Local Anesthesia in Dentistry

Pain and dentistry are often synonymous in the minds of

patients, especially those with poor dentition due to
multiple extractions, periodontal disease requiring surgery,
or symptomatic teeth requiring endodontic therapy.
Members of the public perceive a good dentist as a
practitioner who causes little or no discomfort. In turn,
dental practitioners identify a good anesthetic as one that
allows them to focus solely on operative procedures
without distractions from pain-induced patient movements.
The everyday practice of dentistry is therefore based upon
achieving adequate local anesthesia. Research has shown
that the fear of pain associated with dentistry is closely
associated with the most common method for blocking pain
during dental procedures-intraoral administration of local
anesthetics. This is considered aversive due to the pain
associated with the injection and the perceived threat of
needle puncture prior to the injection.
1 Another survey finding was that those individuals who
reported themselves as highly fearful of dentistry were
worried about receiving oral injections and demonstrated
an association between high dental anxieties and missed or
delayed appointments
2 Pain is a result of stimulation of nociceptors that are
receptors preferentially sensitive to a noxious stimulus
or a stimulus that will become noxious if prolonged.
When nociception reaches the cerebral cortex, it may be
perceived as pain. Pain may be abolished by interrupting
the pathways that carry the information of the stimulus
from the periphery of the body to the central nervous
system, by blocking the central nervous system,or by
removing the stimulus.
Local anesthetics block sensory neuronal conduction of
noxious stimuli from reaching the central nervous system.
NEUROANATOMY
The sensory supply to the teeth, jaws, and oral mucosa
is derived from the maxillary and mandibular division of
the trigeminal (fifth cranial) nerve, whose cell bodies are
found in the Gasserian ganglion. The maxillary nerve
carries purely sensory fibers, exits the skull through the
foramen rotundum, and enters the pterygo-palatine fossa.
At this point the maxillary nerve gives branches to the
sphenopalatine ganglion. Among the nerves that pass
through the sphenopalatine ganglion is the nasopalatine
nerve (also called the long sphenopalatine nerve) that
passes along the nasal septum and emerges at the incisive
foramen on the anterior hard palate. It supplies sensation to
the gingival soft tissues of the anterior hard palate.
Thegreater and lesser palatine nerves also pass through the
sphenopalatine ganglion and course through the greater and
lesser foramina, respectively. The greater palatine
innervates the palatal mucoperiosteum and the gingiva
from the molars to the area near the cuspid region that
abuts tissue supplied by the nasopalatine nerve. The lesser
palatine nerve supplies the tissues of the soft palate and
uvula.
The maxillary nerve also gives rise to the posterior superior
alveolar nerve, which supplies sensation to the buccal
gingiva and periodontium adjacent to the maxillary molar
teeth and the pulps of all molar teeth except the
mesiobuccal pulp of the upper first molar.
That mesio-buccal pulp is supplied by another branch of
the maxillary nerve, the middle superior alveolar nerve,
which also innervates the pulps, buccal gingiva, and
peridontium of the maxillary premolars. The final branch of
the maxillary nerve, the anterior superior alveolar nerve,
supplies the pulps of the upper incisors and cuspid along
with the associated buccal gingiva and periodontium.
Unlike the maxillary division, the mandibular division
of the trigeminal nerve is a mixed motor and sensory nerve.
The mandibular nerve exits the skull through the foramen
ovale to enter the infratemporal fossa. It then divides into
anterior and posterior divisions.
The anterior division has some sensory branches: the long
buccal nerve that supplies the buccal mucosa and the
gingival adjacent to the lower molar and second premolar
teeth.
Other fibers supply sensation to the skin of the cheek.
The posterior division is primarily sensory. It branches
to give the auriculotemporal, lingual, and inferior alveolar
dental nerves. The lingual nerve innervates the lingual
gingiva, floor of the mouth, and anterior two thirds
of the tongue. The inferior alveolar nerve supplies
sensation to the pulp and periodontium of all the molar and
premolar teeth on 1 side of the mouth. Near the mental
foramen, the inferior alveolar nerve branches into the
incisive and mental nerves. The mental nerve innervates
the buccal gingiva and the mucosa from the mental
foramen forward to the midline, including the skin of the
lower lip and chin. The incisive nerve supplies the pulps
of the first premolar, canine, and incisor teeth.
LOCAL ANESTHESIA
Local anesthesia is dfined as a loss of sensation in a
circumscribed area of the body by a depression of
excitation in nerve endings or an inhibition of the
conduction process in the peripheral nerves. In clinical
practice a localized loss of pain sensation is desired.
Although the terms dental anesthesia and dental analgesia
are used synonymously in dentistry, local analgesia is more
accurate. Local anesthesia can be achieved by a number
of mechanisms including mechanical trauma, anoxia,
and use of neurolytic agents in addition to traditional
local anesthetic drugs. However, clinically only reversible
local anesthetic agents and other reversible techniques
such as temperature reduction or electronic stimulation
are useful to prevent pain.
The use of reversible local anesthetic chemical agents
is the most common method to achieve pain control in
dental practice.
Some ideal properties of local anesthetics are as follows:
* Specific action
* Reversible action
* Rapid onset of action
* Suitable duration of action
* Active whether applied topically or injected
* Nonirritant
* Causes no permanent damage
* No systemic toxicity
* High therapeutic ratio
* Chemically stable and a long shelf life
* Ability to combine with other agents without loss of
properties
* Sterilizable without loss of properties
* Nonallergenic
* Nonaddictive
In spite of the major advances made in the field of
anesthesia, the ideal local anesthetic agent does not exist.
Local anesthetic agents can be classified in several
ways
* Chemical structure: local anesthetics are classified
usually as either esters or amides.
* Duration of action: local anesthetics maybe classified
as short acting, intermediate-acting, or long-acting.
The injectable local anesthetics used in dentistry have a
common core structure consisting of
* Hydrophilic amino terminal
* Intermediate chain
* Lipophilic aromatic terminal
The combination of hydrophilic and lipophilic properties in
1 molecule is essential for an injectable local anesthetic to
be effective. The hydrophilic portion of the molecule
consists of a substituted secondary or tertiary amine.
Solubility in water is essential for 2 reasons
-to allow for the dissolution in a solvent to permit injection,
and
-to allow penetration through interstitial fluid following
administration.
The intermediate chain consists of either an amide or
ester linkage. This allows spatial separation of the
hydrophilic and lipophilic components of the molecule.
The older agents, procaine and cocaine, are ester-based
drugs but are no longer widely used as dental anesthetics
due to their unwanted side effects, such as toxic or allergic
reactions.
The lipophilic part of the local anesthetic agent is an
aromatic residue that is essential for its ability to penetrate
fatty tissue such as the lipid sheath of nerves in
order to gain access to the nerve cell membrane to
reach its site of action.
Different drugs have different proportions of hydrophilic
and lipophilic components. These differences
modify the characteristics and/or the properties of the
anesthetic agents in the following ways:
* Intrinsic anesthetic potency: the minimum concentration
of local anesthetic required to reduce the nerve
amplitude by half its amplitude within 5 minutes. It is
a measure of pharmacologic action of the agent.
* Onset of anesthesia: the onset of anesthesia is dependent
on the speed at which the agent passes
through the tissue, the proximity of site of injection
to the nerve to be anesthetized, and the diameter of
the nerve fibers. Thin fibers are anesthetized more
rapidly as compared with thick fibers, possibly because the
nodes of Ranvier are closer together.
* Duration of action: duration of action of anesthesia is
dependent on the rate of diffusion along a concentration
gradient away from its site of action-the ion
channels in the nerves.
* Effects on other tissues including toxicity: the functions
of lipid-containing organs and tissues such as
the brain and heart may be affected by high levels of
local anesthetics.
* Rate of degradation, both systemically and locally:
most amide local anesthetic agents are broken down
by hepatic dealkylation and hydrolysis and are
subsequentially conjugated with glucuronic acid and
excreted in the urine. Esters are metabolized by esterases
that are widely distributed in the body.
The general constituents of a dental cartridge of anesthetic
solution are:
* Anesthetic sgent
* Vasoconstrictor: this is sometimes included to delay
the removal of the anesthetic from the tissues by decreasing
the blood flow through adjacent blood vessels. A
vasoconstrictor produces the following advantages:
(a) longer duration of local anesthetic action,
systemic effects. The most commonly used
vasoconstrictors are epinephrine (adrenaline) and
octapressin (felypressin). Only epinephrine is available in
the United States.
* Reducing agent: this prevents oxidation of the vaso
constrictor and acts by competing with the vasoconstrictor
for oxygen available in the solution. The most commonly
used reducing agent is sodium metabisulfite.
* Preservative: a bacteriostatic preservative prolongs
the shelf life of the solution, but since preservatives
can provoke allergic reactions, they are no longer
contained in dental local anesthetic cartridges in the
United States. The typical shelf life of an anesthetic
without preservative is approximately 18 months to
2 years.
* Fungicide: Thymol is used occasionally as a fungicide.
* Carrier solution: an acidic aqueous solution dissolves
the local anesthetic salt and maintains it at an acceptable
pH.
MOLECULAR BASIS OF LOCAL ANESTHESIA
All local anesthetic agents used in dentistry work by
obstructing the exchange in Na+ permeability, which is
essential for the initial phases of a neuronal action
potential. This mechanism prevents the development and
propagation of the action potential by preventing the
wave of depolarization.
FAILURE OF ANESTHESIA
Failure of local anesthetics to achieve profound analgesia
may be related to:
* Inaccurate anatomic placement of local anesthetic
solution
* placing too little solution
* allowing insufficient time for it to diffuse and take effect
* injecting into inflamed or infected tissues
* using an outdated or improperly stored anesthetic
solution.
It is recommended that a local anesthetic not be injected
in infected tissue because of the risk of spreading the
infection and the increased probability of achieving less
than effective anesthetic results owing to the low pH
within the infected tissue maintaining the ionized, nonlipid-
soluble state to the anesthetic.
COMPLICATIONS OF LOCAL ANESTHETICS
Complications of local anesthetic administration include
both local effects and systemic effects.7 Local complication
include
* Spread of infection: occasionally infection may be
spread into the tissues by the needle passing through
a contaminated tissue or by the needle being contaminated
before use.
* Hematoma: damage of a blood vessel by the tip of a
needle may lead to bleeding into the tissues, resulting
in the formation of a hematoma. Significant bleeding
may produce swelling, act as an irritant to the tissues,
and cause pain and trismus. Theoretically, the localized
collection of blood becomes an ideal culture medium for
bacteria, although infection of a hematoma
is unusual.
* Nerve damage: rarely, during an injection the needle
may pierce a nerve bundle during placement, producing an
immediate electric shock sensation to the
patient. It is usually followed by a partial sensory deficit,
but subsequently a complete return to normal
sensation usually follows.
* Blockade of the facial nerve: if the injection is given
in close proximity to the facial nerve, a motor blockade
causing temporary paralysis of the muscles of facial
expression may occur. The effect may last for 1-2 hours. In
such circumstances, the desired branch of the trigeminal
nerve will not be anesthetized, and a subsequent injection
will be required at the correct anatomic location to achieve
the desired effect.
Systemic complications include:
* Regional or systemic infection: the spread of infection
within the perioral tissues can be potentially spread
through planes of the head and neck by passage of a
needle through an infected area.
* Endocarditis risk: injections such as the
intraligamentary injection can force bacteria into the
systemic circulation and cause bacterial endocarditis.

* Cardiovascular disease: patients with ischemic heart

disease (angina pectoris, previous myocardial infarction) or
who have had previous cardiac surgery or circulatory
dysfunction such as cardiac failure, show higher plasma
levels of lidocaine when compared with healthy subjects
given the same dose. Therefore it is recommended that the
maximum safe dose be halved in such patients.8 Low
plasma potassium levels and acidosis also potentiate
adverse effects of local anesthetics on the myocardium.
* Liver disease: patients with reduced hepatic function
may exhibit an abnormally decreased rate of metabolism of
amide local anesthetics, resulting in potentially toxic blood
levels. Dosage levels must therefore be reduced for these
patients.
* Pseudocholinesterase deficiency: local anesthetics of
the ester type (eg, procaine) should be avoided in patients
who have this rare familial enzyme defect as metabolism of
these drugs is impaired. Ester-type local anesthetics are no
longer routinely used for dental procedures.
* Methemoglobinemia: this is a rare complication
caused by a metabolite of prilocaine that oxidizes the
ferrous component of heme in red blood cells to the
ferric state. This reduces their oxygen-delivering capacity
and results in tissue hypoxia.
USE OF LOCAL ANESTHETICS DURING
PREGNANCY
The adverse drug reactions during pregnancy may affect
either the mother or the fetus. Hypersensitivity, allergy,
or toxicity reactions in the mother may compromise her
health and limit her ability to support a pregnancy.
Fortunately, doses of local anesthetics in dentistry are
usually relatively small and are generally unlikely to cause
complications during pregnancy. All local anesthetics
cross the placenta to some degree.Highest concentrations in
the fetal circulation follow injection of prilocaine, and the
lowest follow bupivacaine, with lidocaine in between.
Felypressin, which is a derivative of vasopressin and is
related to oxytocin, has the potential to cause uterine
contractions. Although this is a highly unlikely effect at the
low dose of felypressin used in local anesthetics, it is best
avoided during pregnancy. Lidocaine with epinephrine is
commonly used for pregnant dental patients.
The performance of common dental treatments for a
pregnant patient is highly variable. In a telephone survey
using a standardized questionnaire, resident dentists
in Germany, Switzerland, and Austria were interviewed
with respect to several aspects of the dental treatment
of pregnant women. Only 58% of the interviewees decided
clearly in favor of using local anesthetics, 59%
supported the use of analgesics, 70% supported a possible
antibiotic therapy, and 33% would agree with a
radiological examination during pregnancy.In addition,
according to references in the specialist literature,
guidelines for the dental treatment, drug therapy, and
radiological diagnosis of pregnant women are presented.
The local anesthetics should have a high plasma
protein bonding capability
(Articaine,bupivacaine,,etidocaine) and minimum
epinephrine concentrations.
Acetaminophen is the usual analgesic of choice for
pregnant dental patients. If an antibiotic treatment is
required, penicillin, cephalosporin, and erythromycin are
recommended. In particular, during the first 3-month
period, radiological examinations should be restricted to
the absolute minimum and performed only if no rea sonable
alternative is available, although the radiological
burden on the fetus falls 500,000 times short of the
limit value of mgray in the case of a microradiogram, and
50,000 times short of the limit value in
the case of an orthopantomogram.

LOCAL ANESTHETICS IN CHILDREN

Fixed pediatric dosage recommendations for a given age
range are no longer endorsed for local anesthetic and
sedative agents. Available data suggest that adverse
reactions in pediatric patients are commonly caused by
inadequate dosage reduction. Maximum recommended
doses of local anesthetics is based upon the weight
of the child, usually expressed as milligrams per kilogram
of body weight. For very obese children, the maximum
dose should be calculated on the basis of leanbody weight
or ideal weight, not the true body weight.
The specific number of milligrams per kilogram used for
calculating the maximum recommended dose differs
among the various local anesthetics.
MEDICAL-LEGAL CONSIDERATIONS
It is incumbent upon every dental practitioner to treat
his or her patients in an appropriate way, taking into
consideration both their dental needs and any special
precautions related to their past medical history. To prevent
any implication of negligence, a practitioner must
administer appropriate treatment. Furthermore the patient
should receive adequate information about the proposed
dental treatment and must submit themselves willingly to a
local anesthetic as a part of the proposed
dental treatment after the benefits and risks are explained.
Medico-legal complaints arising from administration of
local anesthesia are few in number. There are,
however, some particular complications arising directly
from the local anesthetic drugs or their delivery that
merit consideration.
Persisting anesthesia or paresthesia due to damage to
various branches of the trigeminal nerve is a common
complication in dental surgical procedures, especially
associated with lower third molar removal. Cases relating
to sensory loss of lingual nerve and inferior alveolar
nerve following inferior dental block injections for
restorative procedures have occasionally been presented
as a legal complaint.
In a study of over 12,000 inferior dental block injections,
all given for restorative treatment, 18 patients (0.15%) were
found to have some lingual sensory disturbance following
treatment. Of these 18 patients, 17
patients totally regained normal sensation within 6
months, and 1 patient still had a loss of sensation after
1 year (0.008%). Of the 12,000 patients, 856 (7%)
experienced an "electric shock" type feeling in the tongue
at the time of injection, suggesting that the tip of the
anesthetic needle had touched the lingual nerve.3
Although the medico-legal issues tend to frighten the
dental practitioner, statistical data demonstrate that if
the current standards of practice are observed, the dentist is
unlikely to run into these types of problems.

Chemical Classification and Duration of Action of

Local Anesthetic Agents

Local Anesthetic Classification Duration

Lidocaine Amide Intermediate
Prilocaine Amide Intermediate
Mepivacaine Amide Intermediate
Bupivacaine Amide Long-acting
Etidocaine Amide Long-acting
Articaine Amide Intermediate
Procaine Ester Short-acting