ANESTH LEC/LAB (From the videos) THE ARMAMENTARIUM What is the armamentarium for local anesthetic injection?

Basic armamentarium o Syringe o Needle o Cartridge Additional items o Cotton applicator o Sterile gauze wipes o Topical anesthtic o Hemostat o 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 colorcoded so their content may be easily identified. A cartridge of plain drug contains the following: o Local anesthetic o Sterile water o Sodium chloride The following additional ingredients are found in LA that contains a vasoconstrictor: o Epinephrine o 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 short Typical short dental needle (tip to hub) 20mm Long 32mm Ultra-short 10mm Very basic rule regarding insertion of needles in the soft tissue: NEVER insert a needle all the way into the tissue to its hub unless it is absolutely essential for the 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 maximized How 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 use What 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 container What is the proper technique of inserting a second cartridge for additional injections? Unscrew the needle (with cap) Remove the empty cartridge Insert a new cartridge Embed the harpoon using gentle finger pressure Reattach the needle BASIC 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 of 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 Rest on the patients face for many injections. While those with shorter fingers may need to use Elbow Rests. Make tissues taut the tissues at the site of needle penetration should be stretched before the insertion of the needle making the insertion of the needle 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 and discard 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 and hard 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 Palatal (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

Why do we anesthetize the Palatal area? For the beak of the forcep to engage underneath the gums. You have to separate the gums on the labial and on the palatal, if you will not anesthetize the palatal area and you separate the gums that will be too painful. And you know the separation: Nasopalatine and Greater palatine. Not directed towards the Greater Palatine but only up to the distal part of the Canine. When you are having problems like anxiety or nervousness, you will suffer from 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 than the 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 (there should 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 surgery

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

Areas Anesthetized

Insertion Site

1.

One carpule can anesthetize four teeth Insert the needle almost parallel to the bone and stop short at the apex. If you direct the needle 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 a film 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, when you force the needle it will scrape the periosteum, which is rich in capillaries and then it will 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 then reinsert.

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 the needle tip is at or above the apex of the tooth. Perform two negative aspirations. 1/3 of the local anesthetic is slowly injected

Left PSAN 3.

Right PSAN

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 patient 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 exactly at the apex. It should just be near the apex.

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

Areas Anesthetized

Insertion Site

Left MSAN

Right MSAN

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 upper lip is also anesthetized. Right or Left ASAN block: right-handed operator should sit at the 10 oclock 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

Left GPN block

Right GPN block

Areas Anesthetized

Palpate

Insert

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

6. 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 orbit. According to Dr. Romero 27 gauge extra long needle is used.

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 the mesial of the left first premolar. Sit at the 9 or 10 oclock position facing in the same direction as the patient. Multiple Injection Technique First injection infiltration into the labial soft tissues between the two central incisors. 0.3 ml of anesthetic is administered. Second injection infiltration into the now-numbed papilla between the two central incisors. Local anesthetic is administered as needle is advanced until blanching is noted on the palatal soft tissues. Third injection traditional nasopalatine nerve block in which the needle is inserted into the soft tissues just lateral to the incisive papilla. The needle is advanced through soft tissue until bone is contacted and following negative aspiration, 0.3 ml of local anesthetic is administered.

5.

Greater Palatine Nerve Block Also known as the Anterior Palatine Nerve Block Provides anesthesia to the posterior portion of the hard palate and its overlying soft tissues, anteriorly as far as the first premolar and medially 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 of the cartridge of local anesthetic is deposited over 15 to 20 seconds.

Areas Anesthetized

Operators Position

Multiple Injection Technique First Injection

Left IAN block: right-handed operator should sit at the 10 oclock position facing in the same direction as the patient Right IAN block: sit at the 8 oclock position facing the patient

Multiple Injection Technique Second Injection Areas Anesthetized

Multiple Injection Technique Second Injection Observe for blanching Left IAN Block Right IAN Block Three Criteria for locating the correct landmark for needle insertion 1) Height of injection 2) Anterior / Posterior position 3) Depth of penetration a) Multiple Injection Technique Third Injection b) c) A finger is placed on the lingual aspect of the ramus and pulled anteriorly until the coronoid notch is palpated. The coronoid notch is the greatest concavity on the anterior border of the ramus. The barrel and the syringe is placed on the corner of the mouth on the opposite side. The needle tip touches the most posterior aspect of the pterygomandibular raphe. The needle tip is then moved half the distance toward the coronoid notch (-----) and then half the distance back toward the raphe (---). This locates the injection site which is of the distance of the coronoid notch to the raphe (). The needle is then inserted and advanced slowly until bone is contacted. The average depth of penetration is between 20-25mm which is 2/3 to 3/4 the length of a long dental needle. Once bone is contacted, aspiration is performed twice and if negative, 1.5 1.8 ml of local anesthetic is administered slowly.

d) e)

Multiple Injection Technique Third Injection

Nasopalatine nerve block is extremely painful unless a preparatory injection is done. 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 is met and deposit the solution.

MANDIBULAR INJECTION TECHNIQUES What are the injections used to anesthetize the mandibular teeth, soft and hard tissues? Inferior alveolar nerve block Buccal nerve block Gow-Gates mandibular nerve block Vazirani-Akinosi mandibular nerve block Mental nerve block 1. Inferior Alveolar Nerve Block Provides anesthesia to the pulps of eight mandibular teeth in that quadrant, the buccal soft tissues and bone anterior to the mental foramen, the anterior two-thirds of the tongue and the floor of the mouth, and the lingual soft tissues and periosteum 25-gauge long needle is recommended (a) (a) (b)

(c)

(e)

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. Left GGMN Block Right GGMN Block

Areas Anesthetized Needle Insertion Site

Withdrawn 3.

Repositioned

Reinserted

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 the oral cavity, the lingual soft tissue and periosteum as well as the skin of the zygoma at the posterior portion of the cheek at the temporal regions 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 the mesiolingual cusp of the maxillary second molar and then the needle tip is moved just distal to the second molar. This locates the insertion site of Gow-Gates injection. The needle is now inserted until bone is contacted. The average depth of penetration in the Gow-Gates injection is approximately 25mm 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

4.

Vazirani-Akinosi Mandibular Nerve Block Provides anesthesia to the eight mandibular teeth, the buccal soft tissue and bone anterior to the mental foramen, the anterior 2/3s of the tongue and the floor of the oral cavity and the lingual soft tissues and 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 the mandibular molars adjacent to the intergingival junction of the last maxillary 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

Areas Anesthetized

SUPPLEMENTAL INJECTION TECHNIQUES What other techniques are available to anesthetize teeth, soft and hard tissues of the oral cavity? Alternative techniques o Periodontal ligament injection (PDL, ILI) o Intraseptal injection o Intraosseous anesthesia 1. 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 bone anterior 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 buccal fold adjacent to the first premolar and then advanced until the needle tip lies outside the mental foramen Following two negative aspirations, 1/3 of the cartridge of anesthetic is deposited over 20 seconds The syringe is removed and pressure is applied extraorally or intraorally forcing local anesthetic into the mental foramen, blocking the incisive nerve Periodontal Ligament Injection (PDL) Also known as Intraligamentary Injection Provides pulpal anesthesia to a single tooth and supporting soft tissues and bone. 27-gauge short needle is recommended Operator positions vary significantly with PDL injections on different teeth o Sit comfortably o Have adequate visibility o Maintain 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 of 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 cancellous bone in this area. 0.2 ml of local anesthetic is administered

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 pulpal anesthesia of the tooth

(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 sodium channel and thus preventing these depolarizations, thereby preventing the transmission 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 local anesthetics 4) 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 Anesthetics 1) Amides (has 2 i") Articaine, Bupivacaine, Lidocaine, Mepivacaine, Prilocaine 2) Esters Benzocane, Cocaine, Procaine Techniques of Mandibular Anesthesia 1. Inferior Alveolar Nerve Block a. Areas Anesthetized Mandibular teeth to midline Body of mandible, inferior ramus Buccal mucosa anterior to mental foramen Anterior 2/3 of tongue and floor of mouth Lingual soft tissue and periosteum b. Technique Apply topical Area of insertion medial ramus, mid-coronoid notch, level with occlusal plane (1 cm above), posterior from coronoid notch to pterygomandibular raphe advance to bone (20-25 mm) c. Target Area Inferior alveolar nerve, near mandibular foramen d. Landmarks Coronoid notch, pterygomandibular raphe, occlusal plane of mandibular 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 is palpated. This is the internal oblique ridge. Step 3: Insert the needle into soft tissue of the pterygotemporal depression, which is halfway between the palpating finger or thumb and the pterygomandibular raphe. Step 4: Approximate the height of the injection by the middle of the palpating fingernail or thumbnail. Step 5: Ensure that the barrel of the syringe is located over the contralateral mandibular bicuspids. Step 6: Insert until bone is contacted, and then withdraw ~ 1mm. the depth of insertion for the average-sized adult is approximately 25 mm.

Alternative Techniques: Computer Controlled Delivery CompuDent (The WAND) Comfort Control Syringe System (CCS) *This enables the operator to deliver local anesthetic painlessly anywhere in the oral cavity especially on the palate.
Alternative techniques whenever the usual injection does not work PDL injection single anesthesia (one tooth) Infiltration technique may also anesthetize adjacent teeth (tooth 11, 12 will also be anesthetized and sometimes also the canine. Depends on the volume of anesthetic injected) Never deposit 1 whole carpule. Tooth extraction carpule RCT carpule Nasopalatine or Greater Palatine 1/8 Less 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 patient 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 because of the manner (speed/rate) on how you inject. PDL injection needle is forced between the tooth and the bone. There is a specific syringe 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 injection Why did the infiltration technique not work? Difference in bone density of the maxilla and mandible. Maxilla is more porous Mandibular blocking of the mandible is anesthetized. You are only to treat just one tooth 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 single tooth. Intraosseous anesthesia do after mandibular blocking. This is just an additional technique Check your anesthesia if it is expired. Maybe thats the reason why it has no effect. How will you know you are depositing the solution? Observe blanching Nasopalatine only shallow. 45 degrees, not parallel