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The success of contemporary dental practice largely hinges on the use of local anesthesia for patient comfort
and safety. Dental hygienists and dental assistants should have a basic understanding of local anesthesia,
proper methods for handling syringes, possible complications, and how to manage emergencies.
ADAA
This course is part of the home-study library of the American Dental Assistants
Association. To learn more about the ADAA and to receive a FREE e-membership
visit: www.dentalassistant.org
ADA CERP
Crest + Oral-B at dentalcare.com Continuing Education Course, Revised November 12, 2014
The Procter & Gamble Company is designated as an Approved PACE Program Provider
by the Academy of General Dentistry. The formal continuing education programs of this
program provider are accepted by AGD for Fellowship, Mastership, and Membership
Maintenance Credit. Approval does not imply acceptance by a state or provincial board
of dentistry or AGD endorsement. The current term of approval extends from 8/1/2013 to
7/31/2017. Provider ID# 211886
Overview
Local anesthesia is the mainstay of modern dental practice, with patients demanding better and more
painless dental procedures. Even though local anesthesia was introduced to the dental profession more
than one hundred years ago, today's options for anesthetizing specific sites in the mouth have become more
varied, with dental professionals having many more options to ensure the comfort and safety of their patients.
Todays local anesthetics employ a cartridge, needle and syringe. The syringe is reusable, while the
cartridge and needle are single use. Because an estimated 300 million anesthetic cartridges are used each
year, it is critical to have a broad knowledge of the wide variety of products available, correct techniques for
using them, and how to manage reactions or emergency situations.
Dental auxiliaries have an important role in assuring the comfort and safety of dental patients before and
after administration of local anesthesia to patients within a dental practice. This course is intended to provide
dental professionals with basic knowledge on local anesthesia.
Learning Objectives
Upon the completion of this course, the dental professional should be able to:
Briefly describe the historical background of local anesthesia for use in dental procedures.
Be familiar with the anatomy of the oral cavity and the methods for administering local anesthesia.
Understand the importance of a patient's medical history.
Understand the importance of recognizing medical complications and managing emergencies.
List the different types of anesthetics and their usage.
Demonstrate proper loading and unloading of the anesthetic syringe.
Discuss the regulatory issues as they apply to local anesthesia.
Course Contents
Glossary
History of Local Anesthesia
Purpose and Types of Local Anesthesia
Topical Anesthetics
Injectable Anesthetics
Non-injectable Anesthetics
Administration of Anesthesia
Roles of the Dental Assistant
Accuracy of the Medical History
Informed Consent
Patient Monitoring
Recognizing and Managing Contraindications,
Allergic Reactions, and Side Effects
Anatomy
The Maxillary Nerve
The Mandibular Nerve
Relationship of Maxillary Nerve to Maxilla
Glossary
Crest + Oral-B at dentalcare.com Continuing Education Course, Revised November 12, 2014
Crest + Oral-B at dentalcare.com Continuing Education Course, Revised November 12, 2014
Crest + Oral-B at dentalcare.com Continuing Education Course, Revised November 12, 2014
Crest + Oral-B at dentalcare.com Continuing Education Course, Revised November 12, 2014
Injectable Anesthetics
Local anesthetics are classified into two general
categories according to linkages: amide (NHCO)
linkage and ester (COO) linkage. These
specialized linkages join to a common carbon
chain that is joined to a hydrophilic chain of amino
(which confers the pKa of the anesthetic).
Most injectable anesthetics are amides.4 All local
anesthetics that are available in cartridges have
pKas that range from 7.7 for Mepivacaine to 8.1
for Bupivacaine, thus making them weak bases.
Procaine is the prototype for esters, although it is
no longer available in dental syringe cartridge form.5
Topical Anesthetics
The goal for using topical anesthetics is to
reduce discomfort associated with an injection.
A topical anesthetic is used to numb the surface
of the gingiva in preparation for injecting a local
anesthetic at that site.
Unlike injectable anesthesia, topicals anesthetize
only the top portion of the mucous membrane or
tissue and do not provide anesthesia for the teeth
or bony structures. They are used to anesthetize
the surface of an injection site. Most topical
anesthetics require up to a minute to anesthetize
the area, thus, always check the manufacturer's
directions for use. Whenever possible, use
topical anesthetics to minimize the patient's pain
associated with injections. For example, after
the tissue is dried, a topical anesthetic can be
applied to a sterile cotton swab and placed at
the injection site prior to the actual injection. It is
important to use a topical anesthetic for maxillary
lingual injections, just medial to the first molar,
because these can be among the most painful
sites for injection.
Non-injectable Anesthetics
Non-injectable local anesthetics are a more recent
development in dental anesthesiology. U.S. Food
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Administration of Anesthesia
Figure 3. Gray indicates the states where dental hygienists may administer local anesthesia.
Source: American Dental Hygienists Association, December 2012.
Crest + Oral-B at dentalcare.com Continuing Education Course, Revised November 12, 2014
given by a parent, other family member, or courtappointed guardian. Resolve consent issues at a
preoperative appointment, whenever possible.
Patient Monitoring
Dental auxiliaries are involved in monitoring the
patient throughout the dental procedure. During the
actual injection the auxiliary should be positioned
to block the patients arms and hands should the
patient reach for the dentists hand. In addition
to ensuring that the patient is as comfortable as
possible, auxiliaries should continually observe
the patient after anesthesia is delivered to ensure
that the patient is not in distress or developing
an allergic reaction. Signs of an allergic reaction
can include a number of factors, including any
unusual swelling, excessive redness, shortness
of breath or trouble with breathing. These should
be addressed immediately. Since dentists may
leave the treatment room after the injection, dental
auxiliaries have a critical role in patient monitoring
after the injection. Patients should not be left alone
after local anesthesia has been administered.
Patients of all ages should be observed to be sure
they are not biting on anesthetized tissues. After a
procedure is completed, auxiliaries should remind
patients and caregivers to avoid biting or chewing
to avoid tissue damage.
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Anatomy
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Courtesy of VibraJect.
Courtesy of Septodont.
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Crest + Oral-B at dentalcare.com Continuing Education Course, Revised November 12, 2014
Crest + Oral-B at dentalcare.com Continuing Education Course, Revised November 12, 2014
Postexposure Management
Even with engineering controls in place, accidents
can happen. Needlesticks and other occupational
sharps injuries are considered medical
emergencies and must be evaluated promptly by
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Managing Emergencies
Crest + Oral-B at dentalcare.com Continuing Education Course, Revised November 12, 2014
New Technologies
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Summary
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To receive Continuing Education credit for this course, you must complete the online test. Please go to:
www.dentalcare.com/en-US/dental-education/continuing-education/ce364/ce364-test.aspx
1.
2.
3.
4.
5.
6.
7.
8.
Most anesthetics contain __________, which helps the anesthetic remain in the area longer.
a.
b.
c.
d.
William Salk
Nils Lofgren
William Halsted
Alfred Einhorn
a. naturally occurring
b. synthetic
c. derivatives from the coca bush
d. short-acting
a.
b.
c.
d.
a.
b.
c.
d.
a. esters
b. amides
c. Both A and B
d. Neither A nor B
a.
b.
c.
d.
a.
b.
c.
d.
a. vasoconstrictors
b. concentrated
c. esters
d. vasodilators
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Crest + Oral-B at dentalcare.com Continuing Education Course, Revised November 12, 2014
9.
The patients medical history must be complete and up-to-date. The use of recreational
drugs should not be asked of the patient.
a.
b.
c.
d.
10. Most topical anesthetics require ____ seconds to anesthetize the area.
a. 15
b. 30
c. 45
d. 60
root planing
extraction of deciduous teeth
root canal therapy
placement of radiographic receptor/film to relieve gagging
15. Data has shown that of the following, ____________ is the safest anesthetic to use on
pregnant and lactating women.
a. mepivacaine
b. bupivacaine
c. articaine
d. lidocaine
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Crest + Oral-B at dentalcare.com Continuing Education Course, Revised November 12, 2014
17. The highest potential for injuring the lingual nerve occurs during ____________.
a.
b.
c.
d.
18. One of the most effective techniques for minimizing patients' pain during injections is to
____________.
a.
b.
c.
d.
19. Under federal OSHA regulations, all dental offices are required by law to keep a sharps
injury log. Dental offices in states where there is a state run OSHA plan need to comply
with federal OSHA regulations.
a.
b.
c.
d.
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Crest + Oral-B at dentalcare.com Continuing Education Course, Revised November 12, 2014
References
1. Reed KL. A brief history of anesthesiology in dentistry. Tex Dent J. 2002 Mar;119(3):219-24.
2. ADA House of Delegates. Guidelines for Teaching the Comprehensive Control of Pain and Anxiety
in Dentistry. 2007. www.ada.org/sections/about/pdfs/anxiety_guidelines.pdf. Accessed November 6,
2014.
3. Scarlett MI. Current Concepts in Local Anesthetics. Woman Dent J. 2004 Apr; 32-8.
4. Meechan JG. Effective topical anesthetic agents and techniques. Dent Clin North Am. 2002 Oct;
46(4):759-66.
5. Malamed, SF, Reed, KL, Fonner AM. Local Anesthesia Part 2: Technical Considerations. Anesth
Prog. 2012 Fall; 59(3): 127137.
6. Dentsply.com
7. Uckan S, Guler N, Sumer M, Ungor M. Local anesthetic efficacy for oral surgery: Comparison of
diphenhydramine and prilocaine. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1998 Jul;
86(1):26-30.
8. Haas DA. Localized complications from local anesthesia. J Calif Dent Assoc. 1998 Sep;26(9):677-82.
9. Shojaei AR, Haas DA. Local anesthetic cartridges and latex allergy: a literature review. J Can Dent
Assoc. 2002 Nov;68(10):622-6.
10. Eggleston ST, Lush LW. Understanding allergic reactions to local anesthetics. Ann Pharmacother.
1996 Jul-Aug;30(7-8):851-7.
11. Haas DA, Lennon D. A 21 year retrospective study of reports of paresthesia following local
anesthetic administration. J Can Dent Assoc. 1995 Apr;61(4):319-20, 323-6, 329-30.
12. Haas DA. Localized complications from local anesthesia. J Calif Dent Assoc. 1998 Sep;26(9):677-82.
13. Finder RL, Moore PA. Adverse drug reactions to local anesthesia. Dent Clin North Am. 2002 Oct;
46(4):747-57.
14. Blanton PL, Jeske AH. Dental local anesthetics: alternative delivery methods. J Am Dent Assoc.
2003 Feb;134(2):228-34.
15. Blanton PL, Jeske AH; ADA Council on Scientific Affairs; ADA Division of Science. Avoiding
complications in local anesthesia induction: anatomical considerations. J Am Dent Assoc. 2003 Jul;
134(7):888-93.
16. Kaweckyi N. Maxillofacial Surgery Basics for the Dental Assistant. Part 1. American Dental
Assistants Association 2014.
17. Meit SS, Yasek V, Shannon CK, Hickman D, Williams D. Techniques for reducing anesthetic
injection pain: an interdisciplinary survey of knowledge and application. J Am Dent Assoc. 2004 Sep;
135(9):1243-50.
18. U.S. Congress. The Needlestick Safety and Prevention Act (HR 5178). Accessed November 6, 2014.
19. Kohn WG, Collins AS, Cleveland JL, et al. Guidelines for infection control in dental health-care
settings--2003. MMWR Recomm Rep. 2003 Dec 19;52(RR-17):1-61.
20. Protzman S, Clark J. The dental assistant's management of medical emergencies. Dent Assist. 1996
May-Jun;65(3):7-8, 10, 12.
21. Blanton PL, Jeske AH. Misconceptions involving dental local anesthesia. Part 1: Anatomy. Tex Dent
J. 2002 Apr;119(4):296-300, 302-4, 306-7.
22. Milestone Scientific. Accessed November 6, 2014.
23. Phillips EK, Conaway M, Parker G, et al. Issues in Understanding the Impact of the Needlestick
Safety and Prevention Act on Hospital Sharps Injuries. Infect Control Hosp Epidemiol. 2013 Sep;
34(9):935-9.
24. Tavares M, Goodson JM, Studen-Pavlovich D, et al. Reversal of Soft-Tissue Local Anesthesia with
Phentolamine Mesylate in Pediatric Patients. J Am Dent Assoc. 2008 Aug;139(8):1095-104.
25. Hersh EV, Moore PA, Papas AS, et al. Reversal of Soft-Tissue Local Anesthesia with Phentolamine
Mesylate in Adolescents and Adults. J Am Dent Assoc. 2008 Aug;139(8):1080-93.
26. Hirst L. Good Vibrations? DentalVibe vs. Vibraject. Dental Anxiety Network: December 9, 2013.
Accessed November 6, 2014.
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Crest + Oral-B at dentalcare.com Continuing Education Course, Revised November 12, 2014
27. Saijo, M, Ito E, Ichinohe T, Kaneko Y. Lack of Pain reduction by a Vibrating Local Anesthetic
Attachment: A Pilot Study. Anesth Prog. 2005 Summer;52(2):62-4.
Additional Resources
OSHA Form 300: Log of Work-Related Injuries and Illnesses and Form 301: Injury and Illness
Incident Report.
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Crest + Oral-B at dentalcare.com Continuing Education Course, Revised November 12, 2014