anesth-lab (local anesthesia)

7/31/2019 Anesth-Lab (Local Anesthesia)

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ANESTH LEC/LAB

(From the videos)

THE ARMAMENTARIUM

What is the armamentarium for local anesthetic injection?- Basic armamentarium

o Syringeo Needleo Cartridge

- Additional itemso Cotton applicatoro Sterile gauze wipeso Topical anesthtico Hemostato Betadine (oral)*

What is found inside the local anesthetic cartridge?- North American anesthetic cartridges contain 1.8 ml of solution- ADA requirement as of 2003, all cartridges sold in the USA are color-

coded so their content may be easily identified.- A cartridge of plain drug contains the following:

o Local anesthetico Sterile watero Sodium chloride

- The following additional ingredients are found in LA that contains avasoconstrictor:o Epinephrineo Sodium (meta) bisulfite

Shelf life for PLAIN anesthetic: 36 months (3 years)*if with Epinephrine: 18 months

What needles are available for local anesthetic injections in dentistry?- 25-gauge, short and long- 27-gauge, short and long- 30-gauge, ultra shortTypical short dental needle (tip to hub) 20mm

Long 32mmUltra-short 10mm

Very basic rule regarding insertion of needles in the soft tissue: NEVER insert aneedle all the way into the tissue to its hub unless it is absolutely essential forthe success of the injection.

The IDEAL Needle Armamentarium for All Intraoral Injections Consists of:- 25-gauge long- 27-gauge short*in the Philippines, we use 27-gauge long

Use of Recommended Needles will Ensure That:- Aspiration of blood is possible and reliable- Breakage of he needle is extremely unlikely- Patient comfort is maximizedHow do you aspirate?- Positive aspiration: blood is seen in the syringe- TRUE Negative aspiration: perform it twice, rotating needle 45 between

aspirations

What is the proper technique of preparation of the armamentarium?- Retract the piston- Insert the cartridge- Engage the harpoon with gentle finger pressure- Attach the needle- Remove the cap- Expel a few drops of anesthetic to ensure its proper flow

- Recap the needle- Syringe is ready for useWhat is the proper technique of unloading the syringe?- Retract the piston- Remove the used cartridge- Unscrew the needle (with cap)- Dispose of both in the proper containerWhat is the proper technique of inserting a second cartridge for additionainjections?- Unscrew the needle (with cap)- Remove the empty cartridge- Insert a new cartridge- Embed the harpoon using gentle finger pressure- Reattach the needleBASIC INJECTION TECHNIQUE

What are the basic steps in the safe administration of local anesthetic?- Use a sharp, sterilized needle- Check the flow of anesthetic solution- Determine whether to warm cartridge and/or syringe- Position the patient supine with feel elevated- Dry the soft tissue using gauze- Apply topical anesthetic to the site of needle penetration- Communicate with patient: I am using this anesthetic to make the rest o

the procedure more comfortable for you - Establish a firm hand rest to stabilize the syringe. The hand rest will vary

from doctor to doctor. Persons with longer fingers can use Finger Restonthe patients face for many injections. While those with shorter fingers mayneed to use Elbow Rests.

- Make tissues taut the tissues at the site of needle penetration should bestretched before the insertion of the needle making the insertion of theneedle more comfortable for the patient.

- Keep the syringe out of patients line of sight- Gently insert needle into the mucosa- Communicate with and observe patient: I dont expect you to feel this - Inject several drops of anesthetic (optional)- Slowly advance needle toward target- Deposit several drops before periosteum-

Aspirate- Slowly deposit solution (while communicating with the patient)- Slowly withdraw the syringe, cap the needle, and discard - Do the proper disassembling of the needle anddiscard needle in Sharps

container- Observe patient after injection- Record the injection/solution on chart MAXILLARY INJECTION TECHNIQUES

What are the injections used to anesthetize the maxillary teeth, soft andhard tissues?- Infiltration (supraperiosteal injection)- Posterior superior alveolar nerve block (nb) [PSA] - Middle superior alveolar nb [MSA]- Anterior superior alveolar nb [ASA] (aka Infraorbital nb)- Greater palatine nb- Nasopalatine nb- 2nd division nb (Maxillary nb)- Anterior middle superior alveolar nb [AMSA]- Palatal ASA

Additional Notes:Infiltration (supraperiosteal injection)- Anesthetize tooth 11 or tooth 21 on the Labial (ASAN) and on the Palata

(Nasopalatine Nerve).Posterior superior alveolar nerve block (nb) [PSA]- For the upper molars, with the greater palatine also Middle superior alveolar nb [MSA]- For the upper premolars


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Why do we anesthetize the Palatal area?For the beak of the forcep to engage underneath the gums. You have to separate thegums on the labial and on the palatal, if you will not anesthetize the palatal area and youseparate the gums that will be too painful. And you know the separation: Nasopalatine andGreater palatine. Not directed towards the Greater Palatine but only up to the distal part ofthe Canine. When you are having problems like anxiety or nervousness, you will sufferfrom dizziness and you will fall down and that means your blood pressure will go down.When a patient collapses, let him/her lie flat on the floor and raise both legs higher thanthe head (TRENDELENBURG POSITION). If a patient does not revive within 5 minutes,some sort of memory damage may result. Determine if the patient is alive through vessel

pulsation, checking if the patient is still breathing, and focusing of light on the pupil (thereshould be contraction).

*Carotid pulse biggest vessel.*Syncope- fainting. Reason: Fear.

2nd Division Nerve Block (Maxillary Nerve Block)- This is done on cases of removal of maxilla in cases of cancer

Anterior Middle Superior Alveolar nb [AMSA]- Infraorbital- For cleft surgery1. Infiltration

- Used to achieve pulpal anesthesia of one or two maxillary teeth- Areas anesthetized: pulp and buccal soft tissue and bone of the tooth

anesthetized- Recommended needle: 27-gauge short- Insertion site: height of the mucobuccal fold over the apex of the

anesthetized tooth

- Needle is held parallel to the maxillary bone and inserted until theneedle tip is at or above the apex of the tooth.

- Perform two negative aspirations.- 1/3 of the local anesthetic is slowly injected

One carpule can anesthetize four teethInsert the needle almost parallel to the bone and stop short at the apex. If you direct theneedle on the apex, the anesthetic solution will spread on the nose.When there is bulging, needle insertion is very shallow which means it is not good.*Place topical anesthesia first and then Betadine. If Betadine is first applied it will create afilm on the mucosa and will not take effect on the topical. (Betadine antiseptic)Topical anesthesia will numb the mucosa to lessen the pricking sensation. No effect, only

placebo effect.The barrel of the syringe should be pointing towards the bone. If it is the opposite, whenyou force the needle it will scrape the periosteum, which is rich in capillaries and then itwill have a profuse bleeding or hematoma.

After two negative aspirations, meaning youre going to pull the plunger of the syringe

there, blood will sip in that means youre inside the blood vessel. So withdraw thenreinsert.

Infiltration

2. Posterior Superior Alveolar Nerve Block- Provides pulpal anesthesia to the three maxillary molars and the

supporting buccal soft tissue and bone- In 28% of patients, the MB root of the first molar may not be

anesthetized- 27-gauge short needle is recommended- Left PSAN block: right-handed operator should sit at the 10 oclock

position facing the patient- Right PSAN block: 8clock position facing the patient- Insertion site: height of the buccal fold adjacent to the maxillary

second molar- Syringe is held in an upwards, inwards and backwards direction and

is inserted to a depth of 16 mm- Perform two negative aspirations- Half of the cartridge is administered over 30 seconds

When we inject the first molar, target the distobuccalroot and that is where the needle isupposed to be inserted. It will anesthetize the whole single tooth.

Areas Anesthetized Insertion Site

Left PSAN Right PSAN

3. Middle Superior Alveolar Nerve Block- Provides pulpal anesthesia to the maxillary premolars and the MB

root of the maxillary first molar- 27-gauge short needle is recommended- Left MSAN block: right-handed operator should face the patien

directly from the 8 or 9 oclock position- Right MSAN block: 10 oclock position- Insertion site: height of the buccal fold adjacent to the maxillary

second premolar- Needle is inserted until its tip is located well above the apex of the

second premolar- Perform two negative aspirations- Half of cartridge of local anesthetic is slowly deposited.

The syringe is held in upwards, inwards, and backwards direction.

The needle is inserted semi parallel to the bone. The tip of the needle will stop not exactlyat the apex. It should just be near the apex.

Areas Anesthetized Insertion Site

Left MSAN Right MSAN


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4. Anterior Superior Alveolar Nerve Block- Also known as the Infraorbital Nerve Block- Provides pulpal anesthesia to the five maxillary anterior teeth (two

incisors, canine and two premolars)- In addition to the buccal soft tissue and bone overlying these teeth,

the skin of the lower eyelid, the lateral side of the nose and the upperlip is also anesthetized.

- Right or Left ASAN block: right-handed operator should sit at the 10oclock facing in the same direction as the patient.

- Infraorbital foramen is palpated, lip is retracted.- 25-gauge long needle is inserted into the height of the buccal fold

adjacent to the maxillary first premolar.- The needle is held parallel to the maxillary bone and inserted until

bone is contacted at the roof of the infraorbital foramen.- After two negative aspirations, 1/2 to 2/3 the cartridge of local

anesthetic is deposited over 30 to 40 seconds

Areas Anesthetized

Palpate the infraorbital foramen, retract lip, insert needle.

Needle is held parallel to the maxillary bone

The infraorbital foramen is below the rim of your orb it.According to Dr. Romero 27 gauge extra long needle is used.

5. Greater Palatine Nerve Block- Also known as theAnterior Palatine Nerve Block-

Provides anesthesia to the posterior portion of the hard palate and itsoverlying soft tissues, anteriorly as far as the first premolar andmedially to the midline.

- 27-gauge short needle is recommended- Left GPN block: right-handed operator should sit facing the same

direction as the patient at the 11 oclock position- Right GPN block: sit facing the patient at the 7 or 8 oclock position- A cotton swab is placed in the patients mouth to palpate the greater

palatine foramen- The needle is inserted into the soft tissues just anterior to the greater

palatine foramen. As the needle is advanced through soft tissue,local anesthetic is deposited.

- On contacting bone and following negative aspiration, 1/4 to 1/3 ofthe cartridge of local anesthetic is deposited over 15 to 20 seconds.

Areas Anesthetized

Left GPN block Right GPN block

Palpate Insert

The needle is inserted at 45 degree angle the same thing with the nasopalatine.

6. Nasopalatine Nerve Block- Provides anesthesia to the anterior portion of the hard palate, both

soft and hard tissues, from the mesial of the right first premolar to themesial of the left first premolar.

- Sit at the 9 or 10 oclock posit ion facing in the same direction as thepatient.

- Multiple Injection TechniqueFirst injection infiltration into the labial soft tissues between the twocentral incisors. 0.3 ml of anesthetic is administered.Second injection infiltration into the now-numbed papilla betweenthe two central incisors. Local anesthetic is administered as needle isadvanced until blanching is noted on the palatal soft tissues.Third injection traditional nasopalatine nerve block in which theneedle is inserted into the soft tissues just lateral to the incisivepapilla. The needle is advanced through soft tissue until bone iscontacted and following negative aspiration, 0.3 ml of local anestheticis administered.

Areas Anesthetized Operators Position

Multiple Injection Technique First Injection


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Multiple Injection Technique Second Injection

Multiple Injection Technique Second InjectionObserve for blanching

Multiple Injection Technique Third Injection

Multiple Injection Technique Third Injection

Nasopalatine nerve block is extremely painful unless a preparatory injection isdone. It is done by inserting a short needle in the labial between the 2 central incisors.The needle is at right angle to the labial plate passes into the tissue until resistance ismet and deposit the solution.

MANDIBULAR INJECTION TECHNIQUES

What are the injections used to anesthetize the mandibular teeth, soft andhard tissues?- Inferior alveolar nerve block- Buccal nerve block- Gow-Gates mandibular nerve block- Vazirani-Akinosi mandibular nerve block- Mental nerve block1. Inferior Alveolar Nerve Block

- Provides anesthesia to the pulps of eight mandibular teeth in thatquadrant, the buccal soft tissues and bone anterior to the mentalforamen, the anterior two-thirds of the tongue and the floor of themouth, and the lingual soft tissues and periosteum

- 25-gauge long needle is recommended

- Left IAN block: right-handed operator should sit at the 10 oclockposition facing in the same direction as the patient

- Right IAN block: sit at the 8 oclock position facing the patient

Areas Anesthetized

Left IAN Block Right IAN Block

Three Criteria for locating the correct landmark for needle insertion1) Height of injection2) Anterior / Posterior position3) Depth of penetrationa) A finger is placed on the lingual aspect of the ramus and pulled

anteriorly until the coronoid notch is palpated. The coronoid notch isthe greatest concavity on the anterior border of the ramus.

b) The barrel and the syringe is placed on the corner of the mouth onthe opposite side.

c) The needle tip touches the most posterior aspect of thepterygomandibular raphe. The needle tip is then moved half the

distance toward the coronoid notch (-----) and then half the distanceback toward the raphe (---). This locates the injection site which is

of the distance of the coronoid notch to the raphe ().d) The needle is then inserted and advanced slowly until bone is

contacted. The average depth of penetration is between 20-25mmwhich is 2/3 to 3/4 the length of a long dental needle.

e) Once bone is contacted, aspiration is performed twice and inegative, 1.5 1.8 ml of local anesthetic is administered slowly.

(a) (a) (b)

(c)

(e)


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2. Buccal Nerve Block- Provides anesthesia to the soft tissue and periosteum on the buccal

aspect of the mandibular molars- Injection is given immediately following the IAN block.- 25-gauge long needle is recommended- The needle is withdrawn, the syringe is repositioned and the needle

reinserted in the mucobuccal fold distal to the last mandibular molar.- 0.3 ml of anesthetic is administered.

Areas Anesthetized

Withdrawn Repositioned Reinserted

3. Gow-Gates Mandibular Nerve Block- Provides pulpal anesthesia to the mandibular teeth, the buccal soft

tissue and bone, the anterior 2/3s of the tongue and the floor of theoral cavity, the lingual soft tissue and periosteum as well as the skinof the zygoma at the posterior portion of the cheek at the temporalregions

- 25-gauge long needle is recommended- Left GGMN block: right-handed operator should sit in the 10 oclock

position facing in the same direction as the patient- Right GGMN block: sit at the 8 oclock position facing the patient- The coronoid notch is palpated- The barrel and the syringe is placed in the corner of the mouth at the

opposite side, and the needle tip is placed just below themesiolingual cusp of the maxillary second molar and then the needletip is moved just distal to the second molar. This locates the insertionsite of Gow-Gates injection.

- The needle is now inserted until bone is contacted. The averagedepth of penetration in the Gow-Gates injection is approximately25mm

- After negative aspiration, 1.8 ml of anesthetic is slowly administered- Following withdrawal of the syringe, the patient is asked to keep their

mouth open for 2 minutes

Areas Anesthetized

Left GGMN Block Right GGMN Block

Needle Insertion Site

4. Vazirani-Akinosi Mandibular Nerve Block- Provides anesthesia to the eight mandibular teeth, the buccal sof

tissue and bone anterior to the mental foramen, the anterior 2/3s othe tongue and the floor of the oral cavity and the lingual soft tissuesand periosteum

- 25-gauge long needle is recommended- Right or Left VAMN block: right-handed operator should sit at the 8

oclock position facing the patient

- The needle is inserted into the soft tissue on the lingual aspect of themandibular molars adjacent to the intergingival junction of the lasmaxillary molar

- With the bevel facing away from bone, the syringe is inserted 25mm- Following negative aspiration, 1.5 1.8 ml of anesthetic is slowly

injected and the syringe withdrawn

Areas Anesthetized Operators Position


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5. Incisive Nerve Block- Also known as Mental Nerve Block- Provides pulpal anesthesia to the five mandibular anterior teeth

(incisors, canine and premolars), the buccal soft tissue and boneanterior to the mental foramen, the skin of the lower lip and the chin

- 27-gauge short needle is recommended- Right or Left incisive nerve block: the barrel of the syringe is kepot

below the patients line of sight and needle inserted into the buccalfold adjacent to the first premolar and then advanced until the needletip lies outside the mental foramen

- Following two negative aspirations, 1/3 of the cartridge of anestheticis deposited over 20 seconds

- The syringe is removed and pressure is applied extraorally orintraorally forcing local anesthetic into the mental foramen, blockingthe incisive nerve

SUPPLEMENTAL INJECTION TECHNIQUES

What other techniques are available to anesthetize teeth, soft and hardtissues of the oral cavity?- Alternative techniques

o Periodontal ligament injection (PDL, ILI)o Intraseptal injectiono Intraosseous anesthesia

1. Periodontal Ligament Injection (PDL)- Also known as Intraligamentary Injection- Provides pulpal anesthesia to a single tooth and supporting sof

tissues and bone.- 27-gauge short needle is recommended- Operator positions vary significantly with PDL injections on differen

teethoSit comfortablyoHave adequate visibilityoMaintain control over the needle

- Bevel of the needle should face the root of the tooth.- The needle is inserted interproximally into the gingival sulcus on the

mesial and the distal of a two-rooted tooth- To ensure success, there must be resistance in the administration o

the drug and tissue ischemia at the site of the injection- A volume of 0.2 ml of local anesthetic is injected per root

2. Intraseptal Injection- Similar to the PDL- Provides pulpal anesthesia of one tooth, its supporting soft tissues

and bone- 27-gauge short needle is recommended- Needle is inserted into the center of the interdental papilla adjacent to

the tooth being treated and is advanced until it enters the cancellousbone in this area.

- 0.2 ml of local anesthetic is administered


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3. Intraosseous Anesthesia- Used to provide anesthesia of one tooth, usually a mandibular molar,

when other techniques have failed- Local anesthetic is infiltrated into the alveolar soft tissue just distal to

the tooth to be treated.- Using a slow-speed bur, a hole is made to the cortical plate of bone

at the mandible- A 27-gauge short needle is inserted into the bone and local

anesthetic is administered slowly providing profound pulpalanesthesia of the tooth

Alternative Techniques: Computer Controlled Delivery- CompuDent (The WAND)- Comfort Control Syringe System (CCS)*This enables the operator to deliver local anesthetic painlessly anywhere in theoral cavity especially on the palate.

Alternative techniques whenever the usual injection does not workPDL injection single anesthesia (one tooth)Infiltration technique may also anesthetize adjacent teeth (tooth 11, 12 will also beanesthetized and sometimes also the canine. Depends on the volume of anestheticinjected)Never deposit 1 whole carpule.Tooth extraction carpuleRCT carpuleNasopalatine or Greater Palatine 1/8Less concentration, the better. Will it compromise the effect? Look at the patient. If the

patient is relaxed. Injection technique is easier and effect is longer if the pa tient is willing.Technique is more complicated if patient is resistant.Look at the stopper.

Administration should be very slow. 95% of pain experienced during injection is becauseof the manner (speed/rate) on how you inject.PDL injection needle is forced between the tooth and the bone. There is a specificsyringe for this injection which is the gun type syringe.Why do this? The tooth is still feeling pain. When you did an infiltration and it did not work(do it again, still did not work, then stop doing infiltration). There must be something wrong

which is probably because of the bone structure.Preferable for resto cases (Class 2), you did infiltration twice and did not work, do PDL.Mandi-blocking did not work (twice), still painful, do PDL injectionWhy did the infiltration technique not work? Difference in bone density of the maxilla andmandible. Maxilla is more porousMandibular blocking of the mandible is anesthetized. You are only to treat just onetooth but you will anesthetized half of the mandible. You can do a much gentle approach.Intraseptal injection much better is PDL injection and intraosseous injection for a singletooth.Intraosseous anesthesia do after mandibular blocking. This is just an additionaltechniqueCheckyour anesthesia if it is expired. Maybe thats the reason why it has no effect.How will you know you are depositing the solution? Observe blanchingNasopalatine only shallow.45 degrees, not parallel

(Jan 10, 2012)Local Anesthetics (Mechanism of Action)- Local anesthetics reversibly eliminate sensation conducted along

peripheral nerves by blocking the entry of sodium (Na+) into the sodiumchannel and thus preventing these depolarizations, thereby preventing thetransmission of pain information

Adequate Local Anesthesia is Dependent Upon:1) Local anesthetic dose delivered to the injection site and the concentration

that is taken into nerve.2) Myelination decreases the length of nerve necessary to be exposed to the

local anesthetic (nodes of Ranvier)3) Unmyelination nerves must be more completely bathed by loca

anesthetics4) Size of the nerve is important, the larger the fiber the slower the block and

the higher concentration of the local anesthetic needed.

Mechanism of Action

Ionized anesthetic binds to sodium channel

Sodium entry is blocked into these channels

Sodium channel blockage prevents propagation of action potentials

Lack of propagation blocks sensation, as signal is not transmitted to brain

Classification of Local Anesthetics1) Amides(has 2 i")

Articaine, Bupivacaine, Lidocaine, Mepivacaine, Prilocaine2) Esters

Benzocane, Cocaine, Procaine

Techniques of Mandibular Anesthesia1. Inferior Alveolar Nerve Block

a. Areas AnesthetizedMandibular teeth to midlineBody of mandible, inferior ramusBuccal mucosa anterior to mental foramen

Anterior 2/3 of tongue and floor of mouthLingual soft tissue and periosteumb. Technique

Apply topicalArea of insertion medial ramus, mid-coronoid notch, level with

occlusal plane (1 cm above), posterior from coronoid notch to pterygomandibular rapheadvance to bone (20-25 mm)

c. Target AreaInferior alveolar nerve, near mandibular foramen

d. LandmarksCoronoid notch, pterygomandibular raphe, occlusal plane omandibular posteriors

Step 1: Palpate the anterior ramus border at the coronoid [notch?]

Step 2: Slide the finger or thumb posteriorly ad medially until a ridge of bone ispalpated. This is the internal oblique ridge.

Step 3: Insert the needle into soft tissue of the pterygotemporal depressionwhich is halfway between the palpating finger or thumb and thepterygomandibular raphe.

Step 4: Approximate the height of the injection by the middle of the palpatingfingernail or thumbnail.

Step 5: Ensure that the barrel of the syringe is located over the contralateramandibular bicuspids.

Step 6: Insert until bone is contacted, and then withdraw ~ 1mm. the depth ofinsertion for the average-sized adult is approximately 25 mm.

anesth-lab (local anesthesia)

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