SOCM Dental Anesthesia PFN: SOMDSL08slides.jsomtc.org/SOMDSL08/SOMDSL08.pdfAnesthesia" Condition:Given a lecture in a classroom environment Standard:Received a minimum score of 75%

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Slide 1JSOMTC, SWMG(A)

SOCMDental AnesthesiaPFN: SOMDSL08

Hours: 2.0


Terminal Learning Objective

Action: Communicate knowledge of "Dental Anesthesia"

Condition: Given a lecture in a classroom environment

Standard: Received a minimum score of 75% on the written exam IAW course standards


References

Handbook of Local Anesthesia, Malamed, Stanley; 5th Edition, 2004 (chapters 10‐14)

Introduction to Dental Local Anaesthesia (sic), Evers, Hans, Haegerstam, Glenn; Mediglobe SA, 1990

Medical Subjects ‐ Dental, JSOMTC, as issued.

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Reason

You will treat dental emergencies

You will extract teeth, treat facial and oral trauma, and provide temporary dental restorations

You must administer local anesthetic to perform pain management and orofacial treatment


Agenda

Describe the process of local anesthesia

Discuss armamentarium used to provide local anesthetic

Locate the Oro‐facial anatomical sites used to achieve orofacial anesthesia

Define terminology and the disposal of used anesthetic supplies


Describe the process of local anesthesia

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The first experience with dental anesthesia


You are just an average guy, doing a hero’s job


Local Anesthesia

Temporary loss of sensation due to chemical inhibition of nerve conduction

The agent induces a transient and reversible inhibition of nerve conduction

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Function of Local Anesthetic

Block transfer of Na+ and K+ ions

thereby

Inhibits nerve depolarization

thereby

Inhibits nerve conduction

thereby

Inhibits nerve sensation


History

Cocaine: 1st anesthetic agent, 1884

• Toxic when injected; Abuse potential• Epinephrine‐‐1901• added to potentiate the agent• Procaine‐‐1905• Brand name Novocaine®, not commonly used due to allergic reactions


Lidocaine 2%

• Synthesized in 1944

• Brand name: “Xylocaine®”

• Most commonly used since 1955

• Rare allergic frequency

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Functions of the Vasoconstrictor

Increases duration of anesthetic

Decreases hemorrhage

Decreases toxicity of anesthetic

Epinephrine requires O2 scavengerflocculant brown clouds when scavenger is exhausted


Common Dental Anesthetics

• 0.5% Bupivacaine with 1:200,000 epinephrine

• “Marcaine®” in the SF Tac Set

• 2% Lidocaine with 1:100,000 epinephrine

• (Standard in all clinics)

• 2% Lidocaine (no vasoconstrictor)

• Others: 3% Mepivacaine

• Prilocaine 4% Citanest®

• Etidocaine 1.5% Duranest®

• Articaine 4% Septocaine®


0.5% BUPIVACAINE with1:200K Epinephrine

9 mg bupivacaine/carpuleBlue

Duration 6‐8 hours (usually less)

Max 1.3mg/kg or 10 carpules for

a 70kg (15olb) person

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1.8 cc carpule (36 mg lido/carpule)

Duration: 2‐4 hours (soft tissue)

Max with epi: 7mg/kg, to max 500mg,

total of 13 carpules for a 70 kg person

Max without epi: 4.5mg/kg, max 300 mg, total of 8 carpules for 70 kg person

2% LIDOCAINEwith 1:100K Epinephrine


3% MEPIVACAINEaka: Polocaine, Carbocaine

54 mg/cartridge of mepivacaine

Duration: 0.5 to 1.5 hours

Max dosage: 400 mg for any adult

5.3 carpules max for 70 kg (150 lb) person

Consider use if patient reports cardiac problems


Complications of Local Anesthetic

Toxicity‐the degree which a substance can cause damage

Syncope

Tachycardia

Paresthesia/Permanent Anesthesia

Seizure

True Allergy‐(rare)

Trauma‐Hematoma

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Prevention of Anesthetic Complications

Good Medical History

Good Knowledge of appropriate anatomy

Thorough knowledge of technique

Limit Quantity to minimum dose to achieve the clinical effect

Aspirate


Treatment of Toxicity

Airway

Oxygen

IV

Diazepam


Why use an Anesthetic without Epinephrine?

Compromised blood supply

Heart disease

Uncontrolled hypertension

Medications

Pregnancy

Allergy to preservative (sodium bisulfite)

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Adverse Effects of Vasoconstrictors

Local ischemia

Vaso‐vagal response (fight or flight)

Early contractions in pregnancy

Warning: due to ischemia

Do not use dental anesthesia

with vasoconstrictor in

digits, pinna (ear), nose, toes, or penis.


Topical Anesthetic For less noticeable technique

Agents

Benzocaine gel 20%

Lidocaine gel 2%

Apply 30‐60 sec.

Place gauze over to prevent it from going all over



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Equipment Aspirating syringe

(i.e., can pull back with thumb)

1.8 ml “carpule”

(cartridge+ampule) (many companies reporting 1.7 ml)

Long needle: 1 ⅜” long, 27 gauge (YELLOW)

no need to carry short needles


1st: Attach needle

2d: Place anesthetic in barrel

•rubber stopper toward handle

NEEDLE HARPOON

HUB RUBBER STOPPER

3d: Seat harpoon with one hard hit to thumb ring

Prepare Syringe


Attach Needle• Hear ‘snap’ of a new unopened needle

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Load CarpuleHold in palm, push up Drop in rubber stopper on with thumb harpoon first


Seat Harpoon

Slap to engage harpoon into rubber stopper

You cannot aspirate without a harpooned stopper


Aspiration

Pull back on ring with thumb

View carpule

If blood is aspirated into carpule, needle is intravascular, do not inject, pull syringe back and readjust position.

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Locate the Oro‐ facial anatomical sites used to achieve Oro‐facial

anesthesia


Do Not:

Do not kneel down while performing injections. Your balance is decreased and this posture imparts a docile or servile gesture that will not generate trust in your patient.

Do not say “bee sting” when perforating the mucosa since some people are profoundly fearful and allergic to bee venom.

You may say pinch, stick, do not move, etc.


ForwardPosition

For some injections you may benefit from standing in front of the patient at the 7 o’clock

Not between their legs!

Left handed at 5 o’clock

Back straight, Elbows in.

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Posterior Position

For some injections you may benefit from standing behind the patient at the 11 o’clock

Left handed at 1 o’clock

This is the best posture in austere environs with patient head resting against you. Good control.


Anesthetic Injections

For:

Maxillary Teeth


Maxillary Infiltration page 42 & 54

Maxillary bone is porous and allows the anesthetic to perfuse to the nerve sheath, unlike the dense bone of the mandible.

This injection can be used for every maxillary tooth.

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Maxillary Infiltration

Penetrate loose mucosa parallel to tooth/root.

Needle tip should be positioned in the area of the Root Apex. May or may not contact bone.

Aspirate and inject the desired amount of anesthetic.


Infraorbital Nerve (V2)

Blocks large area for small amount of drug

Palpate infraorbital rim to locate foramen

Align needle with canine tooth and insert toward pupil


Infraorbital Block (V

2)

Needle parallels bone to target

Orbital rim and locator finger protect the globe

Goal is aspiration and injection near the foramen, not in the foramen

Good injection to bypass infection at the root apex

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Posterior Superior Alveolar(PSA)

For posterior molars, good to bypass an infected tooth’s apex

45° superiorly

45°medially

Must aspirate

Molar teeth and

buccal tissue, but not

palatal tissue


Maxillary 1st Molar (No. 3 & 14) Mesiobuccalcusp of the upper 1st

molar must be separately anesthetized since it is served by the MSA, not merely the PSA

PSA in red MSA in green


Maxillary Anesthesia Bicuspids are innervated by the Middle Superior Alveolar Nerve. (MSA).

Practically , in the Maxilla, the best way to anesthetize is to infiltrate over the buccal portion of the tooth

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Greater Palatine Use for Palatal Anesthetic

Site –halfway between second molar and midline

Palatal Anesthesia can also be effected by injecting the palatal gingiva adjacent to tooth


Greater PalatineLocate point half way between midline

of palate and 2nd molar

Insert needle to bone, inject several drops of anesthetic


Incisal Nerve Used to anesthetize the anterior palate. Only a few drops in the large papilla between the two central incisors. Tissue can also be anesthetized by injecting below the neck of the selected tooth.

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Anesthetic Injections For: Mandibular Teeth

The Mandibular Branch, V3, of the Trigeminal Nerve, V, has four branches:AuriculotemporalInferior alveolarLong buccalLingual


Used to anesthetize the mandibularteeth and lower lip/soft tissues on the side of injection

(a) Position mandible parallel to floor or have patient

lying supine

(b) Place thumb on

anterior border of

ramus, middle finger

on posterior border

of ramus

Mandibular Block


MANDIBULAR BLOCK

(c) Needle level equates to a line bisecting the thumb

(d) Insert syringe from contralateral bicuspids

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MANDIBULAR BLOCK

(e) Advance needle to contact bone

(f) Aspirate,

if no blood,

deposit desired

amount of

anesthetic

•If blood: reposition, re‐aspirate


Right Left Right Left

Use dominant hand on both sides to control syringe. Helping‐hand always locates

anatomic landmarks.


Successful MANDIBULAR BLOCK

Lingual block

“Lip and Tongue signs”

No pain during procedure

P. 87, fig 145

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Complications of a Block

Trauma to nerve sheath ‐‐ “electric shock”, prolonged or permanent anesthesia

Intravascular injection: apprehension , shaking, tachycardia…

Pain: cold anesthetic, rapid injection, dull or barbed needle, careless technique


Long Buccal Nerve

Used for anesthetizing the buccal soft tissue.

Branches off the ganglion early (red arrow)

Hence requires separate injection (blue arrow)


LONG BUCCAL BLOCK Pull tissue laterally with thumb

Penetrate mucosa distal and buccal to last molar

Aspirate,

if no blood, slowly inject

anesthetic

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Define the terminology of use, and the disposal of used anesthetic

supplies


Practical Exercise

Tables are contaminated—place all instruments on a clean Chux.

One Chux for every student set‐up.

All students

anesthetize sites

as instructed on

both sides of your

dental buddy.


Proper terminology

Your attitude and approach must show confidence and knowledge to the patient. Use correct terminology and body language.

You do not help if you say “Are you all right?” The patient may say “No.” Then what do you do?

Rather, tell them “You’re doing great.”

If they are not, they will tell you.

Do not invite the patient to say “No.”

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Maxillary Infiltration

Penetrate loose mucosa parallel to tooth/root.

Needle tip should be positioned in the area of the Root Apex. May or may not contact bone.

Aspirate and inject the desired amount of anesthetic.


Infraorbital Nerve (V2)

Blocks large area for small amount of drug

Palpate infraorbital rim to locate foramen

Align needle with canine tooth and insert toward pupil


Infraorbital Block (V

2)

Needle parallels bone to target

Orbital rim and locator finger protect the globe

Goal is aspiration and injection near the foramen, not in the foramen

Good injection to bypass infection at the root apex

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Posterior Superior Alveolar(PSA)

For posterior molars, good to bypass an infected tooth’s apex

45° superiorly

45°medially

Must aspirate

Molar teeth and

buccal tissue, but not

palatal tissue


Greater Palatine Use for Palatal Anesthetic

Site –halfway between second molar and midline

Palatal Anesthesia can also be effected by injecting the palatal gingiva adjacent to tooth


Greater PalatineLocate point half way between midline

of palate and 2nd molar

Insert needle to bone, inject several drops of anesthetic

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Used to anesthetize the mandibularteeth and lower lip/soft tissues on the side of injection

(a) Position mandible parallel to floor or have patient

lying supine

(b) Place thumb on

anterior border of

ramus, middle finger

on posterior border

of ramus

Mandibular Block


MANDIBULAR BLOCK

(e) Advance needle to contact bone

(f) Aspirate,

if no blood,

deposit desired

amount of

anesthetic

•If blood: reposition, re‐aspirate


Long Buccal Nerve

Used for anesthetizing the buccal soft tissue.

Branches off the ganglion early (red arrow)

Hence requires separate injection (blue arrow)

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LONG BUCCAL BLOCK Pull tissue laterally with thumb

Penetrate mucosa distal and buccal to last molar

Aspirate,

if no blood, slowly inject

anesthetic


One‐handed

technique

Place needle

cap on

flat surface.

With one hand,

insert needle into

cap while cap is

on table

Recapping Needles


Recapping Needle

Scoop cap up

Secure cap to hub with 2nd hand

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Disassemble Syringe

Once the needle is safely recapped then unscrew the needle from the syringe and, without putting it down, go directly to the sharps container and discard it.

Do not recap the short end(hub end) of the needle.

Always be aware of your surroundings when using uncapped needles


Animated Anatomy Movies


Questions

Polocaine and Carbocaine

a. Are used together because they intensify the anesthetic experience.

b. Are the same drug.

c. Are not used with cardiac patients.

d. Are used to provide extended anesthesia.

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Questions

Polocaine and Carbocaine

a. Are used together because they intensify the anesthetic experience.

b. Are the same drug.

c. Are not used with cardiac patients.

d. Are used to provide extended anesthesia.


Terminal Learning Objective

Action: Communicate knowledge of "Dental Anesthesia"

Condition: Given a lecture in a classroom environment

Standard: Received a minimum score of 75% on the written exam IAW course standards


Agenda

Discuss local anesthetic

Discuss facial anatomy


Discuss injection sites used to achieve orofacial anesthesia

Discuss terminology and the disposal of used anesthetic supplies

26


Reason

You will treat dental emergencies

You will extract teeth, treat facial and oral trauma, and provide temporary dental restorations

You must administer local anesthetic to perform pain management and orofacial treatment


Break

Documents

SOCM Dental Anesthesia PFN: SOMDSL08slides.jsomtc.org/SOMDSL08/SOMDSL08.pdfAnesthesia" Condition:Given a lecture in a classroom environment Standard:Received a minimum score of 75%