the use of anesthesia in endodontics

208 Endodontics 9-TheUseofAnesthesiainEndodontics 209

Inachievingtheeliminationofpainduringdentalpro-cedures,andinparticularendodontictherapiesofvi-tal teeth, it is necessary to use anesthetic solutions.Byblockingthetransmissionofnerveimpulses,theymakeitpossibletocarryoutsuchtherapiesbyputtingthepatientateaseandthuspermittingthedentisttooperateoptimally.Very frequently, the patient anticipates endodontictreatmentwithgreatanxiety.Whatismostfrighteningisthefearofexperiencingpain.Itisthedentist’sre-sponsibilitytocalmthepatientandelicitthemaximalcooperation by successful anesthesia. Nonetheless,onemustnotabuseanestheticsastranquillizers.Iftheplanned treatment isdeinitelypainless, suchas thecleaningandshapingofanecroticrootcanalortheillingprocedureofacanal, it isperfectlyuseless, ifnotinfactcontraindicated,toadministeranesthetics.Thereareseveralreasonsforthis.Inthecaseofthenecrotic tooth, the preparation of the access cavitycorrespondstotheveryimportant“cavitytest”,andifoneisworkingunderanesthesia,onemayrealizetoolatethatalesionthatoriginallyseemedtobeofen-dodonticoriginwasratherofperiodontalorigin,andthusthatthepulpwasvital.Furthermore,ifoneusesanestheticswhennotindicated,oneexcludesthead-mittedlyminimalandnotalwaysreliablecollaborationofthepatient.Thedentisthasmanytechniquesavailableforcontrol-lingpain:topicalanesthesia,localanesthesia,regionalanesthesiaornerveblocks,andotherso-calledsup-plementalformsofanesthesia.

TOPICALANESTHESIA

Topical anesthesia refers to the topical application ofanestheticsforvariousreasons,suchasrenderinglocali-zedareasofmucosainsensible.Theprincipalmeansby

whichtopicalanesthesiaisadministeredareliquids,tro-ches,gels(Fig.9.1),sprays,41andcooling20(Fig.9.2).This typeofanesthesia is indicatedfordesensitizingthemucosatoneedlepricks,whichwouldbeneces-saryforlocaliniltration.

9

TheUseofAnesthesiainEndodonticsARNALDOCASTELLUCCI,KIRKA.COURY

Fig.9.1.Ananestheticgelisappliedtopicallytothemucosa,whe-reittakeseffectafter20-30seconds.

Fig. 9.2. An ice stick achieves anesthesia by cooling the palatalmucosa.Thisallowspainlessintroductionoftheneedle.


LOCALINFILTRATION

Local iniltrationmay be deined as a technique bywhichananestheticsolutionisdepositedwithinthetreatmentarea.30Thistechniquepermitsrapid,efica-ciousanesthesiaforallthemaxillaryteethandmandi-bularincisors.Theneedleisintroducedvestibularlyatthemucogingivaljunctionattheleveloftheaffectedtooth.Ashortneedleisusedtoinjectatleast2ccofanestheticsolutionintotheregionoftheapices.33

Malamed31recommendsthatlocalanesthesiabeper-formedwith a single injection.He suggests deposi-tingthesolutionabovetheperiostiumandthentakingadvantageofitscapacitytodiffusethroughtheperio-stiumitselfandthecancellousbone.Thisblocksthesmallnerveendingsof theaffectedarea.His is the-refore a submucosal and supraperiosteal anesthesia(Fig. 9.3). In contrast, Bence2 recommends that lo-caliniltrationbeperformedintwosteps.First,aboutone-ifthof the anesthetic vial is injected above theperiostium,thusanesthetizingthisstructure.Inthese-condstep,thesyringeneedleisintroducedmoredee-plyuntilitencountersbone,afterwhichitisdirectedapically, below the periostium, as close as possibleto theapexof the toothbeing treated.The remain-derofthevialistheninjected(Fig.9.4).Theanesthe-ticshouldbeinjectedslowlyandonlyaftertheperio-

stiumhasbeenanesthetized,becauseitispainful.Theperiostiumlimitsthediffusionoftheanesthetic;inad-dition, the resulting compression facilitates the ab-sorptionoftheanestheticbythebone.Completepulpanesthesiaisthusattainedinjustafewminutes.Inthetimeitrequirestoplacetherubberdam,thedegreeofanesthesiareachesthedesiredlevel.Toanesthetizethenerveibersthatinnervatethepala-talrootoftheuppermolarsorpremolars,oranyothertooththathasapalatalroot,itisadvisabletoperformapalataliniltrationafterthevestibulariniltration(Fig.9.5).Thepalatal root isusuallycloser to thepalatalthanvestibularcorticalbone;thus,abuccaliniltrationalonemaynotsufice.Toperformapalataliniltration,itisnotnecessarytoreachtheperiostium.Thepalatalmucosaissoadhe-rentandthickthatitisabletolimitthediffusionoftheanestheticandforcethesolutionintotheunderlyingbone,liketheperiostiumofthevestibularside.Palataliniltrationisquitepainful.Therefore,itshouldbe performed slowly by steadily depositing a smallamountofanesthetic(0.5ml)underadequatepressu-re.Beforeperformingthepalataliniltration,itisadvi-sabletoachieveanesthesiaofthemucosa,forexam-plebycooling.20

AsalreadydescribedinChapter8,specialprecautionisrequiredforiniltrationofthemucosaoverlyingthe

Fig. 9.3. Submucosal and supraperiosteal anesthe-sia.

Fig.9.4.Subperiostealanesthesia. Fig.9.5.Teethwithpalatalrootsrequireapalatalin-iltrationtoo.


purulentcollectionofanacutealveolarabscess,befo-remakinganincisionfordrainage.Theneedleshouldnotpenetrate thepurulentcollection,butshouldbeintroducedtangentiallytothemucosaandshouldbevisiblethroughthetransparencyofthetissues,crea-tingarapidischemiceffect.Theuseofanestheticso-lutionwithvasoconstrictorisadvisable(Fig.9.6).

Inferioralveolarnerveblock

Thisisusuallycalled“mandibularnerveblock”.Itser-vestoanesthetizeallthemandibularnervesofthesa-mequadrant.However,becausethelowercentralinci-sorsmaybeinnervatedbythecontrolateralhemiarch,itispreferabletoanesthetizethembyavestibularin-iltrationtoobtainmorecertainresults.Adequate anesthesia is indicated by tingling andnumbnessofthelowerlipand,whenthelingualner-ve isaffected, the tipof the tongue.This techniquedoesnotachieveanesthesiaof thevestibularmuco-saorperiostiumassociatedwiththemolars,whichareinnervatedby thebuccinatornerve.Onemustkeepthis inmind if onemust intervene surgically in thisarea.Anesthesiaofthebuccinatornerveisperformedby inserting the needle into the mucosa distal andbuccaltothelastmolar.To anesthetize the inferior alveolar nerve with thistechnique,theanestheticsolutionmustbedepositedinthevicinityofthenervebeforeitentersthemandi-bularramusatthelevelofthemandibularspine.Eithertheindirectordirecttechniquemaybeused.

Indirecttechnique

The indirect technique is performed with a longneedle.Theneedleisdirectedtowardtheramus,star-ting from the controlateral molars, until it encoun-tersbone.Theneedleisthenwithdrawnslightly,re-directedparallel tothehemiarchtobeanesthetized,andinsertedmoredeeply.Onceitcontactsthebone,theneedleisinsertedslowlyalongthemedialsurfaceofthemandibularramus,forabout2cm(Fig.9.7).With this technique, the onset of anesthesia is of-tenslow,andtheinexactinsertionoftheneedlemayproduceanesthesiainother,unintended,areas.Iftheneedleisintroducedtoosupericially,theanesthesiawill affect only the lingual nerve; if introduced toodeeply,itmayanesthetizethefacialnerve.

Directtechnique

The aforementioned drawbacks are usually avoidedbytheuseofthedirecttechnique,whichisassociatedwithamuchquickeronsetofaction.Ashortneedleisusedtopenetrateascloseaspossibletothemandi-bularspine(Fig.9.8).Withthepatient’smouthwideopen,thedentistplacesthethumbintothepatient’s

Fig.9.6.Anesthesiaofthemucosaoverlyingthepu-rulentcollection,beforetheincisionfordrainage.

REGIONALANESTHESIAORNERVEBLOCKS

Regionalanesthesiaornerveblockinvolvesa largerarea than the forms of anesthesia discussed above;however,itmorepreciselyanesthetizestheentiredi-stributionofaspeciicnerve.Itisachievedbydeposi-tingthelocalanestheticnearthetrunkofamajorner-ve,thusblockingtheafferentimpulsesfromtravellingproximaltothatpoint.Thesuccessofthismethoddependsonthedentist’sprecision in depositing the anesthetic solution at apre-selectedanatomicalpoint.Theanestheticdiffusesfromthispoint insuficientamountsandconcentra-tionstoproducethedesiredeffect.41

Blockoftheinferioralveolarnervewillbediscussedindetail,whiletheothernerveblocksofdentalinte-restwillreceivebrieferattention.


A

D

Fig.9.7.A-F.Blockoftheinferioralveolarnerve,usingalongneedleandtheindirecttechnique.

B

C

E F

A

Fig.9.8.A,B.Blockoftheinferioralveolarnerve,usingashortneedleandthedirecttechnique.

B


mouthtoidentifytheanteriorborderofthemandibu-lar ramus (Fig. 9.9).Themiddleinger supports theposteriorborder,outsidethemouth(Fig.9.10).Withthesyringedirectedalonganimaginarylinepas-singabovethecontrolateralpremolars,onepenetra-testhemid-pointbetweenthethumbandmiddlein-ger, and after aspirating to avoid injecting the ane-sthetic directly into the circulation, the solution isinjected.Thepointofinsertionoftheneedleisjustla-teral to thepterygomandibular raphe,which ismid-waybetweenthetwohemiarches,toadepthofabout1cm.Duringthisprocedure,itisimportanttoaskthepatienttoremainwideopen.33

Thistypeofanesthesiaistheprincipalmeansofane-sthetizingtheteethofthelowerarch,sincelocalane-sthesiawouldnotbeeficacious,giventhebonyden-sityofthemandible.

Mentalnerveblock

Anesthesia of the canine and lower irst premolarcanbeachievedat the levelof themental foramen(Fig.9.11),ratherthanmandibularspine.Thishastheadvantageoftakingeffectsoonerandavoidingane-sthesiaof the tongue, thussparingthepatientpoin-tlessparesthesiae.Itisperformedbydepositingtheanestheticsolutionnearthemandibularcanal,atthelevelofthemen-tal foramen. The needle is inserted in the alveolarmucosabetweenthetwopremolars,about1cmex-ternaltothevestibularsurfaceofthemandible(Fig.9.12).Particularattentionmustbepaid tonot injuring thementalnervewiththepointoftheneedle.Itmustnotbeintroducedinthementalforamen.

Fig.9.9.Thethumbisusedtoidentifytheanteriormarginofthemandibularramus.

Fig.9.11.Mentalnerveblock.

Fig.9.10.Themiddleingerisusedtosupporttheposteriormar-ginofthemandibularramus.

Fig. 9.12.To achieve anesthesia at the level of the mental fora-men, the needle must be introduced into the alveolar mucosabetweentheirstandsecondpremolars,about1cmexternaltothevestibularsurfaceofthemandible.


Nasopalatinenerveblock

Theinnervationofthesofttissuesoftheanterioronethirdofthepalatearisesfromthenasopalatinenerve,whichemergesfromtheincisiveforamen(Fig.9.13).Intheregionofthecanine,terminalbranchesofthisnervearesuperimposedonterminalbranchesoftheanteriorpalatinenerve.Anesthesiaisachievedbyintroducingtheneedlein-to the palatine surface, next to the incisive papilla,andinjectingtheanestheticunderpressure(Fig.9.14).Thisproceduremaybequitepainful.However, it isusuallynecessary in thecaseofextractionsorothersurgicalproceduresinthisarea.

Anteriorpalatinenerveblock

The innervation of the soft tissues of the posteriortwo-thirdsofthehardpalatearisesfromtheanteriorpalatinenerve.Thisnerveemerges from thegreaterpalatineforamen,whichliesbetweenthesecondandthirdmolars,half-waybetweenthealveolarcrestandmidlineofthepalate(Fig.9.15).Anesthesiaisachie-vedbyintroducingtheneedlenearthepointofemer-genceofthenervefromtheforamen(Fig.9.16).Thisprocedureisalsoquitepainfulandisusedforextrac-tionsorsurgicalprocedures,whenanesthesiaofthesofttissuesofthehardpalatefromthetuberositytothe regionof thecanineor from themidlineof thehardpalatetothegingivalmarginisrequired.

A B

Fig.9.14.A,B.Siteof introductionoftheneedle inperforminganasopalati-nenerveblock.

A B

Fig.9.16.A,B.Siteofintroductionoftheneedleinperformingananteriorpa-latinenerveblock.

Fig.9.13.Courseofthenasopalatinenerveafteritsemergencefromtheincisiveforamen.

Fig.9.15.Courseoftheanteriorpa-latine nerve after its emergencefromthegreaterpalatineforamen.


SUPPLEMENTALANESTHETICTECHNIQUES

Applyingthecommonly-usedtechniquesoflocalinil-trationornerveblocktoendodontictherapy,onemaysometimesencounterproblems related to inadequa-teanesthesiaofa tooth.This tipicallyhappenswithlowermolarsaffectedbyirreversiblepulpitis.Theendodonticallyinvolvedtooththatexhibitssymp-toms consistent with an irreversibile pulpitis is per-hapsoneofthemostchallengingandfrustratingcon-ditionstomanageintermsofachievingprofoundane-sthesia. If mismanaged, the patient will often relatetheexperienceasphysicallyandmentallyagonizing.Wearemanytimesatadisadvantage.Asifapprehen-sionisnotenoughtodealwith,whencombinedwithinlammation40,53theybothacttosigniicantlydecrea-sethelevelofpainthreshold.10Theconsequencesofthis hypersensitivity to stimuli that ordinarily wouldnotbeperceivedorinterpretedaspainmayresultinamarkeddificulty inattainingprofoundanesthesia.Whileapprehensionisusuallycommoninmostden-talpatientsandcanbemanagedbyavarietyoftech-niques, inlammationandinfectioncanpresent theirownkindsofuniquechallengesforthedentistwhentrying to achieve profound anesthesia to performcomfortable treatment for the patient.Other knownfactorswhichmaycontributetoanestheticcomplica-tionsincludepatientfatigueandpreviousepisodesofunsuccessfulanesthesia.64,68

Anestheticsolutionsandinlammation

It is well known that the pH of the local anesthe-tic solution and the pH of the tissue into which itis deposited can affect its nerve-blocking action.34

Environmentalchangesinthepulpandperiradiculartissues during inlammation and/or infection signii-cantlyaltersthepHinthetissuessurroundingthein-volvedtooth,loweringitfromanormalpHofaround7,4toaslowas5to6inpurulentconditions.34Thishasamarkedinluenceontheeficacyoflocalane-stheticsolutions.34

Whenananesthetic solution isdeposited into areasof inlammation, the acidic environment decreasesitseffectivenessbyliberatingamuchhigheranesthe-ticconcentrationofthechargedcation(RNH+)relati-vetouncharged(free)baseform(RN).34Itistheun-

charged,free-baseformthatisresponsibleforpene-tratingthenervesheath,therebycreatingthedesiredanestheticeffect.Forexample,injectingananestheticsolutionwithapKa*of7,9(SeeTableI)intonormaltissueswouldresultinapproximately75%ofthelocalanestheticmoleculesinthecationicformand25%inthefree-baseform.34Withinlammation,adropinpHresults inapproximately99%of thesame localane-stheticagent(pKaof7,9)tobeinthecationic(char-ged)form,leavingonlyonepercentofthefree-baseformtopenetrate intothenerve,adverselyaffectingtheanestheticresponse.OnepossiblewaytoovercometheeffectsoftissuepHonanestheticsolutionsistodepositagreatervolumeofanesheticintothearea.Eventually,enoughoftheunchargedfree-basemoleculeswillbecomeavailablefornervepenetrationandwillfrequentlybeadequa-teinachievingthedesiredanestheticeffect.34Anothermethodmightbetoregionallyblocktheareabyinjec-tingintotissuesdistantfromthesiteofinlammationorinfection.Bydoingso,onecanpresumethatthetissuesinthisareahaveamorenormalpHand,the-refore,shouldenhancetheanestheticeffect.Forthisreason,regionalblockscanbeverybeneicialinthetreatmentofsomeendodonticallyinvolvedteeth.

TableI

Dissociationconstants(pKa)

offrequentlyusedlocalanesthetics

ApproximateAnesthetic a%base onsetofsolution pKa atpH7,4 action(min)

Mepivacain 7,6 40 2to4

Etidocaina 7,7 33 2to4

Lidocaina 7,9 25 2to4

Prilocaina 7,9 25 2to4

Bupivacaina 8,1 18 5to8

If conventional anesthetic techniques fail to provi-deeffectiveanesthesia,(i.e.regionalblocksandinil-trations)andproper injection techniquewasperfor-med,(whichisthemostcommonreasonforanesthe-ticfailure34)thenitmaybeusefultorepeataninjec-tiononlyifthepatientdoesnotexibittheclassicsigns

(*)pKaaffectstheonset;thelowerequalsmorerapidonsetofaction,moreRNmoleculespresenttodiffusethroughthenervesheath,thusonsettimeisde-creased.34


ofsofttissueanesthesia.However,iftheanestheticef-fectshavebeenconirmed,butthepatientcannotto-leratedentinorpulpmanipulation,reinjectionisge-nerallyineffective.Thisistheappropriatetimetocon-siderasupplementalanesthetictechnique.68

These typesofanesthesia, intraligamental inparticu-lar,mayalsobenecessaryinpatientsinwhomtheuseofroutineanesthesia,suchasaninferioralveolarner-veblock,iscontraindicated.Thismayapplytopatientswithhemophilia22orotherdisordersofcoagulation,inwhom post-injection bleeding may be dangerous. Itmayalsoapplytomentallyorphysicallyhandicappedpatients,inwhomthereisagreatriskoftraumatizingsofttissuesstillundertheanestheticeffectoftheblock,suchasthetongueorlowerlip30(Fig.4.1C).Ina1981studybyWaltonandAbbott,6647%ofteeththat required supplementary anesthesia were lowermolars.Thismayhavebeenrelatedtotheaccessoryinnervationthattheseteethcanreceivefromdifferentbranchesoftheinferioralveolarnerve.14,60

Supplementary anesthesia includes the lingual inil-tration,theintraseptalinjection,theperiodontalliga-ment injection, the intrapulpal injection and the in-traosseousinjection.

Lingualiniltration

Itisusefulinlowerirstmolarswithpulpitis.Holdingthesyringeparalleltotheocclusalplane,theneedleis introduced into the lingualgingivaabouthalfwaybetweenthegingivalmarginandthebaseofthefor-

nix(Fig.9.17).Thedevelopmentofawhitishareaofischemiaassuresthatthetechniqueiscorrect.If, in-stead,abubble-likecollectionofanestheticformsinthelingualfornix,thetechniqueisincorrect.Theap-proachmustberepeatedbyinsertingtheneedlemo-reocclusally.Schilder51recommendstheroutineuseoflingualin-iltrationeachtimeanendodontictreatmentisperfor-medonalowermolar.Oncethenerveblockhasbeenaccomplishedwith3/4ofthevial,theremaining1/4maybeusedtoperformthelingualiniltration,whichinpractice isnothingmore thanasubperiosteal lin-gualiniltration.

Intraseptalinjection

DescribedbyBandford1 in 1970 andbyMarthaler37in1973,isaccomplishedatthelevelofthebonysep-tumbyintroducingtheneedleintothedentalpapil-laandinjectingaminimumamount(0,2-0,4ml),di-stally to the tooth to be anesthetized.5 Because thistypeofanesthesiamustbeperformeddirectlywithinthecancellousbone,thedentistmustovercomehighpressureswiththeinjection.Forthisreason,theuseofanappropriatepressuresyringe,suchasPeripress(Fig.9.18),isrecommended,togetherwitha27-gau-geshortneedle.Asforalltheintraosseousinjections,itisadvisabletouseananestheticsolutionwithoutvasoconstrictor,inordertoavoidsystemiceffects.Thisanesthesiaisindicatedwhentheperiodontalin-

A B

Fig.9.17.A,B.Subperiosteallingualanesthesia.

Fig.9.18.Peripresspressuresyringe.


volvement precludes the use of the intraligamentalinjection.Theadvantagesoftheintraseptalanesthesiaareseveral:onlyaminimumvolumeofsolutionisre-quired,thereisnolipandtongueanesthesia,imme-diateonsetofaction(lessthan30seconds)andpre-sentsveryfewpostoperativecomplications.47Thepul-palanesthesiahasashortduration,andthishastobeintoconsiderationduringendodontictreatment.

Intraligamentaliniltration

Castagnolaetal.8in1976,WaltonandAbbott66in1981,andMalamed32in1982havedemonstratedthatinjec-tionintothespaceoftheperiodontalligamentismosteffective in situations in which the local anesthesiaachievedwithtraditionaltechniquesisincomplete.Thistypeofanesthesiaisperformedwiththeappro-priatesyringe,suchasPeripress,Citoject(Fig.9.19),or Ligmaject, by introducing the small needle (27-gauge) into the space of the periodontal ligament,makingsurethattheneedle’sbevelfacestheboneofthealveolarcrest (Fig.9.20),according to someau-thors,23,55,57,65,66or,according toothers,30,35 therootofthe toothsoasnot todamage the radicularcemen-tum.According to theauthoropinion, since the so-lutionusuallyentersintothebonemarrowspacesra-therthanpenetratingintotheperiodontalligament61theneedle’sbevelshouldfacethebone.Theneedlemustbe forced to thepointofmaximalpenetration,andtheanestheticmustbeinjectedun-derhighpressure.Iftheanestheticsolutionlowsoutofthevialwithoutmucheffortonthepartof thedentist, theneedle ismalpositioned.Itmustbere-positionedandintrodu-cedmoredeeply. Inmultirooted teeth, theanesthe-siamustberepeatedforeachroot(Fig.9.21),Thein-droductionoftheneedleshouldalwaysbeinthein-terproximalareas,neveronthebuccal.Theanesthe-ticeffectisimmediateandprolonged.Thesizeoftheneedlehaslittlerelationtotheanestheticeffect.Themanufacturersofpressuresyringes recommendverythin needles (0.30mm in diameter), but these tendtobendeasily.Betterresultsareobtainedwithshort,25/27-gaugeneedles.36,58

Numerous studies have investigated the periodontaldamagecausedbythistypeofanesthesia,whichwasirstdescribedbyFischer13in1923butfellintodisu-sebecauseitwasthoughttobedetrimentaltothepe-riodontalligament.Castagnolaetal.8assertthattheyhaveneverfoundthe

Fig.9.21.Inmultirootedteeth,intraligamentalanesthesiamustbeperformedonalltheroots.

Fig.9.20.Someauthorscontendthatthebeveloftheneedlemustfacethebo-neofthealveolarcrest.

Fig.9.19.Citojectsyringeforintraligamentalanesthesia.


sortofdamagethatotherauthorshavefeared,namelynecrosisoftheperiodontalligamentasaresultoftheactionoftheanesthetic,periodontitisfromtheinocu-lationofmicrobes,andtraumaticarthritisfromthein-sertionoftheneedle.Norhassuchdamageeverbeendemonstratedexperimentally;indeed,theclinicalim-pressionarisingfromtheuseofthistechniqueisthatthereisnoirreversibledamagetotheperiodontalli-gament.70Thisclinicalimpressionisconirmedbyhi-stologicstudies inmonkeys67anddogs.15Thesestu-dieshaveshownthattheperiodontalligamentexpe-riencesonlylimited,reversibleinjury.Thedamageisconinedtotheregionoftheinjectionandtothezo-nesimmediatelyadjacenttoit,andit isfollowedbyrapid “restitutio ad integrum”. Thus, thismethod ofanesthesiamaybeconsideredinnocuousforthepe-riodontium.45,46,52

Contraindications to the intraligamental injection in-clude infection or severe inlammation at the injec-tionsiteandprimaryteeth.Brannstrometal.7repor-tedthedevelopmentofenamelhypoplasiainperma-nentteeth,followingtheadministrationoftheperio-dontalligamentinjection.In contrast to intrapulpal anesthesia, which is al-ways painful for the patient, intraligamental ane-sthesia is painless if done after standard anesthesia.Other advantages of intraligamental anesthesia arethatitdoesnotrequirespecialequipment.Itmaybedonewithapressuresyringe,butmayalsobedonewiththesamesyringeandneedleusedforthestan-dardinjection.Nevertheless, the use of appropriate syringes is re-commended, since they may attain pressures more

thantwiceashighasregularsyringes.15Furthermore,sincethevialissheathedinametallicorTeloncon-tainer,theybetterprotectthepatientagainstacciden-talruptureoftheglassvial,whichcanoccurasare-sultofthehighpressuregenerated.Finally,itiseasiertodosetheinjectedanestheticataconsistentvolumewitheachactivationofthesyringe.Ifitbecomesnecessarytousethistypeofanesthesiawhentherubberdamisalreadyinposition,itisnotnecessarytoremoveorliftit.Theopeningoftherub-berdammaybestretchedslightlytoidentifythespa-ceintowhichtoinserttheneedle(Fig.9.22).Regardingtheanestheticsolution’sdistributioninthetissues, intraligamental anesthesia must be conside-red toalleffectsan intraosseousanestesia.36,43,65Theinjectedsolutionsarerapidlyabsorbedbythesyste-miccirculation55,57 (Figs.9.23,9.24).For this reason,theuseofanestheticscontainingcatecholamines forintraligamental anesthesia is inadvisable in patientswithischemicheartdiseaseorhypertension.55Inthisrespect, intraligamental anesthesia is identical to in-traosseousanesthesia;comparedtothelatter,howe-ver, it is easier to perform. In animal experiments,theeffectsofintraligamentally-administeredvasocon-strictor-containinganestheticsonheartrateandblood

Fig.9.23.Alveolusofthelowerirstmolarinahumanskullafterremovalofthetooth.Thecorticalbonehasacribriformappearance,especiallyinthecervicalregion,wheretheanestheticpassesintothemedullaryspaces.Thatwhichisradiographicallydeinedasthelaminaduraisinfactaporousstructure.

Fig.9.22.Iftheneedarises,intraligamentalanesthesiamayalsobeperformedwiththerubberdaminplace.Thereisnoneedtoremovetherubbersheet;itneedsonlybestretchedaside.


pressurearethesameasthosewhichoccurafterin-traosseousorintravenousadministrationofthesamesubstances.However,theseeffectsarecompletelyab-sentiftherouteofadministrationissubmucosal,intra-pulpal,subcutaneous,orintramuscular.43

Therefore,ifweneedtousetheintraligamentalinjec-tionoranyotherintraosseousanesthesiainapatientwith high blood pressure, cardiovascular disease oranycontraindicationtoepinephrineuse,itisprudenttochoose3%mepivacaine,whichhasminimalcardio-vascuareffects.16,47,49

As previously reported by Castagnola et al.8 andLangeland,25Linetal.28havedemonstratedthatintra-ligamentalanesthesiadoesnotcauseanyhistologicaldamagetohealthypulptissuesandisthusalsoindi-cated forproceduresother thanendodonticones. Itmaythereforebeconidentlyusedasadiagnosticaidinlocalizingpulpalgiabyselectivelyadministeringtheanesthetictotheindividualteeth,51thoughsomeau-thorshaveexpressedscepticism.11,23,65

Inconclusion,thepreferredsupplementaltechniquetoobtainprofoundpulpalanesthesiaifthestandardblockoriniltrationinjectionisnoteffective,atthistimeistheperiodontalligamentinjection.Ifeventheperiodontalligamentinjectiondoesnoteffectprofoundpulpalane-sthesia,theintrapulpalinjectionisthenextoption.63

Intrapulpaliniltration

Described by numerous authors,4,18,21,31,39,69 the intra-pulpalinjectionassurescertainresultsin100%ofca-ses.Itrequirestheinjectionofanestheticthroughassmallanopeningaspossibleintheroofofthepulpchamber(Fig.9.25).Thepressurewithwhichtheanestheticsolutionmustbeinjectedisactuallyresponsiblefortheanesthesicef-fectofthistechnique.4Infact,thesamedegreeofane-sthesiamaybeobtainedbyinjectingsalinesolution.63

Itisimportantthatthechamberopeningbesmallandthat theneedlebewellengaged.Thisassuresgoodpressurewithinthechamberitself.Thepressurethustransmitted to the pulp tissue causes instantaneous,profoundanesthesia,evenforveryprolongedendo-donticprocedures.Iftheopeningintothepulpcham-beristoolargetowedgetheneedle,alargersizenee-dlecanbeused.Othertimesitisnecessarytoplacepiecesofrubber,waxorcottonpelletsoveroraroundtheneedletoforastopper.63

In multirooted teeth, however, it may be necessarytorepeatthistypeofanesthesiaintheindividualca-nals.56Theanesthesiamaybepainful,butthesensiti-vitywilllastforonlyafewseconds.Itsuficestoinjectafewdropsofanestheticunderpressuretoobtainthedesiredeffect.31Ifthepulpisnotcompletelyremovedduring thevisit, the remaining tissuewill remainvi-

Fig.9.25.Intrapulpalanesthesia.

Fig. 9.24. Schematic representation of the proba-ble path of distribution of a local anesthetic solu-tion injected into the space of the periodontal li-gament.


taluntilsubsequentappointments.Therefore,theane-sthesiamustberepeated.4

Some authors38 state that intrapulpal anesthesia canalsobeusedinthecourseofpulpotomyinteethwithanimmatureapexandvitalpulpcompromisedbyca-riesortrauma.Thechancesofpreservingthevitalityoftheremainingportionofthepulptissueincreaseswhenonelimitsthedepthofpenetrationofthenee-dleintothepulptolessthan2mmandwhenonere-gulatesthepressureduringtheinjection.Other authors24 claim that intrapulpal anesthesiashouldbeavoidedinpulpotomyonteethwithanim-matureapex,sinceitwouldforcecontaminantspre-sent in thecoronalpulpintotheradicularpulpandwouldcausealacerationinthetissue.The intrapulpal anesthesia has no contraindicationandatthesametimeoffersseveraladvantages: lackoflipandtongueanesthesia,minimumvolumeofso-lutionrequired,immediateonsetofaction,nocardio-vasculareffectandveryfewpostoperativecomplica-tions.Ontheotherhand,itrequestsa“small”openingintheroofofthepulpchamber.Sometimes,togetthelittlepulpexposuretoinserttheneedleisverypain-fulforthepatientwhoisaskedto“cooperate”,eventhoughthepreviousanesthesiafailed!Asaprecaution, it isnotadvisable to inject into in-fectedtissue,toavoidtheriskofspreadingtheinfec-tionintheperiapicaltissues.36

INTRAOSSEOUSANESTHESIA

Intraosseousanesthesiaisatechniquewherebyteethare anaesthetized by injecting local anesthetic solu-tion directly into the cancellous or medullary bonearound the affected tooth.59Historically, the intraos-seous injection was inconvenient and burdensome,requiringthecliniciantomakeasmall(1.0-3.0mm)incision,andwithasmall,roundbur,drillorreamer,penetratethroughthedensecorticalplateofbonein-tocancellousbone.6,26,29,44Then,withashortneedle,approximaytely1.0mlofsolutionwasdeposited.Theresultswereveryfavourable,butthetechniquepro-vedtediousforthedentistandsomewhatintimidatingfor the patient. Currently, two intraosseous systemsareavailablecommarcially(StabidentLocalAnesthesiaSystem, Fairfax Dental Inc. and X-Tip IntraosseousAnaesthesiaDeliverySystem,DentsplyMaillefer)thatsupply thedentistwitha “perforator”andultrashortneedles (Fig.9.26),precluding theneed foran inci-sionandtheuseofaroundbur.Consequently, this

technique,withalittlepractice,ismoreuser-friendlyandiswelltoleratedbythepatient.Thetechniquehasshownfavourableresultsinthatitspulpalanestheticeffectisextremelyrapid,almostimmediate.9Forthisreason,itisverysuccessfulasasupplementaltechni-que,9,12,44anditisparticularlyeffectiveincasesofirre-versiblyinlamedpulpsinmandibularmolars.42Moreimportantly, ifperformedwithcare, itcanbeadmi-nistered to the patient with little or no discomfort.Althoughitsuseasaprimarytechniquehasbeensug-gested,itsshortduration(15-30minutes)precludesitsuseassuchforlengthyendodonticprocedures.9,12,42,48

Theintraosseoustechnique

As previously mentioned, the intraosseous anesthe-tic technique is basedon thepremise that anesthe-ticsolutionisdepositeddirectlyintocancellousboneadjacenttotheaffectedtooth.Thetechniqueinvolvesthreesimplesteps:1. anesthesiaoftheattachedgingiva2. corticalboneperforation3. depositionofanestheticsolutionintocancellousbone.

Step1:anesthetizetheattachedgingiva

Usingtheultrashortneedlesprovidedinthekit,injectafewdropsofsolutionintotheattachedgingivauntilslightblanchingoccurs(Fig.9.27).Thiscanbepain-lessforthepatientiftheinjectionisslowanddelibe-rate.Theuseoftopicalanestheticisoptional.Despite

A B

Fig.9.26.Perforatorsandultrashortneedles.A.X-Tip.B.Stabident.


boneinthisareatendstobethinandfragileandtis-suenecrosiscouldoccur.Conversely, if theperfora-tionismadetoofarapically,thebonebecomesthic-kerandashallowdepthofperforationwouldresultinaninadequateanaestheticeffect.The manufacturer suggests injecting distally ratherthanmesiallywhenever possible, because a smallerdose sufices.59

Frompersonal experience, there has

beennosigniicantdifferencenotedwheninjectionswereperformedmesiallytotheaffectedtooth.Infact,inthemandibularmolarregion,wherethetechniquehasbeenmostuseful, themesialapproach tends tobemoreaccessible.It isalsorecommendedthatthethinbonebetweenthemaxillaryandmandibularcen-tralincisorsbeavoided.Shouldtheseteethrequirein-traosseous anesthesia, approach the perforation sitedistally,orperhapsevenbetter,avoidtousethetech-niquealtogetherandrelyoniniltration.

Perforatingthecorticalbone

Once the sitehasbeen selected, and the tissuehasbeen anaesthetized, place the perforator in a latch-typecontra-angleofaslow-speedhandpieceandre-movethesafetycap.Orienttheperforatorperpendi-cular to the corticalplate at thepredetermined site,andgentlyadvanceitthroughthegingivauntilitrestsirmlyagainstthebone(Fig.9.29).Next,engagethemotorforapproximatelytwosecondsandapplylight,intermittentpressureuntilperforationoccurs.Thiswillbeevidentasthesensationcloselyresemblesthe“gi-ve” experiencedwhen accessing the pulp chamber.Thepatientshouldbeforewarnedofthesensationofslightvibrationandpressure.

itsquestionableeffectiveness,itsuse,iffornootherreason, demonstrates to the patient that every ef-fort isbeingmade toensure theircomfortandwellbeing.17,50,68

Step2:Corticalplateperforation

The“perforator”comprisesa27-gauge, solidneedleshankwithabevelledenddesignedtoitintoastan-dardslow-speed,contra-anglehandpiece.Itis9.0mminlengthandcorrespondtothediameterandlengthoftheneedles.Ithasanarrow-diametercollarwhichprovidesasafetystopagainstexcessivepenetration,withawiderdiametercollarthatisdesignedtoaidinpreventing debris and lubricant from contaminatingthe perforator needle. The perforators are suppliedgamma-raysterilizedandaretobedisposedofafterpatienttreatment.59

Selectionofinjectionsite

To determine the correct placement for the corticalpenetration,imagineahorizontal linealongthegin-givalmarginsoftheteeth,andaverticallinethroughthepapilla.Atapointapproximately2.0mmapicaltowheretheselinesintersectisusuallyasuitablesi-tefortheperforation59(Fig.9.28).Priortoperforatingtheplate,itishelpfultorefertothepreoperativera-diographtoassessthespacebetweentherootsoftheadjacent teethandtonote therelative interproximalboneheighinthearea.Injectingintosofttissuewillresultininadequateanesthesia.Caremustbetakentoavoidinjectingtoofarcoronallyintothepapilla.The

Fig.9.27.Anesthetizetheattachedgingival(Spetp1). Fig.9.28.Generalguidelineforperforationsiteselection.


Step3:Injectingintothecancellousbone

Afterperforationiscompleted,it is importanttono-tetheexactsiteofpenetration.Onesuggestionforitsidentiicationistocompressacottonrollagainstthemucosaforafewsecondstoabsorbanybloodinthearea.Oncethepuncturewoundhasbeenisolated,thechairsideassistantshouldpasstheanestheticsyringeinapengripfashion,alignandgentlyinserttheneed-leintotheperforatingsite(Figs.9.30,9.31).Thismaytakeafewattemptsinitially,butwithexperience,thisphaseofthetechniquebecomeeasier.Ontheotherhand,whenstartingtouseintraosseousanesthesiaini-tially sometimescanbe found somedificulty inser-tingtheneedleinthedrilledhole.InsuchcasescanbeveryhelpfultouseoftheX-TiportheAlternativeStabident. In the X-Tip (Fig. 9.32), drillingwith theperforatorautomaticallyplacestheguide-sleeveinpo-sitioninthecorticalbone,toprovideapreciseinjec-

Fig.9.30.Inserttheneedleintoperforationsiteandslowlyinject(Step3).Fig.9.29.Perforatethecorticalplate(Step2).

Fig.9.31.Diagramrepresentinglocationforpreparationsiteandinjection.

B

A

Fig.9.32.A,B.TheX-Tipleavestheguide-sleeveinpositioninthecorticalbone(CourtesyofDentsplyMaillefer).

tionofanestheticintocancellousbone.TheAlternativeStabidentguide-sleeveismanuallyin-sertedinthedrilledhole(Fig.9.33).Whentheguide-sleevehasbeeninsertedintheboneonewayortheother,theinjectionneedleisloadedintothefunnel-shapedentranceattheotherendoftheguide-sleeve,toslowlyandgentlyinjectthesolution.Agoodruleofthumbistoallow60secondspercar-pule as a guide to the speed of injection. Usually,


onlyabout0.45to0.90mlor1/4to1/2ofacartrigeisall that isrequiredtorenderprofoundanesthesia.However,upto1.8mloronecartrigemustbeused.Aswithanyinjectionmethod,arapidinluxoftheso-lutioncancause transientdiscomfortandan increa-seinheartrate.12,26,48Itisbesttoalwayspreparethepatient for this potential consequence before injec-tionbegins.Astheanestheticisdelivered,theplungershouldadvancewithease.Shouldconsiderableforceberequiredtoinject,assumethateithertheneedleisnotincancellousbone,orisbuttedagainstrootsurfa-ce.Ifconsiderablebackpressureismet,attempttoro-tatetheneedleone-quarterturn.Ifrepeatedattemptstoredirecttheneedleproveunsuccessful,thenchoo-seanotherpenetrationsiteandrepeatStep2.Intheposteriorregionsofthemouth,duetocompromisedaccess,extremecautionmustbetakentoavoidrootperforation.Forbetter access intoposteriorperfora-tionsites,itissometimesbeneicialtobendtheneed-leatthehub45degrees.Beginnersareencouragedtorestrictthemselvestotheanteriorregionsuntil thesystemhasbeenmastered.Thisprecautionissuggestedbecausetheangleofper-forationrequiredintheposteriorregionsofthemouthismorecritical,withagreaterchancefortheoccur-renceofproceduralmishaps,suchasrootperforationsorperforatorandneedlebreakage.

Dosagereccomendations

Absorption of the anesthetic into the blood supplyfollowing intraosseous administration is more rapidthanwithprimaryinjectiontechniques,thusrequiringmuch less to produce the desired anesthetic effects

ascomparedtotraditionalmethods.59Therefore,onlyonecartridgeofanestheticperpatientisrecommen-dedandconcentrationsofvasoconstrictorshouldnotexceed1:100,000.26,34

Therecommendedanestheticagentforthistechniqueis2%lidocainewith1:100,000epinephrine.68Researchhasshownthat3%mepivacainewithoutepinephrinedoesnotproducethedesiredanestheticeffectwhencomparedto2%lidocainewith1:100,000epinephri-ne.48

Durationofanesthesia

As with all supplemental injections, the duration ofanesthesiausingtheintraosseoustechniqueisshorterthanwithstandardiniltrationorblocks.Onecanex-pectapproximately15to30minutesofprofoundpul-palanaesthesia.59Thisshouldprovidethepractitionerwithampletimetoaccessthepulpchamberandextir-patethepulpinacomfortable,expedientmanner.

Considerationsforintraosseousanesthesia

Anatomicalconsiderations

Cautionshouldbeexercisedwheninjectingbetweenthemandibularpremolarsduetotheproximityofthementalforamen,eventhoughaperforationatadistan-ceof2.0mmfromthegingivalmarginshouldbewellawayfromtheneurovascularbundle.Additionally,ca-reshouldbetakentoavoidperforationintothemaxil-larysinus.Althoughthiswouldnotresultinaseriouscomplication,itcouldbeuncomfortabletothepatient

……

………

��

��

……

……

…

.……

��

��

A B

Fig.9.33.A,B.UsingtheAlternativeStabident,theguide-sleeveismanuallyinsertedinthedrilledhole(CourtesyofFairfaxDentalInc.).


andresultininadequateanesthesia.Otherconsiderationsthatmaydiscourageorpreventthe use of the intraosseous technique are listed inTableII.

Patientconsiderations

Variousresearchershaveshownthatsolutionscontai-ning epinephrine injected by the intraosseous routearerapidlyabsorbedintothesystemiccirculationandcancauseadecreaseinbloodpressureandincreaseinheartrateinthemajorityofthepatients.Thiseffectusuallysubsideswithintwotothreeminutes.12,26,27,48

Inanormal,healthypatient,thiscanbefrequentlycir-cumventedbyinjectingslowlyandreassuringthepa-tientthattheeffect,shoulditoccur,willbetransient.For the medically compromised patient, specii-cally those with cardiac deseases, there are genui-ne concerns regarding the use or avoidance of va-soconstrictors. Frequently, however,we allow thoseconcerns toovershadow theactualbeneits that thevasoconstrictoroffers.Thepractitionershouldalwayskeepinmindthatifthemedicallycompromisedpa-tient’s condition is stabilized through medical treat-ment, therearenoabsolutecontraindications to theuseofvasoconstrictors,exceptforthosepatientswithuncontrolled hyperthyroidism with clinical evidenceof thyrotoxicosis andpatientswith suliteallergies.19Patientswithuncontrolledhypertension,and/orapre-sentorpasthistoryofcardiovasculardiseasearecon-ditionsthatmayrequiremedicalconsultationpriortotreatment.

Assuming proper injection technique is performed,vasoconstrictorsareimportantadditionstolocalane-stheticsolutions.34

Epinephrine and other vasoconstrictors provide awidesafetymarginfornormal,healthyadultpatientsand most medically compromised patients who arestabilized.Paradoxicalasitmayseem,thegreaterthemedicalriskofapatient,themoreimportanteffecti-vepainandanxietycontrolbecomes.19Theavoidan-ceoftheirusewillresultinashorterdurationoftheanestheticeffect,therebydiminishingthepotentialforpainlesstreatment.19,34

Otherconsiderations

A small number of patients who receive anestheticviaintraosseousroutemaydevelopexudateorswel-lingat the injectionsite.9Although theareasshouldhealuneventfully,thepossibilityofthisuntowardef-fectmustbeconsideredwhenusingtheintraosseoustechnique.Themanufacturerclaimsthatthewoundsitecreatedby the perforator has a surface area approximately1/700ththesizeofanextractionsocketandgenerallyhasahealthygingivalcovering.59Secondly,theperfo-ratorissuppliedsterile.Aslongastheclinicianispru-dentnottoinjectintoareasofactiveperiodontaldi-seaseandinfection,thepotentialforinfectionisex-tremelyrare.Should swelling or drainage occur, judicious use ofantibiotics, suchaspenicillinor clindamycin,wouldbeindicated.

TableII

Contraindicationsforusingtheintraosseoustechnique

– Physicalstructurespreventperforation

– Inadequatespacebetweenrootsforperforation

– Areasofadvancedperiodontaldiseaseoracuteinfection

– Avoidmandibularpremolarregionduetocloseproximityofthementalforamen

– Avoidinjectingbetweenmaxillaryandmandibularcentralincisors


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the use of anesthesia in endodontics

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andifoneisworkingu anesthesia

anesthetic solutions

successful anesthesia

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andinp teeth

therearesever tooth