilocaine. d) Higher incidences of paresthesia reported with 4 % preparation 7. Bupivacaine (Marcaine) a) Amide type agent of high potency and toxicity. b) Rapid onset and very long duration of action even without vasoconstrictor. 8. Articaine (Septocaine) a) Amide type agent b) Only amide-type local anesthetic that contains an ester group, therefore metabolized both in the liver and plasma. c) Approved by the FDA in 2000 d) Evidence points to improved diffusion through hard and soft tissues as compared to other local anesthetics. e) Reports of a higher incidence of paresthesia, presumably due to the 4% concentration f) Not recommended for use in children under 4 years of age

Local Anesthesia

TOPICAL ANESTHETICS Agent

Chemistry

Property / Uses

Amide

Amide Intermediate Potency, toxicity. Ointment (5%), solution, spray (10%) (also by injection)

Ester

Tetracaine is a potent agent and should be used with great caution to avoid systemic toxicity. Topically applied tetracaine as opposed to benzocaine has a prolonged duration of action. High potency & toxicity Solution, ointment, spray (Citacaine 2%) (also by injection)

Benzocaine

Ester

Relatively weak (20-22%). Ointment, Solution, Powder. Used on oral lesions, dry sockets. In many over the counter remedies.

EMLA[eutectic mixture of local anesthetics] Combination of prilocaine 2.5% and lidocaine 2.5%

Amide

Surface anesthesia of intact skin, must be applied for 1 hour to be effective.

Cocaine

Ester

Solution, used in ENT procedures. Toxic, addicting, a controlled substance.

Lidocaine (Xylocaine)

Tetracaine (Pontocaine)

Topical Anesthetics Benzocaine Benzocaine is a derivative of procaine, an ester type local anesthetic, and is poorly soluble in water and is available only as a topical anesthetic. Localized allergic reactions are sometimes encountered when using benzocaine multiple times on the same patient. Overdosing is unlikely as benzocaine is poorly absorbed into the blood, which decreases the likelihood of systemic toxicity. However, there have been reports of methemoglobinemia with excessive doses of benzocaine. The onset of surface anesthesia is rapid requiring less than one minute. But, more profound anesthesia is achieved with longer application. Benzocaine is available in several formulations including aerosol, gel, ointment and solution. Topical anesthetics that are delivered by pressurized spray should not be used without a metered dose dispenser as overdosing can rapidly occur. Trade names - Anbesol, Hurricaine, Numzident, Orajel, Topex

Tetracaine Tetracaine is an ester type local anesthetic which is available both as an injectable and topical preparation. Tetracaine is a potent agent and should be used with great caution to avoid systemic toxicity. Topically applied tetracaine as opposed to benzocaine has a prolonged duration of action.

Cocaine

Local Anesthesia

Cocaine is a ester type anesthetic that is used exclusively as a topical agent. Cocaine is unique among topical and injectable anesthetics in that it has vasoconstrictive as well as anesthetic properties. It is used sparingly because of its abuse potential but is still used when hemostasis of mucous membranes is essential. Cocaine is generally available in concentrations of 2-10 % solution.

Lidocaine Lidocaine is an amide local anesthetic that is available in injectable and topical formulations. It is available in gel, viscous solution, ointment and aerosol preparations in concentrations ranging from 2-10 %. The onset of anesthesia is slower relative to benzocaine but, the duration is about the same. Absorption into the bloodstream is greater than benzocaine providing a greater risk of systemic toxicity.

REVIEW OF LOCAL ANESTHETIC AGENTS

1. Definition

Agent which reversibly depress nerve conduction

2. Chemistry

a. Weak bases, poorly water soluble - form HCL salts for injections b. Esters of BA, PABA, MABA c. Amides of xylidine or toluidine

3. Absorption

a. Penetrate nerve fiber best as lipophilic free base b. vasoconstrictors slow absorption, prolong action, reduce toxicity, hemostasis

4. Mechanism of Action

Blocks depolarization of nerve axons by preventing sodium ion influx

5. Metabolism

a. Esters - hydrolysis by plasma and liver esterase’s. Don’t use these if patient is deficient in plasma cholinesterase b. Amides - oxidation by liver enzymes

6. Side Action & Toxicity

a. CNS 1. Variable - from stimulation to depression 2. Respiratory depression is usual cause of death. Treat with oxygen. b. Allergy - No cross-allergy between esters and amides c. CVS - Depress myocardium - Xylocaine used to treat cardiac arrhythmias

7. Rate of Injection

The maximum recommended rate - 1 ml / minute

8. Aspirate

To prevent intravascular injection which increases toxicity by 16x Aspiration test is not 100% dependable so inject SLOWLY

9. Benadryl

1% up to 5 ml. can be used if patient is sensitive to both esters and amides

10. Topical Application

Caution with topical anesthetics and topical epinephrine in gingipak etc.

11. Epinephrine 1:50,000 In small amounts and usually only for hemostasis - then with caution due to possible sloughing, toxicity, less profound anesthesia as buffering capacity of interstitial fluid

is decreased in complete ischemia

Local Anesthesia

PHARMACOLOGY OF VASOCONSTRICTORS

All local anesthetics currently used in dentistry today produce some degree of vasodilatation. This characteristic results in the increased vascularity of the injected site and results in a shorter duration of local anesthetic action due enhanced uptake of the local anesthetic into the bloodstream. In 1903 Braun introduced the idea of using a “chemical tourniquet” to prolong the effect of local anesthetics. This was made possible by the discovery of adrenaline a few years before. The decreased uptake of local anesthetic into the blood is a consequence of the effect of epinephrine (adrenaline) on the caliber of the blood vessel. The vasoconstrictive action of epinephrine reduces uptake of local anesthetic resulting in a significant increase in the duration of local anesthetic action. Therefore, the addition of vasoconstrictors in local anesthetic solutions will: 1. 2. 3. 4. 5.

Prolong the effect of the local anesthetic Increase the depth of anesthesia Reduces the plasma concentration of the local anesthetic Reduces the incidence of systemic toxicity Reduces bleeding at surgical site

Mechanism of action A. Adrenergic receptor physiology Adrenergic receptors are a class of receptors that are targets of endogenous and exogenous catecholamines such as epinephrine and norepinephrine. The binding of these receptors by agonists will in general cause cells to respond in a “fight or flight manner”. Adrenergic receptors are categorized into two main groups: 1. - adrenergic receptors 2. - adrenergic receptors These two categories are broken into subcategories as follows:

s -adrenergic receptor categories 1.

(with 3 subcategories) – receptors are located in smooth muscle throughout the body (eye, lung, blood vessels, uterus, gastrointestinal and genitourinary tracts) However the most important cardiovascular effect of stimulation is vasoconstriction of peripheral blood vessels. This results in a “steal phenomenon” of blood away from organs and tissues not involved in the “fight or flight” response and redistribution of blood to the heart, lungs and skeletal muscles.

(with 3 subcategories) - 2 post synaptic receptors are found on vascular smooth muscle 2 which produce vasoconstriction when stimulated. (However, activation of 2 receptors in the CNS and presynaptically results in reduced sympathetic outflow, sedation, vasodilatation and lowered blood pressure)

s ADRENERGICRECEPTORCATEGORIES

1. 2. 3.

receptors- mainly found in the heart resulting in increased heart rate and contractility receptors- relaxes smooth muscle resulting in vasodilatation (most significantly skeletal 2 muscle) and bronchodilation (lungs). receptors- found in adipose tissue 3 1

Receptor potencies of adrenergic vasoconstrictors Local Anesthesia

Drug

alpha-1

alpha-2

beta-1

beta-2

Epinephrine

+++

Norepinephrine

Levonordefrin

+ ++ ++ Potency: +++ = high, ++ = intermediate, + = low

Therefore, in summary local anesthetics containing epinephrine produce:

1. Localized s6ASOCONSTRICTIONMEDIATEDBYALPHARECEPTORACTIVATION i. Hemostasis at surgical site ii. Ischemia of localized tissue 2. Systemic s(EART i. Increased heart rate ( 1) ii. Increased force and rate of contraction ( 1) iii. Increased cardiac output iv. Increases oxygen demand v. Dilation of coronary arteries vi. Decreases threshold for arrhythmias s,UNGS i. Bronchodilation ( 2 ) s3KELETALMUSCLE i. Predominately vasodilation (fight or flight response) ( 2 ) s#.3 i. Minimal direct effect due to difficulty in crossing the blood-brain barrier. Most effects on the CNS are manifestations of the vasoconstrictor on other organs such as the heart.

Concentrations of vasoconstrictors

1. Epinephrine Vasoconstrictors such as epinephrine are prepared as diluted solutions of various strengths depending on the intended use. Epinephrine solutions are typically present in the following strengths: sMGML MCGML sMGML MCGML sMGML MCGML sMGML MCGML s1:100000 (0.01mg/ml)(10 mcg/ml) s1:200000 (0.005mg/ml)(5 mcg/ml) The most commonly used epinephrine dilution in dentistry today is 1:100000. However it appears that a 1:200000 concentration is comparable in effect to the 1:100000 concentration. 2. Levonordefrin (Neocobefrin) Levonordefrin is a synthetic compound very similar in structure to epinephrine. It is the only alternate choice of vasoconstrictor to epinephrine presently available in the USA. It is prepared as a 1:20000 (0.05mg/ml)(50 mcg/ml) concentration with 2 % mepivacaine.

Local Anesthesia

C. Cardiovascular considerations The plasma concentration of epinephrine in a patient at rest is 39 pg/ml.1 The injection of 1 cartridge of lidocaine 1:100000 epinephrine intraorally results in a doubling of the plasma concentration of epinephrine. Therefore it must be appreciated that even minimal doses of vasoconstrictor can elevate plasma levels of epinephrine significantly above baseline levels. The administration of 2 cartridges of lidocaine 1:100000 epinephrine more than triples the plasma levels of epinephrine which results in plasma epinephrine levels equivalent to those observed in individuals engaging in moderate exercise or public speaking2. The administration of the maximum dosage set forth by the AHA of 0.2 mg (200 mcg) would elevate the plasma level of epinephrine to a comparable level seen during strenuous physical exercise.1 Intravenous administration of local anesthetics containing epinephrine can lead to significant increases in heart rate. The administration of 15 mcg of epinephrine (approximately the amount contained in a single dental cartridge of local anesthetic) increased heart rate an average of 25 beats/min with some individuals experiencing an increase of 70 beats/min. The peak effect is seen in about 30-60 seconds and then wanes over the next few minutes, but can persist for up to half an hour. Systolic blood pressure increases about 20 mmHg on average but up to 70 mmHg on some individuals.1 Levonordefrin has very similar effects on the various organ systems as does epinephrine but to a lesser degree. Clinical considerations

It is well documented that reduced amounts of epinephrine should be administered to patients with: sHEARTDISEASEEG ANGINA HISTORYOF-) s0OORLYCONTROLLEDHIGHBLOODPRESSURE It is generally accepted that the dose of epinephrine should be limited to 0.04 mg (40 mcg) for patients that have these medical diagnoses. However, due to the short half-life of epinephrine (~10 minutes) careful administration of additional local anesthetic containing epinephrine is acceptable, if necessary, to complete the planned procedure while paying close attention to the patient’s vital signs (e.g., HR, BP).

D. Special considerations when administering local anesthetics containing vasoconstrictor. 1. TCA’s (tricyclic antidepressants) e.g., amitriptyline, nortriptyline, imipramine, doxepin, desipramine Problem - Elevation in BP s,IMITDOSETO CARTRIDGESOFEPINEPHRINE s!VOIDLOCALANESTHETICSCONTAININGLEVONORDEFRIN-AYRESULTINSEVEREHYPERTENSION

2. Nonselective Beta blockers e.g., propranolol Problem- Elevation of blood pressure/bradycardia s#AREFULINJECTIONOFMLALIQUOTSOFLOCALANESTHETICCONTAININGVASOCONSTRICTORUNTILPROFOUND anesthesia has been obtained is appropriate. After each ml of local anesthetic is administered, vitals signs (BP, HR) must be obtained before additional vasoconstrictor is administered. It is prudent to not administer more than the minimal effective dose of local anesthetic (probably should not exceed 2-3 cartridges of local anesthetic containing epinephrine) The selection of a local anesthetic without vasoconstrictor should also be considered and may be warranted.

3. Cocaine abuse Problem - elevated blood pressure/heart rate/arrhythmias s)FCOCAINEHASBEENABUSEDORTHEREISSOMESUSPICIONOFABUSE THEDENTALAPPOINTMENTSHOULDBE cancelled. The administration of vasoconstrictor within 24 hours of cocaine abuse is contraindicated. 4.

Hyperthyroidism (uncontrolled) Problem - “Thyroid storm” The most extreme form of thyrotoxicosis. s4HECLINICALMANIFESTATIONSOFhTHYROIDSTORMvAREFEVER TACHYCARDIA NEUROLOGICALABNORMALITIES

and hypertension followed by hypotension and shock. Epinephrine administration to these patients is absolutely contraindicated. Signs and symptoms of patients with uncontrolled hyperthyroidism include:

Local Anesthesia

1. Agitation, confusion 2. Tachycardia, hypertension 3. Excessive sweating, elevated temperature 5. Hypertension Problem - Exacerbation of high blood pressure s!T,,53CHOOLOF$ENTISTRY GUIDELINESFORADMINISTRATIONOFLOCALANESTHETICWITHVASOCONSTRICTORARE as follows: 1. 180/110 - don’t administer local anesthetic containing vasoconstrictor. In actuality, all elective dental treatment should be aborted until the patient has been evaluated and treated for hypertension and blood pressure brought under control by their physician. ASA IV patients - Vasoconstrictor contraindicated (No elective dental treatment)

PATIENT EVALUATION A. Introduction A pre-treatment evaluation should be completed on every patient scheduled for treatment in the dental office. This is especially important for those individuals who will receive a local anesthetic with or without sedation (Nitrous Oxide, Oral and IV). In the ambulatory setting (i.e., dental office), it is fortunate that medical emergencies are only occasionally encountered during dental procedures. However, the incidences of medical emergencies are greatly increased in a small segment of the patient population. Therefore, a thorough medical work-up consisting of a sMEDICALHISTORY sANDAPPROPRIATEPHYSICALEXAMATTHEMINIMUMHEARTRATE RESPIRATORYRATEANDBLOODPRESSURE should be done for every patient. The major endpoint of the medical work-up is to determine whether the patient has the physiologic/psychological reserve to undergo the planned treatment without complication. A system for preoperative risk stratifying patients into categories was developed by the American Society of Anesthesiologists. Despite its popularity and acceptance among practitioners in preoperative assessment, it still must be realized that this system is only a guide and presents with many shortcomings and every patient will need to be evaluated and categorized individually. ASA I

A normal healthy patient

ASA II

A patient with mild systemic disease

ASA III

A patient with severe systemic disease

Local Anesthesia

ASA IV

A patient with severe systemic disease that is a constant threat to life

ASA V

A moribund patient who is not expected to survive without the operation

ASA VI

A declared brain-dead patient whose organs are being removed for donor purposes

Exercise tolerance correlation ASA I No dyspnea (or undue fatigue or precordial pain) with normal activity. Normal activity is defined as: 1. climbing one flight of stairs 2. walking 2 level blocks at a normal pace 3. mowing lawn for 5 - 10 minutes ASA II Mild dyspnea after normal activity; may rest at top of flight of stairs = dyspnea after normal activity. Both good risks if other points negative. If Class II patient is apprehensive use pre-op sedation. ASA III Dyspnea during normal activity. Comfortable at rest in any position. May tend toward orthopnea (has to sit up to breathe). Rests before reaching top of a flight of stairs. Ankles swell as day progresses. ASA IV Dyspnea and orthopnea at rest (all the time). The patient will rest several times when climbing a flight of stairs if he can climb them at all). Treatment modifications ASA I Psychological/procedural stress - well tolerated by the patient; no treatment modification necessary (stress reduction?) ASA II Psychological/procedural stress - tolerated by the patient; no treatment modification (stress reduction?) ASA III Psychological/procedural stress - don’t tolerate well s!LTERTREATMENTPLAN AVOIDLONGCOMPLEXPROCEDURES s3TRESSREDUCTIONPROTOCOLISGOODIDEA s-EDICALCONSULTISADVISED ASA IV Psychological stress/procedural- may decompensate the patient s%MERGENCYCAREONLYTHATISSIMPLEINNATUREIE SMOOTHINGOFASHARPTOOTH PLACE temporary filling etc). s)NVASIVEPROCEDURESSUCHASMULTIPLEEXTRACTIONSSHOULDBEREFERREDTOORALAND maxillofacial surgery for removal in a hospital setting. sMedical consultation required B. Medical history 1. Cardiovascular a. HTN Hypertension is very prevalent in our society. The clinician should seek to understand the significance and extent of the hypertensive end organ disease (heart, kidney, cerebral) as well compliance with proscribed medical regimens. At LLUSD, it is appropriate to provide elective treatment for a patient that has a BP reading of